Every finding on record at Hutchinson Operator, LLC

The facility reported a census of 42 residents. The facility identified five Certified Nurse Aides (CNA) employed for more than 12 months. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for four of the five CNAs reviewed. Findings included: - Review of CNA personnel files revealed the following: CNA P, hired on 12/31/24, lacked an annual performance evaluation. CNA Q, hired on 09/04/24, lacked an annual performance evaluation. Certified Medication Aide (CMA) S, hired 07/07/22, lacked an annual performance evaluation. CNA T, hired on 11/21/24, lacked an annual performance evaluation. During an interview on 01/29/26 at 01:52 PM, Administrative Nurse D reported she expected 100 percent compliance in having the annual performances evaluations completed annually. The facility policy Inservice Training Program, Nurse Aide, dated 11/2025, documented the facility would complete an annual evaluation on each nurse aide and utilize such information to validate or change required in-service education.

The facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interviews, and record reviews, the facility failed to ensure adequate infection control practices related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and Transmission Based Precautions (TBP-infection control procedures to limit the transmission of infectious agents), sanitization of shared equipment and hand hygiene. Findings included:- On 01/27/2026 at 08:54 AM, Resident (R)38 had signage posted on the door at the entrance to his room which directed staff to use gloves, mask, and gowns prior to entering his room due to Droplet Precautions. A three-drawer rubberized container with personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) was set-up outside of R38's door. On 01/27/2026 at 08:57 AM, Certified Nurse Aide (CNA) Y delivered a meal tray to R38's room. She entered the room with a mask on which she had been wearing throughout the facility while passing meal trays. She set the tray on the resident's overbed table and exited the room without removing her mask or washing/sanitizing her hands. On inquiry, CNA Y verified she should have initiated Droplet Precautions before entering R38's room due to his diagnosis of COVID. She said she should apply a mask, gloves, and a gown before entering his room, and remove PPE and sanitize her hands prior to exiting his room. She stated she was trying to get the meal trays out. On 01/27/2026 at 09:11 AM, R21 reported the staff do not always wear PPE like gowns when providing care. She said she had pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). On 01/27/2026 at 09:20 AM LN H reported she is on EBP as she has a catheter. On 01/27/2026 at 09:27 AM, Administrative Nurse E stated R21 was on EBP due to having a catheter. She reported that not every resident had PPE set up but the signage on the door lets the staff know what type of PPE should be used to care for the residents. She confirmed there were nine residents in the facility with EBP due to catheters and/or MDRO. On 01/27/2026 at 9:37 AM, R25 had signage posted on the door at the entrance to his room which directed staff to use gloves, mask, and gowns prior to entering his room due to Droplet Precautions. A three-drawer rubberized container with personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) was set-up outside of R25's door. The resident was not in his room. He was sitting in a recliner in the adjoining room with his family member who was also a resident. The adjoining room entrance door lacked signage to indicate the room was shared with a resident on TBP. Neither wore a mask on or any type of PPE. R25 was coughing. On 01/27/2026 at 09:39 AM, Certified Medication Aide (CMA) AA verified resident R25 had COVID. She stated the facility had COVID going on three to four weeks. On 01/27/2026 at 09:54 AM, CNA N entered R25's family member's room, checked on R25, and offered ice water. She wore a mask. She spoke to R25 but did not wear a gown, gloves, or eye protection. She exited the room without removing her mask or performing hand hygiene. She confirmed R25 had COVID and said she should wear PPE when around R25 in keeping with droplet precautions. CNA N said she was unaware R25 was in the room until she went in. She stated R25 spent a lot of time in that room, and staff did not use PPE. CNA N stated she was going to inform the nurse about R25's cough. On 01/27/2026 at 10:01 AM observation revealed R20 in his room with his oxygen tubing wrapped around the tank. The cannula hung down and touched the back of the wheelchair. His continuous positive airway pressure (CPAP- ventilation device which blows a gentle stream of air into the nose to keep the airway open during sleep) mask laid directly on the nightstand, and a nebulizer treatment machine was present with clear liquid in the chamber. Further observation revealed he had a peripherally inserted central catheter (PICC-a thin, flexible tube which is inserted into a vein in the upper arm and threaded into a large vein above the heart). R20's room lacked signage direct staff on proper PPE to use while giving direct care. On 01/27/2026 at 10:06 AM Licensed Nurse (LN) H was at her treatment cart. She set up wound care supplies for R21'S treatment. She reported she was going to place a dressing on R21's arm. She knocked on R21's door, entered, and applied gloves. LN H did not perform hand hygiene prior to donning the gloves and did not apply additional PPE. R21 reported the dressing had been off since yesterday afternoon when she received her shower, and the nurse last night did not have time to apply one. LN H placed all the dressing supplies on the tray table with some of the open 4x4 gauze pieces touching the tray table. She removed the wet 4x4 she had in a cup, sprayed with wound cleanser, and cleansed R21's left arm areas wounds and scabbed areas which extended from elbow to wrist. She then dried the area, and wearing the same gloves, applied hydrogel (water-based gel which donates moisture and aids autolytic debridement) to all the areas with a Q-Tip. Wearing the same soiled gloves, she opened a clean dressing, applied dressing, and wrapped it with Kerlix. LN H put her scissors back in her pocket, picked up all the supplies and walked out of the room wearing the same soiled gloves. She carried the supplies to the treatment cart. On 01/27/2026 at 10:13 AM, CNA L and CNA N transferred R4, who had an indwelling catheter and required the use of EBP. Neither CNA washed their hands prior to applying gloves nor donned a gown as required with EBP. R4 was incontinent because of a small amount of bowel movement. On 01/27/2026 at 10:49 AM, R4 finished on bedside commode. CNA M and CNA N entered and applied gloves. Without performing hand hygiene prior to applying gloves. CNA M took his gloves off, failed to perform hand hygiene, and exited the room. He returned and reapplied gloves without performing hand hygiene, then grabbed a bag and put R4's feces soiled recliner pad in the bag. Wearing the same gloves, he grabbed the drawer handle, retrieved a wipe, and wiped off the floor which also had feces on it. He took off his gloves and applied new pads to recliner, then applied new gloves. CNA M took R4's catheter bag off the side of the commode, then R4 was raised up and the commode was pulled out. CNA M grabbed the package of wipes and washed R4's buttocks, then grabbed another wipe, reached up to her front peri area, and wiped front to back. After providing care, both CNA removed their gloves but did not perform hand hygiene after removing their gloves. They transferred R4 into her recliner, at which time her catheter bag was hung on the lift and higher than her bladder urine, back flowing up the tube towards the bladder. CNA N then pushed the lift out of the room but did not sanitize it. She left it in the hallway. On 01/27/2026 at 11:13 AM, CNA M stated he did not think he had to wash his hands after he removed gloves, and he thought he only needed gloves with a resident who was on EBP, On 01/27/2026 at 11:21 AM, CNA N stated she did not know she was supposed to wear gowns with resident on EBP. She reported she should have kept R4's catheter bag below her bladder. Observation on 01/28/25 at 07:35 AM, revealed R20 sat in his recliner with a half-full urinal on his over bed table. His CPAP mask remained on the nightstand. An observation on 01/28/2026 at 09:36 AM revealed Consultant JJ and LN G entered R20's room after they had a discussion whether R20 was on EBP or Covid TBP, as he had no sign on his door. Consultant JJ reported she believed he was not on any type of precautions anymore. Consultant JJ placed a bag of 4x4s and a wound bottle on R20's tray table which had half-full urinal and an empty breakfast tray on it as well. Consultant JJ applied gloves, picked up the breakfast tray, and gave it to the dietary aide. Wearing the same gloves, she assisted in rolling R20, then pulled down his brief and removed his dressing. There were feces on the dressing. She cleansed the area with 4x4 and wound cleanser which she grabbed with her gloved hands. Consultant JJ took a Q-tip out of her bag of supplies on the tray table and inserted it into the wound. LN G then carried those supplies into R11's room. During an interview on 01/28/26 at 09:55 AM, LN G reported she did take the same open package of 4x4's and wound cleanser bottle into each residents' rooms. She reported she should not have placed the wound supplies on the tray table, and she usually took a cup with wound cleanser and 4x4s in the rooms instead of the same supplies into each room. She said she should not have placed the supplies on the tray table without a barrier. She said she should have washed her hands prior to applying gloves and she should not have picked up the tray with the same gloves she used to remove and cleanse the wound. She reported R21 should have had EBP after she realized he had a PICC line. She also reported she should have washed her hands after removing her gloves before she touched items. Consultant JJ reported she had no place to put her supplies in a resident's room, and she could not keep a hold of the bag and then reported that maybe they should have a treatment cart on the wound rounds to just take in what is needed for each individual resident. During an interview on 01/28/26 at 10:15 AM, LN H reported she did not realize she wore the same gloves and reported she should have worn all the PPE required when providing care to R21. On 01/28/2026 at 02:34 PM, CNA Y exited a resident's room with a full body lift after giving direct care and proceeded down the hall to enter another resident room without sanitizing the lift between resident use. LN J confirmed the staff should sanitize lift in between residents. He stated it had been a long time since he had seen a lift sanitized. On 01/28/2026 at 05:10PM, Consultant GG confirmed the above findings were inadequate infection control practice. She reported the facility should utilize proper infection control techniques to include proper use of PPE, hand hygiene, and sanitizing reuseable equipment to prevent the spread of infection and cross contamination. The facility policy, titled Cleaning and disinfection of Environmental Surfaces F880, documented environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens standards. Protective gloves, masks, and other appropriate PPE will be used. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects which enter sterile tissue (e.g., urinary catheters) or vascular system (e.g. intravenous catheters) are considered critical items and must be sterile.

The facility reported a census of 42 residents. Based on observation, interview, and record review, the facility failed to ensure the daily staff posting included the actual hours worked by the nursing staff as required. Findings included:- During an observation on 01/29/26 at 11:50 AM, the daily staff posting document lacked documentation of actual hours worked. Review of the daily staff posting documents from 01/26/26 to 01/29/26 revealed a lack of documentation of actual hours worked. During an interview on 01/29/26 at 11:52 AM, Administrative Staff B stated she had never been educated to post the actual hours worked for the posted staff sheet. During an interview on 01/29/26 at 01:36 PM, Administrative Staff C reported she expected the actual hours to be posted on the staff sheet. The facility did not provide a policy of posted nursing staff.

The facility identified a census of 42 residents. Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) possessed the required certification. Findings included: - Upon request, the facility was unable to provide proof of certification for the designated IP. On 01/28/2026 at 05:30 PM, Administrative Nurse E stated she was the designated IP. She stated she had not completed the certification course in infection control prior to her appointment to the position about a month ago. Administrative Nurse E stated she was about halfway through the course requirements for certification. The facility did not provide a policy related for certification and qualification of the IP.

The facility reported a census of 42 residents; the sample included 12 residents with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to acknowledge the Consultant Pharmacist's monthly medication regimen review (MRR) and failed to ensure the MRR recommendations were filed in the clinical record for Resident (R) 1, R3, R6, R20, and R33. Findings included:1. R1's Electronic Medical Record (EMR) recorded the following Medication Regimen Review (MRR): R1's Pharmacy Consultant Note on 09/25/2025 documented MRR completed, irregularities noted, see report. R1's Pharmacy Consultant Note on 10/24/2025 documented MRR completed, irregularities noted, see report. R1's Pharmacy Consultant Note on 12/11/2025 documented MRR completed, irregularities noted, see report. R1's clinical record lacked the actual recommendations made and lacked evidence that the facility and physician acknowledged and responded. 2. R3's EMR recorded the following MRR: R3's Pharmacy Consultant Note on 10/25/25 documented MRR completed, irregularities noted, see report. R3's Pharmacy Consultant Note on 12/11/25 documented MRR completed, irregularities noted, see report. R3's clinical record lacked the actual recommendations made and lacked evidence that the facility and physician acknowledged and responded. 3. R6's EMR recorded the following MRR: R6's Pharmacy Consultant Note on 10/16/25 documented MRR completed, irregularities noted, see report. R6's Pharmacy Consultant Note on 11/21/25 documented MRR completed, irregularities noted, see report. R6's clinical record lacked the actual recommendations made and lacked evidence that the facility and physician acknowledged and responded. 4. R20's EMR recorded the following MRR: R20's Pharmacy Consultant Note on 09/26/25 documented MRR completed, irregularities noted, see report. R20's Pharmacy Consultant Note on 10/24/25 documented MRR completed, irregularities noted, see report. R20's Pharmacy Consultant Note on 12/11/25 documented MRR completed, irregularities noted, see report. R20's clinical record lacked the actual recommendations made and lacked evidence that the facility and physician acknowledged and responded. 5. R33's EMR recorded the following MRR: R33's Pharmacy Consultant Note on 10/24/25 documented MRR completed, irregularities noted, see report. R33's clinical record lacked the actual recommendations made and lacked evidence that the facility and physician acknowledged and responded. During an interview on 01/29/26 at 11:32 AM, Administrative Nurse D reported she would not have any of the MRRs before 12/02/25 and could not locate MRRs which were requested. Administrative Nurse D reported she expected the MRRs to be answered within seven days after they were received from the pharmacist. The facility's policy Medication Regimen Reviews, dated 02/2025, documented the Consultant Pharmacist shall review the medication regimen per state and federal guidelines. Reporting of irregularities to the attending physician, the facility medical director, and the Director of Nursing. Provision of irregularity reports on a separate, written report (to those identified in a), which includes the resident's name, the relevant drug, and the irregularity which has been identified.

The facility identified a census of 42 residents. The sample included 12 residents with five residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided ADL assistance with personal hygiene for Resident (R) 4, R21, R7 and R40, who did not receive fingernail care and/or showers. Findings included:1.R4's Electronic Medical Record (EMR) recorded a diagnosis of bladder dysfunction and inflammatory reaction due to an indwelling urethral (tubelike part of the body conveys urine from the bladder to the exterior) catheter and bipolar disorder (a major mental illness which causes people to have episodes of severe high and low moods). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R4 had no rejection of cares during the observation period. The MDS noted R4 was dependent on staff for most ADL, including showering and personal hygiene. R4's Care Plan, dated 11/29/17, informed staff that R4 prefers to bathe in the afternoons twice a week. The Shower List, dated 12/19/25, had R4 scheduled for a shower on Tuesday, Thursday, and Saturday. R4's Shower Sheets, reviewed from 11/05/25 through 01/27/26, revealed R4 had 39 showers scheduled. R4 received eight showers, two bed baths, she refused twice as showers were offered in the morning, and one time she refused as she was ill. During an observation and interview on 01/27/26 at 9:36 AM, R4 in her recliner, she reported she should receive a shower Tuesday, Thursday, and Saturday. She reported she had no shower last week except for a bed bath on Saturday, as it was too cold to have a shower in the shower room. R4 reported she disliked bed baths, as she did not get cleaned well in her bed. During an interview on 01/28/26 at 01:20 PM, R4 reported she did not have a shower again the previous night; staff told her the water was shut off for the shower room because there was a leak which was being fixed. She reported she was quite sad she had not received a shower in over a week. 2. R21's EMR recorded diagnoses of sepsis (a life-threatening systemic reaction which develops due to infections which causes inflammation throughout the entire body) and neuromuscular dysfunction of the bladder (a condition where nerve disease or injury disrupts signals between the brain and the bladder). 3R21's Quarterly MDS, dated 01/09/26, recorded a BIMS score of 15 indicating intact cognition. R21 had no rejection of care during the observation period. R21 was dependent on staff for toileting hygiene, and showers and required maximal/extensive staff assistance with personal hygiene. R21's Care Plan, dated 07/30/24, educated staff R21 had an ADL self-care performance deficit related to weakness. R21's care plan lacked documentation regarding bathing preferences or assistance required. The Shower List, dated 12/19/25, had R21 scheduled for a shower on Monday and Friday. R21's Shower Sheets, reviewed 11/05/25 through 01/27/26, revealed R21 had 27 showers scheduled. R21 received one shower, four bed baths, she refused one time as she was ill. Two of the scheduled days she was in the hospital. During an observation an interview on 01/27/26 at 09:11 AM, R21 laid in her bed and watching television. She reported she had a shower the previous day, but before then, the last shower was 01/12/26. R21 reported the facility was frequently short staffed and said she did not always get a shower at least twice a week. She stated there was only one functional shower room because the other was down. R21 said she preferred her showers in the afternoon because she liked to go to activities like BINGO. She missed BINGO the previous day, as she had her shower before the activity, and there was not a dry lift sling available for use to get her up after her shower and go to BINGO. 3. R7's EMR documented diagnoses of urinary retention (lack of ability to urinate and empty the bladder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R7's Quarterly MDS, dated 12/12/25, recorded a BIMS score of 13 indicating intact cognition. R7 had no rejection of care during the observation period. R7 was dependent on staff for toileting hygiene, showers, and dressing. She had an indwelling catheter. R7's Care Plan, revised date 02/12/25, educated staff R7 had an ADL self-care performance deficit related to weakness/limited mobility. R7's care plan lacked documentation regarding personal hygiene/nail care assistance required. During an observation on 01/27/26 at 02:30 PM it was revealed R7 had long, dirty fingernails. During an observation on 01/28/26 at 07:33 AM, R7 was in bed watching TV. The room smelled strongly of urine Her fingernails were long, jagged, and had brown debris under the nails. During observation on 01/28/26 at 12:15 PM, R7 was in the dining room eating lunch. Her fingernails remained long, jagged and she had brown debris under her nails. R7 reported she could not cut her nails; she would need help. Observation on 01/29/26 at 09:07 AM revealed R7 was in bed with her eyes closed. There was a strong urine smell present in her room. Her fingernails were unchanged from previous observations. 4. R40's EMR recorded diagnoses which included hypertension (high blood pressure) and depression (a mood disorder which causes a persistent feeling of sadness and loss of interest) and COVID-19. R40's Quarterly MDS, dated 01/09/26, documented a BIMS score of 15. He had no rejection of care during the observation period. He was dependent for showering and required maximal /extensive assistance for personal hygiene. R40's Care Plan, 06/09/22, educated staff R40 had an ADL self-care performance deficit related to an unsteady gait. R40's Care Plan, 09/02/22, directed staff R40 required one staff participation with bathing and R40 preferred evening baths twice a week. The Shower List, dated 12/19/25, had R40 scheduled for a shower on Wednesday, Friday, and Sunday. R40's Shower Sheets, reviewed 11/03/25 through 01/21/26, documented R40 had his nails clean and trimmed four times, last time documented was 01/11/26. The facility was unable to provide shower sheets from 01/22/26 through 1/27/26. R40 had a shower documented on 01/21/26. During an observation and interview on 01/27/26 at 01:20 PM, R40 stood at the bathroom sink washing his hands. R40 reported it was almost two weeks since his last shower. He said he thought it was due to the fact he had COVID but went on to say he still needed to get bathed. During an observation and interview on 01/28/2026 at 8:45 AM, R40 was seated in his recliner observed to have very long jagged fingernails with brown color residue underneath nails, visible from the tops and the backsides of hands. R40 asked if someone was going to cut his nails for him, then reported no one else would help him.During an observation and interview on 01/27/26 at 01:20 PM, R40 stood at the bathroom sink washing his hands. R40 reported it was almost two weeks since his last shower. He said he thought it was due to the fact he had COVID but went on to say he still needed to get bathed. Review of Resident Council Concerns Form, dated 12/19/25 and 01/23/26, concern documented on both was showers not being completed when scheduled. Recommendations/Solutions both forms were dated 01/26/26 and documented educated staff Administrative Nurse D would review shower sheets and will discipline staff who do not complete. During an interview on 01/28/26 at 02:34 PM, Certified Medication Aide (CMA) R produced an updated shower list, dated 12/19/25. CMA R reported the residents only get showers from 06:00 AM-06:00 PM. CMA R reported residents do not get showers offered on the night shift. Additionally, CMA R reported the facility had only one working shower room since last year. CMA R reported if a resident missed a shower they should document why, and sometimes they would not get them done. Additionally, CMA R reported the staff would trim and clean the residents' nails who could not complete it independently. During an interview on 01/29/26 at 09:15 AM, Licensed Nurse (LN) G reported showers had been very difficult to correlate between North and South hallway, as the facility was down to one shower room since August 2025. LN G reported if a resident missed a shower, it would be ideal to have that shower made up the next day. LN G reported it would not always happen. LN G reported the staff were required to trim and clean residents' fingernails during the bath day or as needed. During an interview on 01/29/26 at 01:52 PM, Administrative Nurse D revealed the facility had one shower which both the North and South hallways had to share. She reported the North hallways shower room had been under repair since August 2025. Administrative Nurse D reported she expected the showers to be completed and had been working on a plan to have the issue resolved. Additionally, she expected the staff to trim and clean residents' nails on shower days and as needed. The facility's policy Quality of Life - Activities of Daily Living, dated 04/2025, documented residents who are unable to carry out activities of daily living would receive the necessary care and services to maintain good grooming and personal hygiene. The facility's policy Shower/Tub Bath, dated 10/2025, documented the purposes of this procedure are to promote cleanliness, provide comfort to the residents, observe the condition of the skin, and to not trim the residents' fingernails unless otherwise instructed by the supervisor.

The facility identified a census of 42 residents, two medication rooms and four medications carts. Based on observation, record review, and interview, the facility failed to store insulin (a hormone that lowers the level of glucose in the blood) appropriately to include an opened date on insulin pens in use. Findings included:- Observation on 01/28/26 at 08:29 AM revealed the following insulin pens were open, and undated. 1. Resident (R) 2's Lantus (long-acting insulin) had no label or open date. Her insulin lispro (fast-acting insulin) had no legible open date. 2. R15's insulin lispro had no open date. 3. R4's Lantus has no open date. 4. R17's glargine (long-acting insulin) had no cap and no open date. According to medlineplus.gov, open Lantus, glargine, and insulin lispro pens must be stored at room temperature and may be used for up to 28 days after the first use. During an interview on 01/28/26 at 08:29, AM Licensed Nurse (LN) J reported that the insulin pens should b e labeled when opened. During an interview on 01/29/26 at 08:55 AM, Administrative Nurse D stated she expected the staff to label the insulin pens with an open date. The facility did not provide a policy for medication storage.

The facility identified a census of 42 residents. The sample included 12 residents with five reviewed for immunizations. Based on record review and interview, the facility failed to provide education and obtain consent or informed declination for the pneumococcal (type of bacterial infection) vaccine for Resident (R) 1, R20 and R25. Findings included:- Review of R1's Immunization Record lacked documentation of education provided by the facility, regarding the risk verses benefits of pneumococcal vaccine administered on 10/11/22, since his entry on 08/29/19. Review of R20's Immunization Record lacked documentation of education provided by the facility regarding the risk verses benefits and/or the offer of pneumococcal vaccine since his entry on 09/25/25. Additionally, the documentation lacked indication of historical data of the resident's pneumovax status. Review of R25's Immunization Record lacked documentation of education provided by the facility, regarding the risk verses benefits and/or the offer of pneumococcal vaccine, since his entry on 04/06/23. Additionally, the documentation lacked indication of historical data of the resident's pneumococcal vaccine status. On 01/29/2026 at 11:05 AM, Administrative Nurse E confirmed the facility failed to provide the above residents with education regarding the risk verses the benefits for pneumococcal as they should to allow residents to make an informed decision regarding the pneumococcal vaccine. The facility policy titled F883, F884, F887 Vaccination of Residents including Influenza, Pneumococcal, and COVID-19, Reporting of documentation included residents will be offered pneumovax vaccinations. Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations. Provisions of such education shall be documented in the residents' medical record.

The facility identified a census of 42 residents. The sample included 12 residents with three residents reviewed for urinary catheters (a tube inserted directly into the bladder to drain urine). Based on observation, interview, and record review, the facility failed to ensure adequate catheter related care for Resident (R) 4, R7 and R21 when staff did not ensure each resident's catheter tubing was secured to prevent pulling or dislodgement. The facility additionally failed to ensure each resident was provided with a dignity bag to cover the urine collection bag and failed to ensure the urine collection bags remained sanitary and off the floor. Findings included:1.R4's Electronic Medical Record (EMR) recorded a diagnosis of bladder dysfunction and inflammatory reaction due to an indwelling urethral (tubelike part of the body conveys urine from the bladder to the exterior) catheter.R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R4 had no rejection of cares during the observation period. The MDS noted R4 was dependent on staff for most activities of daily living (ADL). She had an indwelling catheter. R4's Care Plan, dated 02/04/25, directed staff to provide foley catheter care. Change the foley catheter as needed. Directed staff to observe catheter tubing for kinks and to keep the foley catheter below the level of the bladder. R4's EMR listed the following orders: Indwelling catheter, 20 French (Fr) 30 cubic centimeters (cc), change catheter and bag as needed for signs and symptoms of infection, obstruction or when the closed system has been compromised as needed, dated 10/11/25. During an observation on 01/27/26 at 10:13 AM, Certified Nurse Aide (CNA) M and CNA N transferred R4 with mechanical lift onto the bedside commode. Her catheter tubing was not secured onto her skin, the catheter tubing hung freely. During an observation on 01/28/26 at 07:40 AM, R4 was in her recliner with her eyes closed. Her urine collection bag hung on the garbage can with no cover. The bag touched the floor.During an interview on 01/27/2026 at 11:21 AM, CNA N stated good luck when asked if the facility had securement devices for catheter tubing available.During an interview on 01/28/26 at 01:20 PM, R4 reported she was being treated for another possible urinary tract infection (UTI).2. R7's EMR documented diagnoses of urinary retention (lack of ability to urinate and empty the bladder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R7's Quarterly MDS, dated 12/12/25, recorded a BIMS score of 13 indicating intact cognition. R7 had no rejection of care during the observation period. R7 was dependent on staff for toileting hygiene, showers, and dressing. She had an indwelling catheter. R7's Care Plan, dated 02/28/25, directed staff to provide foley catheter care. Change the foley catheter as needed. Directed staff to observe catheter tubing for kinks and to keep the foley catheter below the level of the bladder. R7's Care Plan, revised date 01/11/26, staff instructed to maintain a16 Fr. 10 cc. Foley catheter temporarily placed to assist with decreased moisture to promote healing of pressure wound. R7's EMR listed the following orders: Indwelling catheter, 16Fr, 10 cc, change catheter and bag as needed for signs and symptoms of infection, obstruction or when the closed system has been compromised as needed for wound healing, dated 03/03/25. A Provider Progress Note, dated 12/29/25, documented the resident had a history of frequent UTI with resistant bacteria. During an observation and interview on 01/28/26 at 07:33 AM, R7 was in bed watching TV. The room smelled strongly of urine. Further observation revealed she had no securement device on the catheter tubing. R7 reported she had never had anything to hold her tubing down.During an observation on 01/29/26 at 09:07 AM, R7 was in bed with her eyes closed. There was a strong urine smell present in her room. Her catheter bag was not covered and there was no urine visible in the bag.3. R21's EMR recorded diagnoses of sepsis (a life-threatening systemic reaction which develops due to infections that cause inflammation throughout the entire body) and neuromuscular dysfunction of the bladder (a condition where nerve disease or injury disrupts signals between the brain and the bladder). R21's Quarterly MDS, dated 01/09/26, recorded a BIMS score of 15 indicating intact cognition. R21 had no rejection of care during the observation period. R21 was dependent on staff for toileting hygiene, and showers and required maximal/extensive staff assistance with personal hygiene. She had an indwelling catheter. R21's Care Plan, dated 10/09/24, directed staff to provide foley catheter care. Change the foley catheter as needed. Directed staff to observe catheter tubing for kinks and to keep the foley catheter below the level of the bladder.R21's EMR listed the following orders: Indwelling catheter, 16Fr, 10 cc, change catheter and bag as needed for signs and symptoms of infection, obstruction or when the closed system has been compromised as needed for wound healing dated 01/20/25.A Nursing Progress Note, dated 01/02/26 at 06:36 AM, documented R21 was admitted to the hospital with urosepsis (sepsis related to UTI).During an observation and interview on 01/27/26 at 09:09 AM, it was revealed R21's urine collection bag was not covered and was positioned towards the doorway of the room. CNA M knocked, entered the room, and reported he needed to cover the bag for dignity purposes. During an interview on 01/27/26 at 09:11 AM, R21 reported she has no anchor or securement device to keep the catheter in place and said she was lucky if she got catheter care. She reported staff did not provide the catheter care every day and she had to ask for her catheter to be cleaned. She was unsure why she had a catheter and said she thought it was because she was incontinent, and staff did not have the time to assist her.During an interview on 01/28/26 at 09:55 AM, CNA O reported she had not really seen a securement device for any residents foley catheter used at this facility. She reported all the foley catheter drainage bags should always be covered, and the catheter bag should not be placed on the floor.During an interview on 01/28/26 at 06:25 PM, Administrative Nurse E reported she expected staff to apply securement device to each resident foley catheter to prevent pulling or dislodgement. She also expected the staff to cover catheter drainage bags with a dignity bag.The facility's policy Indwelling Urinary Catheters, dated 05/2025, documented if the resident had an indwelling urinary catheter, the staff would cover the urine bag to provide privacy. The staff would ensure the catheter remained secure with a leg strap to reduce friction and movement at the insertion site.

The facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 20's psychotropic (alters mood or thought) medications, and R7's activities of daily living (ADLs) for a dependent resident. Findings included:1. R20's Electronic Medical Record (EMR) revealed diagnoses of major depressive disorder (major mood disorder which causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R20's 09/29/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R20's MDS documented no behaviors and minimal depression. R20's MDS recorded he received an antianxiety, (a class of medications which calm and relax people), an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality), and an antidepressant (a class of medications used to treat mood disorders) in look-back period. R20's 10/17/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R20 triggered related to high-risk medications. R20 would continue to take medication as prescribed by provider. Medications would be reviewed by provider for therapeutic effect. R20's Care Plan, revised date 01/05/26, documented R20 used antidepressant, psychotropic, and antianxiety medications. The care plan lacked documentation for any interventions related to his mental health medications. R20's Physician's Orders documented trazadone (antidepressant medication) 50 milligrams (mg), give one tablet every 24 hours as needed, by mouth, for insomnia, date ordered 10/10/25. R20's Physician's Orders documented Celexa (antidepressant medication) 40 mg, give one tablet, by mouth, daily for depression, date ordered 10/11/25. R20's Physician's Orders documented Caplyta (antipsychotic medication) 10.5 mg, give one tablet at bedtime for depression, date ordered 12/05/25. R20's Physician's Orders documented lorazepam (antianxiety medication) 1 mg, give one tablet twice a day for anxiety, date ordered 01/24/26. Observations on 01/28/26 at 07:35 AM revealed R20 sat in his recliner. He reported he did not get much sleep last night. 2. R7 's EMR revealed diagnoses of major depressive disorder (major mood disorder which causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R7's 05/17/25 Annual MDS documented a BIMS score of 10, which indicated moderately impaired cognition. R7's MDS documented she had an impairment on both her upper and lower extremities. R7's MDS documented she required total assistance with personal hygiene. R7's 06/13/25 Functional Abilities (Self-Care and Mobility) CAA documented R7 triggered related to a self-care deficit. R7's 11/77/25 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. R7's MDS documented she had an impairment on both her upper and lower extremities. R7's MDS documented she required total assistance with personal hygiene. R7's Care Plan, revised date 02/12/25, educated staff that R7 had an ADL self-care performance deficit related to weakness/limited mobility. R7's Care Plan lacked documentation regarding personal hygiene/nail care assistance required. During an observation on 01/27/26 at 02:30 PM, it was revealed R7 had long, dirty fingernails. During an observation on 01/28/26 at 07:33 AM, R7 was in bed watching TV. Her fingernails were long, jagged, and had brown debris under the nails. During observation on 01/28/26 at 12:15 PM, R7 was in the dining room eating lunch. Her fingernails remained long, jagged and she had brown debris under her nails. R7 reported she could not cut her nails; she would need help. During an observation on 01/29/26 at 09:07 AM, R7 was in bed with her eyes closed. Her fingernails were unchanged from previous observations. During an interview on 01/29/2026 at 02:56 PM Licensed Nurse (LN) K reported care plans are developed by the Administrative Nurses. During an interview on 01/29/26 at 02:58 PM, Administrative Nurse E reported R20's psychotropic medications should have been documented on the care plan within 30 days. Administrative Nurse E reported a care plan is developed by the interdisciplinary team and expected the care plan to be an accurate up to date. The facility's policy Comprehensive Care Plans, dated 03/25, documented an individualized comprehensive person-centered care plan, which included measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural, and psychological needs, was developed for each resident.

The facility had a census of 42 residents. The sample included 12 residents with two reviewed for discharge and three for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy including duration for Resident (R)21, and R20. The facility also failed to notify the Office of the Long-term Care Ombudsman (LTCO) of a transfer for R46.Findings included:1.R21's Electronic Medical Record (EMR) recorded a Quarterly Minimum Data Set (MDS), dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R21's Nursing Progress Note, dated 01/02/26 at 06:36 AM, which documented R21 was admitted to the hospital with urosepsis (sepsis related to UTI) and a verbal bed hold was given before departure. R21's EMR lacked evidence a written bed hold notice was provided to R21. During an interview on 01/27/26 at 09:11 AM, R21 reported she did not know anything about a bed hold. 2. R20's Quarterly MDS, dated 12/30/25, documented a BIMS score of 15. R20's Nursing Progress Note, dated 01/17/26 at 08:40 AM, documented the resident was unresponsive. Staff notified the physician who gave orders to send the residents to the emergency room. The note documented the resident was unable to sign a bed hold because he was unresponsive. The note also lacked evidence that a written bed hold was sent with the resident or provided to his party responsible. During an interview on 01/27/26 at 12:26 PM, R20 reported he had no knowledge what the bed hold policy was or if one had been done. 3. R46's admission MDS, dated 12/06/25, recorded a BIMS score of 15. R46's EMR included a note, dated 12/08/25 at 05:47 PM, which documented R46 discharged from the facility at approximately 05:45 PM via a private vehicle in route to his new home accompanied by a family member. The discharge summary and medication orders were provided to the resident and his representative upon discharge. Upon request, the facility was unable to provide evidence the LTCO received notification of the discharges. During an interview on 01/28/26, Social Service Designee (SSD) X revealed she had not updated the LTCO since 08/25/25 for transferred/discharged residents. During an interview on 01/29/26 at 09:15 AM, Licensed Nurse (LN) G reported that a bed hold would be completed at the time of transfer to the hospital, if it was not completed a copy of the bed hold would be sent. LN G reported SSD X would complete a bed hold the next day if not completed. During an interview on 01/29/26 at 09:35 AM, SSD X reported that the nurse would complete a bed hold when a resident was transferred to the hospital. SSD X reported she would be told if a bed hold was not completed and then a bed hold would be obtained. During an interview on 01/29/26 at 01:52 PM, Administrative Nurse D reported she expected the bed holds to be completed in a timely manner. Administrative Nurse D reported she expected the LTCO to be updated monthly on all transfers. The facility's policy Bed Hold, dated 04/2025, documented the staff shall inform resident upon admission and prior to a transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed hold policy. When emergency transfers are necessary, the facility would provide the resident and the resident's representative with information of the bed hold policy per state law as applicable. A copy of the resident's bed hold, or release record would be filed in the resident's medical record. The facility's policy Transfer and/or Discharge, Including Against Medical Advice, Discharge notification, dated 10/2025, documented would send a copy to the notice of the State Long Term Care Ombudsman, note in record.

The facility identified a census of 42 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 6 and R20's as needed (PRN) psychotropic medication (alters mood or thoughts) had a 14 day stop date, or a specified duration with a physician rationale for extended use. The facility failed to ensure R6's PRN antipsychotic (a psychotropic medication used to treat severe mental disorders) had the required 14 day stop date. Findings included:1. R6's Electronic Medical Record (EMR) listed a Physician's Order for haloperidol (an antipsychotic medication) 0.5 milligrams (mg) tablet, give one tablet by mouth every four hours as needed for agitation/aggression, dated 10/18/25. The order lacked a stop date. R6's EMR documented an order lorazepam (antianxiety a class of medications that calm and relax people) 0.5 mg tablet, give one tablet by mouth every two hours as needed for anxiety/seizure, dated 11/04/25. The order lacked a stop date. An observation on 01/28/26 at 09:50 AM revealed R6 walked in the hall using a walker. He had no behaviors and answered questions with ease. 2. R20's EMR documented an order trazodone (antidepressant) 50 mg by mouth every 24 hours at bedtime as needed for insomnia (inability to sleep), dated 10/10/25. The order lacked a stop date. Observations on 01/28/26 at 07:35 AM revealed R20 sat in his recliner. He reported he did not get much sleep last night. During an interview on 01/29/26 at 09:15 AM Licensed Nurse (LN) G reported all as-needed psychotropic medication orders required a 14 day stop date. LN G reported the nurse who documented the order in EMR was responsible to document a stop date. During an interview on 01/29/26 at 01:52 PM Administrative Nurse D reported she expected all as-needed psychotropic medications to have a 14 day stop date to have medication re-assessed. The facility's policy Use of Psychotropic Drugs, dated 04/2025, documented as needed orders for all classes of psychotropics. Antipsychotic medications enter a 14 day stop date. To renew the as-needed order, the physician must evaluate the resident for appropriateness to write an additional 14 days for that medication. All other psychotropic medications enter a 14 day stop date. Repeated doses given with the 14 days should be reviewed for standing dose.

The facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, homelike environment for Resident 33, R7, and R40. Findings included:- An observation on 01/27/2026 at 08:59 AM revealed R33's room had a strong foul odor, and his linen on his bed was dirty and gray in color. An observation on 01/27/2026 at 01:20 PM revealed R40's recliner had vinyl peeling off the chair. He said the recliner was broken and he thought he had reported it. An observation on 01/28/2026 at 07:33 AM revealed R7 laid in bed watching TV. The room had a strong urine odor. An observation on 01/28/2026 at 08:06 AM revealed Certified Medication Aide (CMA) R opened the door to R33's room, and strong foul odor was evident from the room all the way out in the hallway. His sheets remained the same dirty sheets as the previous day. An observation on 01/28/2026 at 10:47 AM revealed R40 had a pile of food crumbs and dirt in front of his chair, and red dried smears on his tray table. The tray table had duct tape on it in two different places. An observation on 01/29/2026 at 9:07 AM R7 was in bed with her eyes closed. There was a strong urine smell present in her room. Her catheter (tube inserted into the bladder to drain urine) bag was not covered and there was no urine visible in the bag. During an interview on 01/28/2026 at 08:06 AM, CMA R stated she had not noticed how soiled R33's sheets were when she was in the room to give R33 his medications. During an interview on 01/28/2026 at 08:08 AM, Certified Nurse Aide (CNA) O reported R33 would allow staff to change his linens on his bed, and it would be completed on shower days or as needed. CNA O reported R33's room always had a foul odor and management staff had spoken to him about the smell. CNA O reported R33 would not allow staff to touch his boxes in his room. During an interview on 01/28/2026 at 08:10 AM, CNA O reported R7's room smelled of urine quite often and R7 had a foley catheter and stated maybe the urine was spilled when the staff drained the catheter bag. During an interview on 01/28/2026 at 08:13 AM, R33 reported he would allow staff to clean his room, and no staff had spoken to him about the odor in his room. R33 stated no staff had asked him to assist him with his boxes. He reported he had a shower on 01/27/26 in the evening and his dirty laundry was in the basket in his room. During an interview on 01/28/26 at 12:09 PM, Housekeeping Staff W reported R33's room smelled foul all the time, and R33 was scheduled for a daily cleaning of his room. Housekeeping Staff W reported sometimes R33 would not leave his room so the staff could not always clean under his bed. Housekeeping Staff W reported R7 had a strong urine smell in her room often and was not sure why. During an interview on 01/28/2026 at 02:21 PM, Housekeeping Staff W reported staff typically cleaned R40s's room twice a day because he was messy and gross. She said staff had to go into R40's room and get stuff off the floor with a paint scraper. She also stated staff had not cleaned R40's room the previous day at all, nor had they done it that day either. During an interview on 01/29/26 at 09:15 AM Licensed Nurse (LN) G reported housekeeping staff cleaned all the residents' rooms daily. During an interview on 01/29/26 at 01:52 PM Administrative Nurse D reported she expected the residents' rooms to be cleaned daily. Administrative Nurse D reported the facility had tried to remove the foul odor from R33's room and had been unsuccessful. She expected the residents' rooms not to have a lingering odor in their rooms. The facility's policy Cleaning and Disinfection of Environmental Surfaces, dated 10/2025, documented routine cleaning and disinfection should be completed of frequently touched or visibly soiled surfaces in common areas, resident rooms, and at time of discharge. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.

The facility identified a census of 42. The sample included 12 residents with three reviewed for beneficiary notifications. Based on interviews and record review, the facility failed to use the appropriate Advance Beneficiary Notice of Notice of Non-coverage (ABN) Form CMS-10055 and failed to ensure section G recorded the resident's selection for Resident (R) 4 and R6 and failed to issue the ABN to R35. The facility failed to issue the Notice of Medicare Non-Coverage for R35. Findings included:1. R4's facility provided documentation noted her Medicare Part A last covered day was 11/20/25. The resident remained in the facility. R4's ABN Form CMS-R-131, dated 11/20/25, lacked section G selection. 2. R6's facility provided documentation noted his Medicare Part A last covered day was 07/23/25. The resident remained in the facility. R6's ABN Form CMS-R-131, dated 11/20/25, lacked section G selection. 3. R35's facility provided documentation revealed his Medicare Part A services ended 12/24/25. The resident remained in the facility. Upon request, the facility was unable to provide evidence that Form CMS-10055 or Form CMS-10123 were provided to R35. In an interview with Administrative Nurse F on 01/29/26 at 02:57 PM, he stated the ABN should be provided to the resident or resident's representative, so the notification can be appealed, if chosen to do so, prior to the last day of Part A coverage. The facility's policy F582, F584 Beneficiary Notice, last revised on 08/2024, documented the Skilled Nursing Facility ABN is issued to the resident if resident intends to continue services which may no longer be covered by Medicare.

The facility reported a census of 42 residents; the sample included 12 residents with five reviewed for unnecessary medications. Based on interview and record review, the facility failed to inform Resident (R) 3 and R20 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:1. R3's Electronic Medical Record (EMR) documented an order for olanzapine (antipsychotic medications used to treat major mental conditions that cause a break from reality) five milligrams (mg) by mouth once daily, dated 06/25/25. R3's EMR lacked evidence R3, or her representative, received education and/or informed consent with regards to the olanzapine dose and frequency increase. 2. R20's EMR documented an order for trazodone (antidepressant) 50 mg by mouth every 24 hours at bedtime as needed for insomnia (inability to sleep), dated 10/10/25. The order lacked a stop date. The EMR noted an order for citalopram hydrobromide (antidepressant medication) 40 mg daily by mouth, dated 10/10/25. R20's EMR lacked evidence R20, or his representative, received education and/or informed consent with regards to the Celexa and trazadone. During an interview on 01/29/26 at 09:15 AM Licensed Nurse (LN) G reported that Social Service Designee (SSD) X would complete the informed consents for the use of psychotropic medications. During an interview on 01/29/26 at 12:00 PM SSD X reported she could not locate the informed consents for R20 and produced signed consents for R20's trazadone and Celexa dates 01/29/26. SSD X reported she would have the resident or responsible party complete the consent when a new psychotropic medication was ordered. During an interview on 01/29/26 at 01:52 PM, Administrative Nurse D reported she expected the informed consents for psychotropic medications to be obtained prior to a medication being administered to a resident. The facility's policy Use of Psychotropic Drugs, dated 04/2025, documented the facility would inform the resident and or/representative of a new or changed orders for a psychotropic medication, including the benefits, risks, and alternatives for the medications, which included a black box warning for psychotropic medication prior to being initiated or increased.

The facility reported a census of 42 residents. Based on observation and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry. Findings included:- On 01/29/2026 at 10:31 AM, an inspection of the laundry with Housekeeping Staff/Maintenance Staff U revealed the following concerns: Three soiled laundry bins with an unsanitary, cracked top on the outer edge rim. The floor of the sorting room had paint missing, resulting in an unsanitary surface throughout the laundry room. The table used for folding clean laundry had two USB cables lying across the table surface where staff processed clean laundry. Four cardboard boxes sat directly on the floor and a tray carrier with chemicals was directly on the floor. Four uncovered pillows were stored under a table leaning in direct contact with the wall. There were four feet of missing baseboard at the junction of the soiled linen sorting room wall and floor. Broken and missing tile at the soiled laundry sorting room door transition tile missing at transition at tile floor. On 01/29/2026 at 10:31 AM, Housekeeping /Maintenance Staff U confirmed the above findings and agreed the laundry needed repairs to ensure a safe and sanitized area for staff to process the residents clothing and linen. The facility policy titled Storage Areas, Environmental Services, dated 10/2025, documentation included housekeeping and laundry department areas shall be maintained in a clean safe manner.

The facility reported a census of 41 residents. The sample included six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free of accident hazards when on 10/07/25 at approximately 12:15 PM, staff pushed R1 down the hallway in the shower chair. R1's right lower leg became entangled in the shower chair causing R1 to fall out of the chair, resulting in a right tibia (the large bone in the lower leg) and right fibula (the small bone in the lower leg) fractures. Findings included:- R1's Electronic Health Record (EHR) included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), morbid obesity (excessive body fat), abnormal involuntary movements and generalized muscle weakness.R1's 09/19/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R1 utilized a wheelchair for locomotion and required the use of a mechanical lift for transfers. R1 was dependent on staff assistance for all transfers.The 09/19/25 Activity of daily Living (ADL) Functional / Rehabilitation Potential Care Area Assessment (CAA) documented R1 had impaired balance during transfers. The 09/19/25 Falls CAA documented R1 was a high risk of falls although had no recent history of falls. R1's Care Plan documented on 09/02/17 R1 was at risk for falls. Interventions dated 09/02/17 directed staff to encourage the resident to wait for staff assistance prior to transfers if she was feeling week (revised on 01/24/24) and noted R1 would wear proper footwear during transfers. The plan directed staff would place non-skid tape on the floor in front of R1's recliner and staff would keep the floors free from clutter and spills. An update on 11/24/17 documented staff would educate R1 to take more time and go slowly with transfers and walking. On 05/13/24, the plan was updated to include two staff members would assist R1 with all transfers and an update dated 10/24/24 documented R1 required the use of a full lift and assistance of two staff members.R1's EHR, under the Progress Notes documented a late entry note, created on 10/09/25 at 11:28 AM which noted on 10/07/25 at 12:15 PM, Licensed Nurse (LN) H heard someone say they needed help, so he left the office and found R1 face down in the hallway in front of the shower chair with a Certified Nurse Aide (CNA) kneeling on the floor beside her. R1 complained of pain in her right leg. LN H documented there was swelling and discoloration to R1's right leg. Upon the arrival of additional staff, staff covered R1 with a bath blanket to protect her privacy. LN H documented staff rolled R1 onto a full lift sling and contacted Emergency Medical Services (EMS) related to R1's right leg shape displacement and noticeable shortening compared to the left leg. Upon the arrival of EMS personnel, LN H and the CNA staff moved R1 onto the EMS cot using a mechanical lift with the assistance of EMS and fire department personnel; R1 was transported to the local hospital.Review of the facility's undated fall investigation revealed on 10/07/25, staff wheeled R1 from the shower room to her room via a shower chair when R1's foot slipped off the foot rail which caused R1 to fall face first onto the floor. The investigation documented the root cause of the fall was R1 tipped forward in the shower chair while being transferred down the hall. The investigation documented camera footage was reviewed, and nothing appeared to visibly obstruct the wheels and R1's feet were still on the footrest.A Progress Note dated 10/11/25 at 02:20 PM documented R1 returned to the facility at approximately 02:15 PM with a diagnosis of right tibia and fibula fractures with an order to wear a splint to the right lower leg at all times and follow up with the orthopedic (bone specialist) physician within one week.A Progress Note dated 10/11/25 at 04:30 PM documented R1 was dependent on three staff for all transfers, one to stabilize the right lower leg splint and two staff to operate the full mechanical lift. On 10/14/25, R1's Care Plan The was updated with an intervention effective 10/07/25 that directed staff to wheel and/or roll R1 backward when transporting her down the hallway in the shower chair. Observation of the shower room on 10/21/25 at 01:00 PM revealed four shower chairs, two of which had an apparatus installed to hold residents' feet.On 10/21/25 at 01:25 PM, R1 reported that earlier in the month a CNA assisted her with her shower, completed the shower, covered her with two bath blankets and was propelling her back to her room to get dressed for a doctor appointment. R1 reported that the CNA was in a hurry due to R1's upcoming appointment and while the CNA pushed down the hallway in the shower chair, the footrest portion of the shower chair folded back under the chair and her legs dropped to the floor. R1 reported that her legs got caught under the front of the shower chair while the CNA was pushing the shower chair, and she fell forward onto the ground and felt extreme pain in her right leg. R1 stated the staff responded immediately and closed the doors to the common areas that were nearby and the doors to the hallways to protect her dignity as much as they could since she was naked, lying face down on the ground. R1 said staff then assessed her and determined that she needed to be seen in the Emergency Department (ED) because of the pain in her right leg. R1 stated she went to the local hospital by ambulance for and said the ED found a fracture in her right leg near the hardware from her total knee replacement. R1 said it was still uncertain whether she would require surgery as she has not yet been to see the bone doctor. On 10/22/25 at 09:00 AM CNA N that when staff propelled residents in their chairs, pedals should always be used and if a foot slipped off the pedals and the resident tumbled onto the floor, staff utilized their two-way radios to summon help. CNA N also stated that before showers, residents should be transported to the shower room in their wheelchair and then transferred to the shower chair and after the shower was over, residents would be transferred back to their wheelchair and then transported back to their rooms in their wheelchair. CNA N stated under no circumstances should residents be transported down the hallways in a shower chair. On 10/22/25 at 09:52 AM, CNA O stated that all assisted wheelchair locomotion should include the use of foot pedals. CNA O stated that if a resident's foot got caught during wheelchair locomotion and the resident tumbled out of the wheelchair, staff would call for help, close off the area and wait for assistance. CNA O also stated that residents should never be transported in the hallways in the shower chairs, only in the resident's wheelchairs. On 10/22/25 at 10:20 AM, LN I stated that if a resident's feet became entangled with a wheelchair that caused the resident to fall, staff should encourage the resident to not move and staff would summon assistance from other staff utilizing the two-way radio and close any applicable doors to protect privacy and dignity. LN I stated that the facility did have some obese residents whose wheelchairs will not fit into the shower room, so it was then acceptable to transport residents in a shower chair down the hallways if they were completely covered to provide privacy.On 10/22/25 at 10:40 AM, Administrative Nurse D stated that unless the resident has interventions care planned to the contrary, all residents should be transported to and from the shower room in their wheelchair and then be transferred into the shower in the shower room.On 10/22/25 at 11:00 AM during an interview with Administrative Staff A, Consultant GG and Administrative Nurse F, Administrative Staff A and Administrative Nurse F revealed that the facility contained three bariatric (associated with obesity) residents whose wheelchairs would not fit into the existing shower room door. The facility obtained verbal consent from those residents to transport them to and from the shower room in a shower chair. Consultant GG stated residents should be transported to and from the shower room in their wheelchairs and then transferred into the shower chairs. Consultant GG stated shower chairs were not intended for longer distance transfers. Consultant GG and Administrative Staff A stated the facility had two shower rooms and one was currently under construction to accommodate the larger wheelchairs. Consultant GG suggested to Administrative Staff A and Administrative Nurse F for residents to be transported to the door to the shower room, staff would set up privacy screens then utilize mechanical lifts to lift the residents then pull the resident [and the lift] inside the shower area to transfer to the shower chairs. The facility's Accidents and Incidents - Incident Reporting F 689 policy, dated 05/2025 did not address transportation of residents in shower chairs. The facility's F 689 Accidents policy, dated 10/2025 documented the facility strived to make an environment as free from accident hazards as possible. Safety, supervision and assistance to prevent accidents were a facility-wide priority. The policy did not address the use of shower chairs.The facility's Shower/Tub Bath policy dated 10/2024 documented instructions and steps for staff to perform showers that included instructions for staff to place a robe and slippers on the resident then assist the resident into the bath chair, if applicable, and cover the resident from the neck down with a bath blanket then transport the resident to the bath area. After the completion of the bath or shower was completed, staff would assist the resident back into his or her robe and slippers, cover the resident from the neck down with a bath blanket and transport the resident back to his or her room and ensure the resident's feet did not drag on the floor. All corrective actions were completed prior to the onsite survey therefore the deficient practice was deemed past noncompliance and remained at the scope and severity of G (actual harm, isolated).

The facility identified a census of 42 residents with three residents reviewed for code status. Based on interviews and record review, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 1, who desired resuscitative measures indicated by her full code status. At 05:20 PM on [DATE] Licensed Nurse (LN) G left R1's room to obtain a breathing treatment for R1. Before she could return to the room, Certified Medication Aide (CMA) R told LN G that R1's spouse reported R1 was unresponsive. LN G assessed R1 and noted a weak apical pulse. LN G asked R1's spouse if he wanted staff to start CPR and R1's non-DPOA spouse nodded and confirmed that was what R1 wanted. R1's spouse then recanted and told staff not to start compressions. At 05:29 PM R1 had no heartbeat but staff did not initiate resuscitative measures despite her full code status. This deficient practice placed R1 and all 22 residents with full code status in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), lymphedema (swelling caused by accumulation of lymph), heart failure congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and hypertension (high blood pressure). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R1 required maximum assistance for toileting, bathing, dressing, bed mobility, and transfer. The MDS documented R1 required continuous oxygen and a non-invasive mechanical ventilator (Trilogy machine - bilevel positive airway pressure BiPAP-medical device which helps with breathing). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documented R1 had orientation, memory, and recall deficits. The care plan would be initiated to improve R1's cognitive status, activity of daily living (ADLs) status, and mobility. The Functional Ability CAA, dated [DATE], documented R1 required assistance with ADLs, had impaired balance and transition during transfers, and functional impairment in activity. R1's care plan would be initiated to improve her current ADL status and functional abilities. R1's Care Plan, dated [DATE], documented R1 requested that CPR measures be performed and R1 was a full code. The care plan documented the facility staff would respect R1's wishes and rights to have CPR performed. The care plan directed staff to communicate R1's choice to all appropriate staff members, continue to administer ordered medications and treatments per physician's orders, follow the instructions as detailed in the Advanced Directives and/or Living Will, and initiate CPR when appropriate and continue until paramedics arrive to take over. R1's banner on her EMR page showed R1 was a full code. The Physician's Order, dated [DATE], documented R1 was a full code. The Full-Code Resuscitate Directive, dated [DATE], documented R1 understood that Code meant that if her heart stopped beating or if R1 stopped breathing, medical procedures to restart R1's breathing or heart functioning would be instituted. The request documented R1 understood this decision would not prevent her from obtaining other medical care by care providers or medical care directed by a physician prior to R1's death. The directive documented the code directive would remain in effect while R1 was admitted to a medical care facility or care home as well as during transport to or from a home or facility. The directive was signed by R1 with a witness declaration of the said signage and was signed by the attending physician. The Nursing Progress Note, dated [DATE] at 02:10 AM, documented the nurse entered R1's room to administer her nebulizer treatments and R1 appeared to be short of air and used accessory muscles to breathe. R1's oxygen saturation was 68% on the Trilogy with two liters (L) of oxygen. R1's oxygen was increased to 3L and R1's oxygen saturation increased to 72%. R1's lung sounds had rhonchi (low-pitched continuous lung sounds that are caused by fluid in the respiratory system), crackles (discontinuous and explosive sounds that can be heard in the lungs of someone with respiratory disease when they inhale), and wheezes (a high-pitched whistling or rattling sound that occurs when air moves through narrowed airways in the lungs). Staff notified R1's provider of R1's condition at 09:30 PM and orders were received to send R1 to the emergency room . Staff called Emergency Medical Staff (EMS) at 09:32 PM. At 09:40 PM, EMS arrived at the facility. R1's oxygen saturation had increased to ,d+[DATE]% with the Trilogy using 3L of oxygen. EMS evaluated R1. R1 and her spouse decided not to go to the emergency room . At 09:52 PM, EMS left the facility. At 09:53 PM, staff notified R1's provider of R1's choice not to go to the emergency room . The provider directed the nurse to watch R1 and if R1 changed her mind and wanted to go to the emergency room then she had the order to send. The Nursing Progress Note, dated [DATE] at 08:51 AM, documented R1 struggled with air hunger at 07:00 AM. R1's oxygen saturation fluctuated from 67% to 90% on the Trilogy with respirations between 20 to 24 breaths per minute. The Trilogy foam filter was checked and cleaned. R1 received treatments by mask to help with breathing issues. R1's spouse went home to get new filters for the Trilogy. Staff administered lorazepam (medication to help relieve anxiety) to R1 at 07:45 AM. R1's oxygen saturations stabilized between ,d+[DATE]% with respirations between 14 to 17 breaths per minute. R1 rested easier with the Trilogy machine on. The Nursing Progress Note, dated [DATE] at 07:40 PM, documented R1 had been resting throughout the day with the Trilogy mask except during her respiratory therapy treatments. R1's spouse was by R1's side most of the day. LN G asked R1's spouse if he was okay with R1 resting with her Trilogy here at the facility and informed the spouse this is what the hospital would do for R1 if she was there. R1's spouse was okay with how R1 was being cared for at the facility. At approximately 05:15 PM, LN G went in to check on R1 and see if R1's spouse wanted R1 to do her respiratory therapy treatment that was due and R1's spouse said Okay. R1's oxygen saturation was 85%. LN G left to get R1's respiratory treatments. At approximately 05:20 PM, LN G was headed back to R1's room when CMA R came around the corner and stated R1 was not responding. LN G went back to R1's room and sent CMA R to get a stethoscope so LN G could listen for a heartbeat. R1's heartbeat was very weak. LN G asked R1's spouse if he wanted staff to start chest compressions. R1's spouse said, That is what she wanted. R1's spouse then paused for a moment and stated, No, do not start compressions. LN G clarified with R1's spouse a couple of times. The note documented that compressions were not attempted. Staff notified Administrative Nurse D and R1's provider at approximately 05:29 PM that R1 was without a heartbeat. Staff then notified Administrative Staff A. Physician GG's Physician Progress Note, dated [DATE], documented the provider was notified of R1's death over the weekend. R1 had end-stage cardiac disease as well as end-stage hypoxic (insufficient oxygen) respiratory failure due to severe COPD. R1 had multiple hospitalization s in recent months for exacerbations of her respiratory failure, which indicated R1's prognosis was very poor. Despite aggressive interventions, R1 continued to decline. The provider documented that during R1's final day, R1 deteriorated quickly, and she did not wish to return to the hospital. R1 quickly declined and died . Given R1's end-stage disease and inevitable death that was rapidly approaching, there was no medical indication to perform advanced cardiac life support (ACLS-refers to a set of clinical guidelines established by the American Heart Association for the urgent and emergent treatment of cardiac arrest using advanced medical procedures, medications, and techniques) since there was no probability of changing the inevitability of R1's death on that day. Physician GG documented that performing chest compressions could have indeed caused R1 suffering. The note documented that R1's spouse appropriately requested no chest compressions despite R1's full code status and there was no rationale for performing CPR if R1 did not want to be hospitalized again. Consultant GG noted that per ACLS protocols, it was not appropriate to perform chest compressions when there was no probability of success. The note documented that attention to R1's peaceful passing was the medically appropriate approach. A review of LN G's CPR certification documented LN G had an active basic life support (BLS) CPR certification. On [DATE] at 10:45 AM, Certified Nurse Aide (CNA) M stated there was no physical sign in resident's rooms to distinguish which residents were full code and which residents were do not resuscitate (DNR). CNA M stated staff had to check the resident's EMR to find out the resident's code status. On [DATE] at 11:15 AM CMA R stated R1's spouse came out of R1's room and stopped her and told her R1 was not breathing. CMA R stated she knew R1 was a full code and that was why she got LN G. CMA R stated it happened during supper meal pass and she ran and got the crash cart and stopped the Certified Nurse Aides (CNAs) from delivering meals and told them all hands-on deck in R1's room. CMA R stated she felt really bad for not providing CPR to R1 because it was R1's wish to be a full code. CMA R said she followed the chain of command. On [DATE] at 11:30 AM, LN G stated she asked R1's husband what he wanted LN G to do, start compressions or not. At first, R1's husband said to start compressions and then he told her to not start compressions. LN G stated she verified with R1's husband several times he did not want staff to start compressions, so staff did not start compressions. On [DATE] at 11:00 AM, Administrative Nurse D stated that she expected the staff at the facility to follow the resident's code status if a resident was found unresponsive. Administrative Nurse D stated CPR was not initiated on R1 because her husband said not to start compressions and LN G tried to keep her comfortable during the dying process. Administrative Nurse D stated R1 did not want to go to the hospital the previous night when she was having breathing difficulty. Administrative Nurse D stated there were twenty-two residents out of forty-two residents that were full code. Administrative Nurse D stated the facility had nineteen staff at the facility who were CPR-certified, and the scheduler always made sure CPR-certified staff were on shift. The facility's Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) Policy, revised ,d+[DATE], documented that the community staff, certified in CPR, will provide basic life support, including CPR, to a resident requiring such an emergency prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives. Staff certified in CPR will be available 24 hours a day. This is posted in the community. Verify the presence of advanced directives regarding CPR upon admission per policy. If the CPR order is missing or the resident's wishes are different from the admission order, notify the physician immediately to update such order and document it in the medical record. If CPR is to be withheld, or awaiting the physician's order, document discussions with the resident or their representative, including as needed the wish to withhold CPR. Verbal declination of CPR by the resident or representative should be witnessed by two staff members or per state directives. While waiting on a change in a physician's order, the current order will be honored. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or There are obvious signs of irreversible death (e.g., rigor mortis, lividity) then initiate CPR. On [DATE] at 12:58 PM, Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed the facility failure to ensure staff provided CPR to R1, who desired resuscitative measures indicated by her full code status, placed R1 and all 22 residents with full code status in immediate jeopardy. The facility submitted an acceptable plan to remove the immediacy on [DATE] at 03:26 PM which included the following corrective actions: Current nursing staff were re-educated on initiating the current code status. When a resident is declining, review the code status with the resident and/or DPOA and if changes are desired, notify the provider. Educated current nurses to initiate advance directives as ordered until new orders are obtained from the provider. Current residents were audited and updated as needed for desired code status. Current residents' code statuses were audited for validation of code status. On [DATE], an onsite survey verified the facility completed the above corrective actions to remove immediacy. The deficient practice remained at a scope and severity of G.

The facility had a census of 42 residents. Based on observation, record review, and interview the facility failed to store food in a safe and sanitary manner and failed to adequately sanitize dishes for the 42 residents that resided in the facility and received meals from the kitchen. This placed the residents at risk for foodborne illness. Findings Included: - On 04/09/24 at 08:30 AM, observation during the initial kitchen tour revealed the upright refrigerator-freezer contained the following items in the bottom freezer drawer: One bag of approximately 50 pepperoni circles with an open date of 09/15/23 and an expiration date of 03/15/24. One bag of eight Salisbury steak patties with an open date of 03/18/24 and an expiration date of 03/25/24. On 04/09/24 at 09:00 AM, observation revealed Dietary Staff (DS) DD operated the dishwasher and the wash temperature was at 105 degrees Fahrenheit (F) and the rinse temperature was at 110 degrees F. DS DD ran five loads and the temperature remained at 105 - 110 degrees F. The Dishwasher Temperature Logs, dated April 2024, documented morning, noon, and evening temperatures were 100-110 degrees F. The documented chemical sanitization checks recorded 200 parts per million (the amount of chlorine left over after a process where there is more chlorine than contaminate present.) On 04/09/24 at 08:45 AM, DS BB verified the refrigerator contained outdated food that needed to be discarded. On 04/09/24 at 09:15 AM, DS BB verified the April 2024 Dishwasher Temperature Log recorded the temperatures were 105-110 degrees F. On 04/09/24 at 12:45 PM, Maintenance Staff U verified the kitchen had a separate water heater and it was set at 120 degrees. He turned it up to 140 degrees after Dietary Staff BB informed him of the low dishwasher temperatures. The facility's Food Safety Requirements, policy, dated October 2024, documented that food shall be received and stored in a manner that complies with safe food handling practices. The community would procure food from approved sources or those considered satisfactory by federal, state, and local authorities. The policy documented that all foods stored in the refrigerator or freezer would be covered, labeled, and dated. Expiration dates on unopened foods would be observed and use by dates indicated once the food is opened. The facility's Dishwashing Machine Use, policy, dated October 2023, documented that food service staff required to operate the dishwashing machine would be trained in all steps of the dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitization. Staff would record the wash temperature and the rinse parts per million or temperature as applicable) on the appropriate log. Dishwashing machines that use chemicals to sanitize, must maintain a wash temperature of 120 degrees. The facility failed to store food in a safe and sanitary manner and failed to sanitize dishes adequately for the 42 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for foodborne illness.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 42 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 04/09/24 at 08:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 04/09/24 at 08:40 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had three residents with mechanical soft diets and one with a pureed diet who is in the hospital. On 04/11/24 at 02:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The facility's Food Service Staffing dated 10/2024, documented the community will employ sufficient staff with the appropriate competencies and skills to carry out the function of the food and nutrition services. The qualified Dietician would help oversee clinical nutrition and dietary services in the facility. The policy documented that if the Dietician is not full time the community would employ another qualified nutritional professional, to serve as the Dietary Manager. The person a minimum must meet one of the following qualifications: A) A certified Dietary Manager, b) A certified food service manager, c) Have similar certification in food service management and safety from a national certifying body, d) Has an associate or higher degree in food services management or hospitality, if the course study includes food service or restaurant management from an accredited institution or higher degree, e) Has two or more years of experience in the position of dietary manager in a nursing facility setting and has completed a course of study in food safety management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illnesses, sanitization procedures, and food purchasing/receiving; and f) meets the state-established standards if applicable. The Dietary Manager would receive frequently scheduled consultations from a qualified dietician. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 42 residents in the facility. This placed the residents at risk for inadequate nutrition.

The facility reported a census of 39 residents with five residents selected for review for dietary services. Based on interview and record review, the facility failed to provide Resident (R)1, who had a history of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and dysphagia (difficulty swallowing), her physician ordered mechanical soft diet with ground meat on [DATE]. On [DATE] R1 displayed symptoms of choking and required Emergency Medical Services (EMS) transport for treatment. EMS discovered the presence of food in R1's airway and R1 went into respiratory distress while in the transport vehicle, and a small amount of meat passed from the side of her vocal cords and more meat came forth from her esophagus during compressions. EMS transported R1 to the hospital where she admitted on [DATE] and expired on [DATE] following removal of ventilation per family request. Failure of the facility to provide the physician ordered ground meat diet resulted in R1 choking and later died and placed in the resident in immediate jeopardy. Additionally, the facility placed R2 and R3 at risk, after recently returning from hospitalization and the facility failed to change/clarify the new diet order with the physician. Findings included: - The hospital Nursing Home Admission Orders dated [DATE] for R1 included diagnoses of pneumonia (inflammation of the lungs) and respiratory failure, she had admitted to the hospital on [DATE], and ordered a regular diet. The Medical Diagnosis tab located in the electronic medical record (EMR) for R1 included but was not limited to diagnoses of pneumonia, acute respiratory failure with hypoxia (inadequate supply of oxygen), Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure, anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, dysphagia (swallowing difficulty) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis of one side of the body) affecting left nondominant side, and schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought] and mood disorder [any of several psychological disorders characterized by abnormalities of emotional state]). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R1 had physical behaviors one to three days of the assessment period and verbal and other behavioral symptoms four to six days of the assessment period. R1 did not reject care. She required supervision and setup assistance for eating, had range of motion impairment to one side of the upper extremities, received a mechanically altered diet, and did not display signs and symptoms of a swallowing disorder. R1 required oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Annual MDS dated [DATE] assessed R1 with a BIMS score of 12 indicating moderately impaired cognition. R1 did not have any physical behavior symptoms or rejection of care and continued to have verbal and other behavior symptoms four to six days of the assessment period. She continued to have limited range of motion to one side of her upper extremities and required limited assistance of one staff for eating. She had signs of swallowing disorder of coughing and choking during meals or when swallowing medications and continued to have a mechanically altered diet. She continued to require oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Nutritional Status Care Area Assessment (CAA) dated [DATE] revealed R1 required a mechanical soft diet and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Care CAA dated [DATE] revealed R1 had broken teeth and the care plan would be reviewed to maintain her chewing and swallowing ability. The Care Plan dated [DATE] revealed R1 had multiple broken and missing teeth, preferred to eat in the dining room for meals, required oxygen, had a contracture to her left hand, and could feed herself. Her behaviors of banging items resolved on [DATE]. The Care Plan for R1 lacked interventions regarding signs of a swallowing disorder, dysphagia, risk for aspiration, or a mechanically altered diet. The Order tab for R1 revealed an order dated for [DATE] for regular diet, mechanical soft, chopped meat texture (discontinued on [DATE]) and a new order entered, dated [DATE], for a regular diet, mechanical soft, ground meat texture. The facility failed to ensure the meal Tray Ticket changed on [DATE] to reflect the order to downgrade the consistency of the meat served to R1, from chopped to ground. The Tray Ticket for R1's evening/supper meal dated [DATE] (24 days after the order to change to ground meat) revealed a diet order of regular, mechanical soft, with chopped meat. The Nursing Note dated [DATE] at 08:40 PM by Administrative Nurse D revealed she was called to the dining hall because R1 was having difficulty breathing. Administrative Nurse D noted when arrived, R1 had a grey color to her face, and she was cold and clammy. Administrative Nurse D checked R1's oxygen tank and noted it was on 3 liters, and found R1's oxygen saturation level measured at36%, her pulse was 136 beats per minute, respirations at 21 breaths per minute, and blood pressure was ,d+[DATE] millimeters of mercury (mmHg). The staff connected R1's oxygen to a concentrator and her oxygen level did not come up. Around 05:25 PM, staff called 911 and EMS arrived at 05:40 PM. When EMS checked R1's oxygen level, it was 55%. The EMS staff, Certified Nurse Aides (CNAs), and Administrative Nurse D moved R1 from the wheelchair to the stretcher. The note lacked any other assessment or interventions performed by the Administrative Nurse or other staff in the facility. The EMS Patient Care Report for service date of [DATE] for R1 revealed EMS received a call from the facility at 05:35 PM regarding a female with a breathing problem, not responding, and with oxygen saturations in the 40%'s. EMS arrived to the patient at 05:42 PM, and found R1 seated in a wheelchair in the dining hall, held in the seated position by staff members. R1 had a slightly painful response, and her breathing was very shallow and labored at approximately eight breathes per minute. R1 was ashen grey, pale in color, and cold to the touch. The staff advised EMS that R1 was seated at the dinner table and began banging on the table with a knife and residents began yelling for help. R1 was in respiratory distress and not responding and they placed her on her oxygen concentrator and noted no improvement, a rapid decline, and called 911. EMS asked the facility staff if R1 could have choked and if they took measures to possibly correct this and the facilty staff denied this stating, they did not believe she choked and believed it was her COPD. EMS lifted and placed R1 on the EMS cot and ventilated R1 using a bag valve mask (BVM, handheld tool consisting of a self-inflating bag, one-way valve, mask and an oxygen reservoir, used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths) at 15L of oxygen. R1 had improvement in color and her oxygen saturations increased to the high 80's to 90%. The EMS staff opened R1's airway and noted no visible object or foreign body at this time. EMS secured R1 to the cot and into the EMS unit. Once in the unit R1 began to have a clenched jaw and would move one arm upward but had no other response. EMS obtained R1's intravenous (IV, into the vein) access and administered Succinylcholine (medication used to provide a quick onset of skeletal muscle relaxation) for optimal intubation (placement of a breathing tube through the mouth and down the throat into the lungs). When EMS staff placed the King Vision laryngoscope (brand name of device used to look into the throat and larynx, designed to enable quick and easy intubation with a display to provide a view of a patient's airway) they found an obstruction blocking the view of the epiglottis (thin flap of cartilage in the throat which prevents food and drink from entering the trachea [wind pipe] and lungs). The EMS staff could not remove the obstruction with forceps due to lack of room with the King Vision in place, the King Vision removed and BVM ventilation resumed. Direct laryngoscopy then used to visualize the presence of food in R1's airway, and multiple pieces of food were removed from her airway. Due to a large amount of obstruction, EMS cleared some of the food and then ventilated R1. R1 had a decline in pulse, went into respiratory arrest, and then asystole (a heart rhythm indicating lack of a heartbeat) and EMS performed compressions. During compressions, a small piece of meat passed from the other side of R1's vocal cords and EMS removed, and noted more meat came forth from the esophagus which was removed and EMS performed orotracheal suctioning which allowed the vocal cords to be visible. EMS then intubated R1 and noted when they suctioned through the tube, they noted blood and food particles. The EMS departed with R1 at 06:17 PM. The hospital Discharge Summary dated [DATE] revealed R1 choked while eating dinner at the facility and was mechanically ventilated during the course of the stay. She had a poor prognosis and anoxic (lack of oxygen) brain injury. On [DATE] R1 passed away following removal of mechanical ventilation per family request. The facility's investigation dated [DATE] revealed R1's diet was not properly sent over via the electronic medical record system to the tray card and R1's diet continued to show chopped meat diet and she was served chopped meat up until [DATE]. On [DATE] at 01:57 PM Dietary Staff BB stated she prepared R1's meal on [DATE] which was a hot roast beef and cheddar sandwich. Dietary Staff BB stated she had cut her meat up for the sandwich, which she had dripping with the cheese, placed it on the sandwich, and cut the bun in half for R1 so she could eat it better. R1 ate the first sandwich, then wanted another, so Dietary Staff BB fixed her an additional sandwich just like the first one. Dietary Staff BB stated chopped meat would be cut up into bite size pieces using a knife and fork and ground meat would go through a blender. Dietary Staff BB stated she served R1 the diet that her tray ticket had on it. Dietary Staff BB stated the tray tickets have the diet order at the top of the ticket and the dietary manager prints out the tickets. If a diet order changed, she would was alerted by a group chat, in writing from nursing by a sheet they fill out and give to the kitchen, and a communication board in the kitchen. The dietary manager would ensure the tray ticket had the new order and if she was not there when the order was received, then the kitchen staff would write the new order on the tray ticket. On [DATE] at 02:36 PM Consultant Staff GG stated R1 had been diagnosed when in the hospital in May with aspiration pneumonia. Consultant Staff GG stated R1 admitted to the facility from the hospital on [DATE] on a regular diet and the facility was proactive and downgraded the diet on [DATE], she had been on a chopped diet prior. Consultant Staff GG stated when a new diet order was put in the EMR it triggered to the tray ticket program and the new order for R1 on [DATE] did not trigger and she remained on a chopped meat diet as the regular diet order when she returned on [DATE] did not get changed. Consultant Staff GG stated the regional dietician looked and there was a glitch in the system. Consultant Staff GG stated the dietary manager was alerted also with a diet communication form with changes in orders. On [DATE] at 03:22 PM Administrative Nurse D stated R1 came in for dinner and sat in the middle of the dining room. Certified Medication Aide (CMA) R came to her and said R1 was having difficulty breathing, so she went to the dining room and saw R1 seated upright and breathing rapidly. Administrative Nurse D stated there were issues in the past where R1 took her oxygen off, however it was in place and when she checked her oxygen saturation level it was 36%. R1 had a grayish color to her face, her lips were a little blue, and her pulse was 136 beats per minute. Administrative Nurse D checked R1's oxygen tank and noted it was close to red (indicating approaching empty), and she turned it up from three to five liters and hollered for an aide to go get an oxygen concentrator. The aide was not moving fast enough so Administrative Nurse D told another aide to run and get one. Administrative Nurse D stated she was stroking R1's face and telling her to calm down, as R1 gets very high anxiety. R1's oxygen saturation increased to 46% and her pulse decreased to 99 beats per minute, and when asking her questions, she would respond with her eyes or move her head but would not talk. Administrative Nurse D stated she called 911 and told them she was a full code (indicating if her heart stopped beating, she wanted cardiopulmonary resuscitation [CPR] to be performed) and they needed to get to the facility now. Administrative Nurse D stated it took EMS about 12 minutes to arrive, R1 was still breathing and was basically calming down at that point. When EMS arrived and they put their pulse oximeter on her, her oxygen saturation level was 55%. Administrative Nurse D stated herself, two EMS personnel, and a facility aide moved R1 to the stretcher. Administrative Nurse D stated R1 was flat on the stretcher and EMS placed the BVM on her and then took R1 out of the facility. Administrative Nurse D stated R1's family came in the next day and was told by hospital staff R1 was choking and wanted to know why she was told R1 was having respiratory issues. Administrative Nurse D stated she went over the events and at no time was R1 choking, she never put her hands up to her neck, and kept them at her side the whole time. Administrative Nurse D stated it was common for R1 to complain she could not breathe and did not say that or any other words when with her in the dining room, she would just shake her head to respond and make contact with her eyes. Administrative Nurse D stated she felt R1's anxiety was so high the time that is why she did not talk. [DATE] 10:38 AM Administrative Nurse E stated she entered the order for R1 in the EMR on [DATE] for the ground meat diet and the process was to notify the kitchen with orders. Administrative Nurse E stated they discussed R1's diet in a clinical meeting, she had been asked to get an order to downgrade the diet, assumed dietary knew of the change, and she did not communicate the order to the dietary department. On [DATE] at 12:12 PM Dietary Staff CC stated before [DATE] the process for new diet orders was a new diet sheet would be presented to the kitchen or herself. If the tray tickets were printed, then she let the dietary staff know of the change and remake the ticket. Dietary Staff CC stated if she was not there when the diet changed, then the dietary staff were to write the change on the ticket and write on the communication board in the kitchen. Dietary Staff CC stated she had checked for R1's diet change form and did not have any for her when she looked back to [DATE] and did not receive a form for when the diet changed to ground meat on [DATE]. On [DATE] at 12:50 PM Administrative Staff A stated she expected the nursing staff to notify the kitchen when there were diet order changes. The facility policy Interdepartmental Notification of Diet [Including Changes and Reports]) dated [DATE] revealed nursing services shall notify the Food Service Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. When a new resident admitted , or a diet changed, the Nurse Supervisor shall ensure the Food Services Department receives a written notice of the diet order. The Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. The facility failed to ensure staff served the appropriate diet to R1 to prevent choking on [DATE], and death of R1. The facility failed to notify the dietary department of a physician ordered diet of ground meat on [DATE] and served R1 a chopped meat diet from that time until [DATE]. On [DATE] at 04:35 PM Administrative Staff A was informed of the immediate jeopardy and was provided the Immediate Jeopardy Template for failure to notify the dietary staff of physician ordered diet change for R1 and failure to serve the correct diet to R1, who subsequently choked. The facility provided a plan of removal of the immediacy on [DATE] at 04:56 PM, which included the following corrective measures to completed by [DATE] at 10:00 PM. 1. On [DATE] an audit completed of current resident's diet orders in the electronic health record to tray card system and providers most recent diet order to ensure accuracy of diets. 2. The following reeducation initiated and completed with current nursing and dietary staff: a. Initiated on [DATE]: reeducation to Licensed nursing staff on the following topics: Diet orders to be reviewed and implemented with new admissions through communication via the electronic health record and completion of the diet communication tool. Readmissions are to have their orders discontinued upon discharge and new diet orders compared diet prior to discharge for any discrepancies. Any discrepancies found will be addressed upon admission with their provider. Completed via electronic messaging ([NAME] system) on [DATE] at 08:54 PM. All signatures were obtained by [DATE] at 05:00 PM. b. Initiated on [DATE]: Reeducation of topic a above to Licensed nursing staff completed on [DATE] at 10:00 PM. c. Initiated on [DATE]: reeducation to current nursing staff and dietary on the following topics: Reviewing meal ticket tray cards to ensure accuracy prior to reaching resident. Meal ticket tray cards are to remain with resident during the consumption of their meal. This was completed on [DATE] at 10:00 PM. d. On [DATE]: initiated a test to current nursing and dietary to assess knowledge and understanding of the reeducation. This was completed on [DATE] at 10:00 PM. e. For staff that were unable to complete sections b through d above have been notified that they will not return to work until completion of the reeducation and test. 3. Compliance will be monitored by IDT through the following: b. DON/Designee will audit current residents for any new or changed diet orders during morning clinical meeting. c. DON/Designee will audit that nursing is ensured communication to the dietary department via the diet communication tool with new admits and readmits. d. Dietary manager will audit current residents' diets on the tray card software for any discrepancies during morning clinical meeting. The surveyor verified the implementation of the above corrective actions onsite on [DATE] at 08:30 AM and the deficient practice remained at a G scope and severity. - The Medical Diagnosis tab located in the electronic medical record (EMR) for R2 included diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), altered mental status, acute and chronic respiratory failure, and pneumonia (inflammation of the lungs). The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. R2 did not reject care, had no signs or symptoms of a swallowing disorder, required a therapeutic diet but not a mechanically altered diet, and required oxygen. R2 did not require speech therapy or restorative nursing services for eating/swallowing. The Nutritional Status Care Area Assessment (CAA) dated [DATE] revealed R2 was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Status CAA dated [DATE] revealed R2 was edentulous (lacking natural teeth) with full upper and lower dentures and the care plan would be reviewed to maintain chewing and swallowing ability. The Quarterly MDS dated [DATE] assessed R2 with a BIMS score of 14, indicating intact cognition and she continued to not reject care. She had no signs or symptoms of a swallowing impairment, did not require a mechanically altered diet, speech therapy services, or restorative nursing services for eating/swallowing. R2 required a therapeutic diet and oxygen. The MDS tab revealed R2 discharged with return anticipated on [DATE] and re-entered the facility on [DATE]. The Care Plan dated [DATE] revealed R2's dentures were lost while in the hospital and had been replaced on [DATE]. An additional intervention dated [DATE] was to serve the diet as ordered. The hospital Nursing Home Admission Orders dated [DATE] included a diet order of regular, renal diet and Juven (nutritional supplement) or renal house supplement with all meals. R2 had orders for speech therapy and diagnoses included acute/chronic respiratory failure, bilateral (both) pleural effusions (abnormal accumulation of fluid in the lungs), COPD, and end stage renal disease. The facility diet Order Listing Report dated [DATE] revealed two active diet orders for R2. On [DATE] an order for mechanical soft ground meat texture with extra gravy/house supplement with all meals and on [DATE] a regular texture diet. The Tray Ticket for R2 dated [DATE] at lunch time revealed a carbohydrate controlled, renal, mechanical soft, ground meat diet, and no added sodium. On [DATE] at 12:30 PM, staff served R2 a meal of two corn dogs and potato chips. On [DATE] at 12:31 PM, R2 stated she ordered the corn dogs and potato chips for lunch. On [DATE] at 01:07 PM R2 stated she did not have any problems swallowing and that her meat had to be ground up, however, she did okay with hot dogs. R2 stated she could eat potato chips but was not supposed to because she was on dialysis. R2 stated the facility provides her the right diet according to her physician orders unless she asks for something different. On [DATE] at 02:01 PM, Dietary Staff BB stated the tray tickets have the diet order at the top of the ticket and the dietary manager would print out the tickets. Dietary Staff BB stated if there was a change to a diet order, she would be alerted by a group chat, in writing by nursing by a sheet they fill out and give to the kitchen, and a communication board in the kitchen. The dietary manager would ensure the tray ticket had the new order and if she was not there when the order received, then the kitchen staff would write the new order on the tray ticket. Dietary Staff BB stated she worked on [DATE], [DATE], [DATE], and today ([DATE]) and was not aware of the new order. Dietary Staff BB stated she did not serve her potato chips but seen R2 had some and they were not mechanical soft however R2 would ask for them. Dietary Staff BB stated if she prepared R2's meal, she would have removed the corn dogs from the stick and cut them up for her. On [DATE] at 04:41 PM, Consultant Staff GG stated R2 readmitted on [DATE] with a regular diet, her previous diet was for chopped meat. The old diet had not been discontinued in the orders. On [DATE] at 12:29 PM Dietary Staff CC stated R2's diet order came in Friday ([DATE]) and did not get communicated to the kitchen. Dietary Staff CC stated she was home on [DATE] and noticed the order and told the staff to have the order changed by supper, and that she had spoken to one of the staff about the diet order before that. Dietary Staff CC stated R2 had two diets under her orders due to the previous order not getting discontinued in the EMR. Dietary Staff CC stated the nursing staff did not provide notification to the kitchen regarding the diet change. On [DATE] at 12:50 PM, Administrative Staff A stated she expected the nursing staff to notify the kitchen when there were diet order changes. The facility policy Interdepartmental Notification of Diet [Including Changes and Reports]) dated [DATE] revealed nursing services shall notify the Food Service Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. When a new resident admitted , or a diet changed, the Nurse Supervisor shall ensure the Food Services Department receives a written notice of the diet order. The Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. The facility failed to ensure the new diet order for R2 had been communicated to the kitchen when the order changed on [DATE]. - The hospital Nursing Home Admission Orders dated [DATE] for R3 included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS) dated [DATE] assessed R3 with a Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition. R3 had coughing/choking during meals or when swallowing medications, complained of pain with swallowing, and was on a mechanically altered diet. The Nutritional Status Care Area Assessment (CAA) dated [DATE] revealed R3 had swallowing issues, a mechanically altered diet, and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Care CAA dated [DATE] revealed R3 had broken teeth and the care plan would be initiated to maintain chewing and swallowing ability. The Quarterly MDS dated [DATE] assessed R3 with a BIMS score of 15 indicating intact cognition, she had no signs and symptoms of a swallowing disorder and was on a mechanically altered diet. The MDS tab revealed R3 discharged from the facility on [DATE] and returned on [DATE]. The Care Plan dated [DATE] for R3 revealed a regular, mechanical soft, chopped meat texture diet. The staff were to ensure R3's food was appropriately prepared to provide safe intake of food and drinks. The hospital Nursing Home Admission Orders dated [DATE] for R3 revealed a diet order for staff to provide regular consistency foods/drinks and an order for speech therapy to evaluate and treat. The facility Order Listing Report dated [DATE] revealed a diet order for R3 dated [DATE] for mechanical soft consistency and ground meat texture with gravy/sauce. The facility failed to update or clarify the change in diet order with the resident's physician or dietician upon return from the hospital. The lunch Tray Ticket dated [DATE] for R3 revealed a mechanical soft, ground meat diet. On [DATE] at 12:33 PM R3 sat on the side of her bed with an overbed table in front of her and her lunch on the table. R3 had goulash, green beans, and a popsicle. On [DATE] at 12:35 PM R3 denied having any problems swallowing and stated she would get ground meat if needs to be. On [DATE] at 02:01 PM Dietary Staff BB stated the tray tickets have the diet order at the top of the ticket and the dietary manager prints out the tickets. Dietary Staff BB stated if there was a change to a diet order, she would be alerted by a group chat, in writing from nursing by a designated sheet they filled out and gave to the kitchen, and/or a communication board located in the kitchen. The dietary manager would ensure the tray ticket had the new order and if she was not there when staff received the order, the kitchen staff would write the new order on the tray ticket. On [DATE] at 03:22 PM Administrative Nurse D stated the facility had a diet communication sheet they filled out to communicate a new diet order. When staff put a new diet order in the EMR, it went to the dietary tray ticket program and the dietary manager would update the tray ticket. On [DATE] at 12:33 PM Dietary Staff CC stated R3 returned with a regular diet order and from what she understood her orders were just found today (six days after returning to the facility). Dietary Staff CC stated R3 received chopped meat since she came back from the hospital (prior orders were for ground meat). Dietary Staff CC stated the facility came up with a new system today for new admissions or readmissions noting the nurse would start the orders and the unit managers would check the orders to make sure they were correct and delivered to where they needed to be. Dietary Staff CC stated sometimes when residents went to the hospital the diet order was left in the EMR and did not get changed when the resident came back to the facility. Dietary CC stated the facility would start discontinuing all diets and medication orders when a resident went out. On [DATE] at 12:50 PM Administrative Staff S stated the diet order in the EMR was her order on admission and the order did not get upgraded. Administrative Staff S stated she expected the nursing staff to notify the kitchen when there were diet order changes. The facility policy Interdepartmental Notification of Diet [Including Changes and Reports]) dated [DATE] revealed nursing services shall notify the Food Service Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. When a new resident admitted , or a diet changed, the Nurse Supervisor shall ensure the Food Services Department receives a written notice of the diet order. The Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. The facility failed to ensure staff communicated a new diet order for R3 to the kitchen when her diet order changed on [DATE].

The facility identified a census of 39 residents with five selected for review. Based on interview and record review, the facility failed to ensure competent nursing staff implemented interventions for choking Resident (R)1. On [DATE], R1 sat at the table during supper and exhibited signs of choking. The staff alerted the Licensed Nurse that R1 was not breathing right. When the Licensed Nurse responded, R1 was grayish in color with blue lips, her oxygen saturation level was 36%, and she was breathing rapidly. The Licensed Nurse increased R1's oxygen from three to five liters and called 911. The Licensed Nurse failed to implement any interventions to address R1's choking. While in the EMS (Emergency Medical Service) transport vehicle, EMS staff discovered the presence of food in R1's airway and removed multiple pieces. R1 went into respiratory arrest and during compressions, a small amount of meat passed from the side of her vocal cords, and more meat came forth from her esophagus. R1 admitted to the hospital on [DATE], required intubation, and expired on [DATE] following removal of ventilation, per family request. The lack of competent nursing staff to implement interventions to address the signs of R1's choking, placed R1 in immediate jeopardy. Findings included: - The hospital Nursing Home Admission Orders dated [DATE] for R1 included diagnoses of pneumonia (inflammation of the lungs) and respiratory failure and noted R1 admitted to the hospital on [DATE]. The Medical Diagnosis tab located in the Electronic Medical Record (EMR) for R1 included diagnoses of pneumonia, acute respiratory failure with hypoxia (inadequate supply of oxygen), Chronic Obstructive Pulmonary Disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure, anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, dysphagia (swallowing difficulty) following cerebral infarction (stroke, damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis of one side of the body) affecting left nondominant side, and schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought] and mood disorder [any of several psychological disorders characterized by abnormalities of emotional state]). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R1 had physical behaviors one to three days of the assessment period and verbal and other behavioral symptoms four to six days of the assessment period. R1 did not reject care. She required supervision and setup assistance for eating, had range of motion impairment to one side of the upper extremities, received a mechanically altered diet, and did not display signs and symptoms of a swallowing disorder. R1 required oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Annual MDS dated [DATE] assessed R1 with a BIMS score of 12, indicating moderately impaired cognition. R1 did not have any physical behavior symptoms or rejection of care and continued to have verbal and other behavior symptoms four to six days of the assessment period. She continued to have limited range of motion to one side of her upper extremities and required limited assistance of one staff for eating. She had signs of swallowing disorder of coughing and choking during meals or when swallowing medications and continued to have a mechanically altered diet. She continued to require oxygen and did not require respiratory services, speech therapy, or restorative nursing for eating and/or swallowing. The Nutritional Status Care Area Assessment (CAA) dated [DATE] revealed R1 required a mechanical soft diet and was at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). The Dental Care CAA dated [DATE] revealed R1 had broken teeth and the care plan would be reviewed to maintain her chewing and swallowing ability. The Care Plan dated [DATE] revealed R1 had multiple broken and missing teeth, preferred to eat in the dining room for meals, required oxygen, had a contracture to her left hand, and could feed herself. Her behaviors of banging items resolved on [DATE]. The Care Plan for R1 lacked interventions regarding signs of a swallowing disorder, dysphagia, risk for aspiration, or a mechanically altered diet. The Order tab for R1 revealed an order dated for [DATE] for regular diet, mechanical soft, chopped meat texture (discontinued on [DATE]) and a new order entered, dated [DATE], for a regular diet, mechanical soft, ground meat texture. The facility failed to ensure the meal Tray Ticket changed on [DATE] to reflect the order to downgrade the consistency of the meat served to R1, from chopped to ground. The Tray Ticket for R1's evening/supper meal dated [DATE] (24 days after the order to change to ground meat) revealed a diet order of regular, mechanical soft, with chopped meat. The facility's investigation dated [DATE] revealed R1's diet was not properly sent over via the electronic medical record system to the tray card and R1's diet continued to show chopped meat diet and she was served chopped meat up until [DATE]. The Nursing Note dated [DATE] at 08:40 PM by Administrative Nurse D revealed she was called to the dining hall because R1 was having difficulty breathing. Administrative Nurse D noted when arrived, R1 had a grey color to her face, and she was cold and clammy. Administrative Nurse D checked R1's oxygen tank and noted it was on 3 liters, and found R1's oxygen saturation level measured at 36%, her pulse was 136 beats per minute, respirations at 21 breaths per minute, and blood pressure was ,d+[DATE] millimeters of mercury (mmHg). The staff connected R1's oxygen to a concentrator and her oxygen level did not come up. Around 05:25 PM, staff called 911 and EMS arrived at 05:40 PM. When EMS checked R1's oxygen level, it was 55%. The EMS staff, Certified Nurse Aides (CNAs), and Administrative Nurse D moved R1 from the wheelchair to the stretcher. The note lacked any other assessment or interventions performed by the Administrative Nurse or other staff in the facility. The EMS Patient Care Report for service date of [DATE] for R1 revealed EMS received a call from the facility at 05:35 PM regarding a female with a breathing problem, not responding, and with oxygen saturations in the 40%'s. EMS arrived to the patient at 05:42 PM, and found R1 seated in a wheelchair in the dining hall, held in the seated position by staff members. R1 had a slightly painful response, and her breathing was very shallow and labored at approximately eight breathes per minute. R1 was ashen grey, pale in color, and cold to the touch. The staff advised EMS that R1 was seated at the dinner table and began banging on the table with a knife and residents began yelling for help. R1 was in respiratory distress and not responding and they placed her on her oxygen concentrator and noted no improvement, a rapid decline, and called 911. EMS asked the facility staff if R1 could have choked and if they took measures to possibly correct this and the facility staff denied this stating, they did not believe she choked and believed it was her COPD. EMS lifted and placed R1 on the EMS cot and ventilated R1 using a bag valve mask (BVM, handheld tool consisting of a self-inflating bag, one-way valve, mask, and an oxygen reservoir, used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths) at 15L of oxygen. R1 had improvement in color and her oxygen saturations increased to the high 80's to 90%. The EMS staff opened R1's airway and noted no visible object or foreign body at this time. EMS secured R1 to the cot and into the EMS unit. Once in the unit R1 began to have a clenched jaw and would move one arm upward but had no other response. EMS obtained R1's intravenous (IV, into the vein) access and administered Succinylcholine (medication used to provide a quick onset of skeletal muscle relaxation) for optimal intubation (placement of a breathing tube through the mouth and down the throat into the lungs). When EMS staff placed the King Vision laryngoscope (brand name of device used to look into the throat and larynx, designed to enable quick and easy intubation with a display to provide a view of a patient's airway) they found an obstruction blocking the view of the epiglottis (thin flap of cartilage in the throat which prevents food and drink from entering the trachea [wind pipe] and lungs). The EMS staff could not remove the obstruction with forceps due to lack of room with the King Vision in place, the King Vision removed and BVM ventilation resumed. Direct laryngoscopy then used to visualize the presence of food in R1's airway, and multiple pieces of food were removed from her airway. Due to a large amount of obstruction, EMS cleared some of the food and then ventilated R1. R1 had a decline in pulse, went into respiratory arrest, and then asystole (a heart rhythm indicating lack of a heartbeat) and EMS performed compressions. During compressions, a small piece of meat passed from the other side of R1's vocal cords and EMS removed, and noted more meat came forth from the esophagus which was removed and EMS performed orotracheal suctioning which allowed the vocal cords to be visible. EMS then intubated R1 and noted when they suctioned through the tube, they noted blood and food particles. The EMS departed with R1 at 06:17 PM. The hospital Discharge Summary dated [DATE] revealed R1 choked while eating dinner at the facility and was mechanically ventilated during the stay. She had a poor prognosis and anoxic (lack of oxygen) brain injury. On [DATE] R1 passed away following removal of mechanical ventilation per family request. On [DATE] at 01:04 PM Certified Nurse Aide (CNA) O stated R1 could feed herself and sometimes she would have off days where one of the staff would sit with her and feed her. CNA O stated R1 would cough when in the dining room and if she wanted to eat in her room, then a staff member would have to sit with her. On [DATE] at 01:57 PM Dietary Staff BB stated she prepared R1's meal on [DATE], which was a hot roast beef and cheddar sandwich. Dietary Staff BB stated she had cut her meat up for the sandwich, which she had dripping with the cheese, placed it on the sandwich, and cut the bun in half for R1 so she could eat it better. R1 ate the first sandwich, then wanted another, so Dietary Staff BB fixed her an additional sandwich just like the first one. Dietary Staff BB stated chopped meat would be cut up into bite size pieces using a knife and fork and ground meat would go through a blender. Dietary Staff BB stated she served her the diet that her tray ticket had on it. On [DATE] at 03:22 PM Administrative Nurse D stated R1 came in for dinner and sat in the middle of the dining room. Certified Medication Aide (CMA) R came to her and said R1 was having difficulty breathing, so she went to the dining room and saw R1 seated upright and breathing rapidly. Administrative Nurse D stated there were issues in the past where R1 took her oxygen off, however it was in place and when she checked her oxygen saturation level it was 36%. R1 had a grayish color to her face, her lips were a little blue, and her pulse was 136 beats per minute. Administrative Nurse D checked R1's oxygen tank and noted it was close to red (indicating approaching empty), and she turned it up from three to five liters and hollered for an aide to go get an oxygen concentrator. The aide was not moving fast enough so Administrative Nurse D told another aide to run and get one. Administrative Nurse D stated she was stroking R1's face and telling her to calm down, as R1 gets very high anxiety. R1's oxygen saturation increased to 46% and her pulse decreased to 99 beats per minute, and when asking her questions, she would respond with her eyes or move her head but would not talk. Administrative Nurse D stated she called 911 and told them she was a full code (indicating if her heart stopped beating, she wanted cardiopulmonary resuscitation [CPR] to be performed) and they needed to get to the facility now. Administrative Nurse D stated it took EMS about 12 minutes to arrive, R1 was still breathing and was basically calming down at that point. When EMS arrived and they put their pulse oximeter on her, her oxygen saturation level was 55%. Administrative Nurse D stated herself, two EMS personnel, and a facility aide moved R1 to the stretcher. Administrative Nurse D stated R1 was flat on the stretcher and EMS placed the BVM on her and then took R1 out of the facility. Administrative Nurse D stated R1's family came in the next day and was told by hospital staff R1 was choking and wanted to know why she was told R1 was having respiratory issues. Administrative Nurse D stated she went over the events and at no time was R1 choking, she never put her hands up to her neck, and kept them at her side the whole time. Administrative Nurse D stated it was common for R1 to complain she could not breathe and did not say that or any other words when with her in the dining room, she would just shake her head to respond and make contact with her eyes. Administrative Nurse D stated she felt R1's anxiety was so high the time that is why she did not talk. On [DATE] at 04:15 PM CNA M stated on [DATE] she sat at the table with R1 and she had asked for more chocolate milk, so she got up from the table to get some, and as she was turning around back toward her, R1 began banging her knife on the table. CNA M stated she sat down the milk, patted her on the back, and her color was normal at that time, however she looked like she was choking, looked like she could not hardly breathe, and was gasping for air. CNA M stated CMA R went to go alert the nurse, Administrative Nurse D. Until Administrative Nurse D arrived, R1 was gasping. When Administrative Nurse D arrived, she asked R1 questions and R1 would shake her head, and when asked if she could breathe, she shook her head to indicate no. CNA M stated she did not mention to Administrative Nurse D that she thought R1 was choking, as she was freaking out at the moment and R1's face had turned a little blue in color. On [DATE] at 02:55 PM CNA N stated on [DATE] CMA R went to go talk to R1 to calm her down as she was banging on the table with her knife, she did not see R1 do that, but turned around when she heard it. Her color was normal, and someone went to go get the nurse, then her color started fading to blue, but then would turn back to normal when Administrative Nurse D started talking to her. CNA N stated Administrative Nurse D checked her oxygen saturation level and thought it was in the 30's or 40's percent. CNA N stated Administrative Nurse D got R1 to calm down by the time EMS showed up. CNA N stated R1 kept breathing really heavy and kept eye contact with Administrative Nurse D and when Administrative Nurse D asked R1 if she was choking R1 did not answer. On [DATE] at 03:09 PM CMA R stated on [DATE] when R1 came back inside to the dining room following her smoke break she connected her back up to her oxygen, meanwhile R1 was saying she could not breath, which was normal for her, and she had checked to make sure the oxygen was on and it was. CMA R stated she turned to pass a tray and made eye contact with R1 and noticed she was trying to breathe, like she was trying to get air, making shallow short breaths, sounded like someone choking and she was reddish/grayish/purple in color like someone holding their breathe. CMA R stated she told R1 to spit out her food and she spit out roast beef. CMA R stated she was on her knees looking at R1 and she was still gasping after spitting the food out. Administrative Nurse D would ask her a question and R1 would nod her head in response but did not recall what questions she asked R1. On [DATE] at 03:55 PM Administrative Nurse D stated the staff told her R1 was having respiratory issues and breathing funny and did not tell her they had her spit food out of what was in her mouth. Administrative Nurse D stated she told R1 to calm down and she shook her head yes and asked if she was okay and she shook her head yes, however did not ask R1 if she was choking. On [DATE] at 04:00 PM CMA S stated she was in the kitchen getting herself food and heard banging on the table and seen silverware in R1's hands and CNA M and CMA R was beside her asking if she was okay. CMA S stated Administrative Nurse D arrived at her table and R1 was breathing heavy and not acting normal. CMA S stated Administrative Nurse D asked her to run and get a concentrator and when she got back EMS was called. CMA S stated Administrative Nurse D asked R1 if she was choking and R1 sat there heavily breathing and did not answer or nod her head, and she did not talk at all that she saw. On [DATE] at 04:18 PM Administrative Nurse D stated at no time did she think on [DATE] that R1 was choking, and that R1 was mouth breathing and she did not see any food in her mouth. On [DATE] at 04:44 PM Consultant Nurse GG stated Administrative Nurse D responded appropriately to R1 at the dining room table, however she should have visually assessed her mouth and would not have suctioned her if she did not think R1 was choking. The facility staff should have told Administrative Nurse D they thought she was choking and had her spit food out of her mouth. Consultant Nurse GG stated she believed Administrative Nurse D assessed her appropriately with the expectation R1 was hypoxic and with her low oxygen level would not have expected R1 to have normal color. Consultant Nurse GG stated she believed Administrative Nurse D would have performed the Heimlich if she truly thought R1 was choking. The facility lacked a policy regarding staff measures to be taken for possible choking. The facility failed to ensure competent nursing staff to implement interventions for choking experienced for R1 on [DATE], which placed R1 in immediate jeopardy. On [DATE] at 04:35 PM Administrative Staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to provide interventions for choking experienced by R1. On [DATE] at 10:00 PM the facility completed corrective action of re-education to Licensed Nurse's on airway protection, hypoxemia, signs and symptoms of choking, and how to intervene. The deficient practice was deemed past non-compliance due to the implemented corrective actions prior to the surveyor entrance and the deficient practice existed at a J scope and severity.

The facility reported a census of 43 residents, with seven residents sampled. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 3, at high risk for falls, remained free from neglect. On 05/05/23 a Certified Nurse Aide (CNA) used a mechanical lift to transfer R3 by herself, against facility policy and the Occupational Safety and Health Administration (OSHA) guidelines, which documented the lift required two licensed/certified staff to be present with use. The CNA left the room and left R3 standing up in the lift, holding onto the handles, and suspended by the lift. R3 required oxygen via nasal cannula and the CNA did not check on the oxygen tank level for R3 before leaving the room, which was found empty. As a result of these failures R3 fell and was suspended by just the lift sling, was cyanotic (bluish/purple discoloration to the skin due to lack of oxygen) in the lips and face, and fractured (broke) her humerus (bone of the upper arm). The facility further failed to identify the fracture for seven days despite the resident's complaints of pain. This failure placed the resident in immediate jeopardy. Findings Included: - R3's diagnoses from the Electronic Health Record (EHR) included displaced fracture (traumatic bone break where two ends of the bone separate out of their normal positions) of the upper end of the humerus (bone of the upper arm), diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 04/25/23 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. R3 required extensive assistance of two staff with all activities of daily living (ADL) and R3 used oxygen. The 04/25/23 Falls Care Area Assessment (CAA) documented R3 required assistance with ADL, had impaired balance and transition during transfers, and functional impairment in activity. The 05/15/23 Care Plan documented on 02/23/23 staff were to follow facility fall protocol, and staff were to encourage R3 to participate in activities that promoted exercise for strengthening and improved mobility. On 05/05/23, staff lowered R3 to the floor, after R3 became pale. On 05/11/23 R3 had a fractured right humerus with her arm in a sling, staff were to use a full lift with two staff members for transfers, and staff were to ensure R3 had oxygen in place, during transfers. Staff were to place a nonslip chair pad between the sling and the cushion in the wheelchair. The 03/22/23 Fall Risk assessment documented R3 was a high fall risk. The Progress Note dated 05/05/23 at 01:50 PM Licensed Nurse (LN) D heard a yell I need a nurse and she ran down the hall into R3's room and found her on the floor in between the sit-to-stand lift and the wall. LN D noted R3 was cyanotic (bluish/purple discoloration to the skin due to lack of oxygen) in the lips and face, and R3's lung sounds were clear. CNA E assisted R3 out of the mechanical lift to the floor, R3 did not hit her head. CNA F replaced the oxygen tank, as it was empty. The provider advised staff to monitor R3's oxygen saturations (measure of how much oxygen the blood carried as a percentage of the maximum it could carry) since R3 was put on the concentrator. LN G came into the room and offered an oxygen mask, which was placed on R3. R3 had a bowel movement and was cleaned up and placed into her bed. The Progress Note dated 05/05/23 at 06:31 PM, LN D documented R3 complained of right shoulder pain at an eight out of 10 (on a scale of one to 10, with 10 being the most pain). She obtained vital signs with a low oxygen saturation level of 82%, she educated R3 the oxygen cannula needed to stay in her nose and noted R3 had a low blood pressure. Recheck of R3's oxygen saturation level revealed 93%. LN D gave R3 acetaminophen for the pain. LN D notified the provider of the low blood pressure. The Progress Note dated 05/06/23 at 01:36 PM by LN H documented R3 complained of shoulder discomfort and staff applied analgesic cream to the affected area, per standing orders. The Progress Note dated 05/11/23 at 08:25 AM by LN I documented R3 complained of mild to moderate pain in her right shoulder. The Progress Note dated 05/11/23 at 02:21 AM by LN I documented R3 was transferred by facility transportation to the emergency room . The note included R3 had a fracture of the right shoulder, involving the surgical neck of the humerus. The Witness Statement for the incident on 05/05/23 regarding R3, by Administrative Staff A, documented late afternoon on Wednesday, 05/10/23, they were approached by family of R3. The family member of R3 stated R3's shoulder had been bothering her since the incident with the lift and said R3 was now in pain. Administrative Staff A stated she did not know of an incident with the lift and took R3's family member to the conference room to visit with LN H, LN D, and Administrative Nurse B. Administrative Nurse B confirmed the incident with R3 being lowered to the floor from the wheelchair of R3 by CNA E. Administrative Staff A stated she would let R3's nurse know about the pain and begin an investigation into the incident. The (typed by Social Service Designee (SSD) M) Witness Statement for the incident on 05/05/23 for R3, by R3's family member documented on 05/05/23 he was in R3's room and she pressed her call light. CNA E and Hospitality Aide L went in the room and answered the light. R3 requested to be changed and CNA E put R3 on the sit-to-stand lift. When R3 was in the air, staff noticed no wipes were in the room, and Hospitality Aide L left to find wipes; he did not come back. CNA E said I need wipes, I will be back while CNA E left R3 in the lift, and did not lower her down to the chair. R3's oxygen tank was running out during this process instead of switching R3 to the concentrator. R3 collapsed to a hanging position. CNA E entered the room with no wipes, saw what happened to R3, and lowered R3 to the floor with the sit-to-stand lift. At that point CNA E hollered for the nurse, and the medical team came in and assisted throughout the process of getting R3 up and in the chair. The nurse checked R3's blood sugar due to her thinking it was that [low blood sugar] which caused her to collapse. Once they found the blood sugar was okay, the staff checked her oxygen which was low. The nurse gave R3 oxygen to help regulate her stats. The (typed by SSD) Witness Statement for the incident on 05/05/23, revealed R3 stated she did not remember a lot of the events that occurred because her oxygen was out. R3 stated the last thing she remembered was she fell out of the sling while utilizing the sit-to-stand lift. The Witness Statement for the incident on 05/05/23, for R3 by CNA E, documented she and Hospitality Aide L went into R3's room. CNA E got R3 hooked up to the sit-to-stand and stood her up. CNA E noticed there were no wipes, she asked Hospitality Aide L to go get some. Hospitality Aide L took too long because he could not find any, so CNA E left the room, and ran to get some. When CNA E returned R3 was pale and non-responsive, so CNA E slowly lowered her to the ground and screamed for the nurse. They came in and figured out it was her oxygen. R3's oxygen raised, staff cleaned her up, and got her back in bed. The Witness Statement for the incident on 05/05/23 for R3, by Hospitality Aide L, documented he and CNA E helped R3 get changed and CNA E had me go get wipes while R3 was on the lift. Hospitality Aide L documented he had trouble finding them, so it took a while, and when he returned there were a bunch of people in R3's room and he guessed she fell when he was gone. The Witness Statement for the incident on 05/05/23 for R3, by LN D, documented LN D heard a yell need a nurse and ran down the hall into R3's room. LN D found R3 her on the floor in between the sit-to-stand (lift) and the wall. LN D grabbed vital signs. R3 was cyanotic in the lips and face, and her lungs were clear. CNA E found R3 and assisted her to the floor, out of the sit-to-stand. R3 did not hit her head according to R3 and R3's family member. CMA K followed LN D into the room and recorded vital signs. CNA F showed up to help, replaced the (oxygen) tank on back of R3's wheelchair, as it was empty. Took R3 off of the oxygen tank and put her on her oxygen concentrator. Administrative Nurse B and LN H came in to assist. Administrative Nurse B phoned the provider for notification of the incident, and LN D took the phone and stepped out of the room. The provider advised to monitor R3. LN G came in and asked if we wanted an oxygen mask, so she provided one. Staff rechecked R3's vital signs, R3 had a bowel movement and was cleaned, and moved into bed. R3 was resting comfortably with call light in reach. The Witness Statement for the incident on 05/05/23 for R3, by CNA F, documented R3 asked to be changed after CNA F was done with lunch trays. CNA F charted while waiting for staff (CNA E) to help. CNA E and Hospitality Aide L went to R3's room. Hospitality Aide L came out looking for wipes, and none were at the nurse's station, she he went to the south side. CNA E came out, so CNA F went to find some wipes in the bath house, and CNA E ran back to R3's room. When she got back, she yelled for a nurse and lowered R3 to the floor due to no oxygen and R3 was turning blue. The nurses ran to help and got R3's breathing back and staff cleaned her and put her back to bed, to be watched. The Witness Statement for the incident on 05/05/23, for R3 by CMA K, documented she had just got back from her lunch break and was talking with the north unit manager, LN D, when she started hearing yelling coming from the hall. CNA E yelled from R3's room. LN D and CMA K went into the room to see what happened. When she arrived to R3's room she saw R3 lying on the floor, her skin was pale, the sit-to-stand lift was by her feet, and sling was down by her feet. LN D assessed R3, checked her blood sugar, blood pressure, and vitals. CMA K went over by the wheelchair and noticed the oxygen tank was empty. CMA K ran to get a new tank. LN D continued to assess R3. CMA K recorded the vital signs and time for LN D, noted an oxygen mask placed on R3, and CNA E, LN D, and CMA K put R3 in bed. The Witness Statement for the incident on 05/05/23 for R3, by Administrative Nurse B, documented at approximately 01:50 PM several staff at R3's room. Administrative Nurse B went to R3's room and saw R3 lying on the floor, incontinent of bowel. LN D assessed R3, and CNA E was with R3. Administrative Nurse B called the provider at 01:55 PM to advise of condition and orders. R3 was responsive while she was present in the room. CNA E explained she had her up in the sit-to-stand (lift), needed wipes, and left the room. CNA E came back and R3's condition was deteriorating. They asked CNA E if R3 fell , and CNA E reported no. Administrative Nurse B understood R3 was in the wheelchair when the episode occurred. Staff asked R3 if she hurt anywhere, and she denied pain. CNA E and Administrative Nurse B cleaned her up, R3 denied pain while moving her. Staff retrieved a pillow for under R3's head and rolled blankets for under her knees for comfort. R3 was encouraged to take deep breaths while having oxygen mask on at three liters per minute (L/min). While Administrative Nurse B was in the room R3's oxygen saturation fluctuated between 85% and 87%. R3's family member was in the room during the incident and had no verbal communication with staff, he sat in the recliner with his arms crossed. Staff had to work around him to care for R3. The Witness Statement for the incident on 05/05/23 for R3, by LN H, documented at the time she was notified she was in the conference room completing clinical. LN H rushed to the room, when she arrived R3 was on the floor, several staff were with R3, so she felt she was not needed so she exited the room. The Witness Statement for the incident on 05/05/23 for R3, by Administrative Staff N, documented they assisted with investigation regarding R3, phone call was made to CNA E. CNA E verbalized acknowledgement of the incident, while Administrative Staff N inquired of the lowering of R3 with the sit-to-stand lift, CNA E stated she came back to R3's room, found her in her wheelchair, still attached with the sling to the lift. CNA E stated R3 was unresponsive so CNA E bear hugged R3 and lowered her to the ground. This statement did not match what was reported to any nursing staff or her witness statement. The facility and supervisory determination made to terminate employment agreement due to not following the care plan, or company policy. The 05/16/23 Physician Orders lacked documentation of an order for acetaminophen or bio freeze ointment. On 06/15/23 at 02:05 PM, R3 was in bed with the head of the bed elevated, oxygen cannula in her nose, running at three liters per minute (L/min). R3 was alert and awake and wore an immobilizer on her right arm. On 06/15/23 at 02:05 PM, R3 revealed she remembered the fall and stated she had called for assistance with changing. CNA E came in and got her on the mechanical lift and had a hospitality aide with her. CNA E noticed there were no wipes, so she sent the hospitality aide out to get some. When he did not return, CNA E went out of the room, and left R3 hooked to the mechanical lift, to get the wipes. R3 revealed all she really remembered was coming too and her head was close to the radiator. On 06/15/23 at 02:05 PM, R3's family member revealed he was there in the room when CNA E entered alone and called for the hospitality aides assistance. R3's family member stated the hospitality aide left to get supplies, and then CNA E left. He stated R3 lost consciousness because she ran out of oxygen in the tank. R3 fell and broke her arm, she told them she was in pain, and her shoulder hurt. The staff gave her acetaminophen one time, a cream one time, and then they started ignoring it. They finally got an x-ray, and it was broken, and she had to go the hospital. On 06/19/23 at 03:26 PM, Administrative Nurse B revealed she and LN D went into R3's room and she was lying on the floor, she had been incontinent of bowel. LN D took care of assessing and the oxygen. Administrative Nurse B and CNA E cleaned R3 up, R3's family member sat in the recliner with no expression on his face, and staff had to basically crawl over him to assist R3. Administrative Nurse B revealed R3 had no complaints of pain and was stable, so the provider told them to get R3 up. Administrative Nurse B revealed there were no reports to her of pain in the following days. Administrative Nurse B revealed she expected all staff to know and follow the guidelines of two staff assistance with the use of a mechanical lift. Administrative Nurse B stated the facility terminated employment of CNA E, they educated all nursing staff on having two certified and/or licensed staff present with the use of a mechanical lift, and the facility nursing management team was auditing all lift usage weekly. On 06/20/23 at 09:06 AM, Certified Medication Aide (CMA) K revealed on 05/05/23 she had just finished lunch and was sitting in the unit managers office. They heard CNA E yelling, so they went down the hall following the sound to R3's room. R3 was on the floor and other staff were cleaning her up. CMA K kept record of what the nurse was doing. CMA K noticed the oxygen tank was empty, she did not assist with the cleaning of R3 but did assist with getting her into bed. CMA K revealed at the time of the fall R3 was out of it and could not really tell them if she was in pain. On 06/20/23 at 12:42 PM, LN D revealed she was sitting in her office when she heard, I need a nurse, she went to the room. R3 was lying on the floor, the wheelchair was almost in the closet, the lift was on the side of R3. LN D's first thought was R3's blood glucose was out of parameters, so CMA K got the glucometer (instrument used to calculate blood glucose), the reading was within normal limits. LN D noticed the oxygen tubing was off R3, so she placed it on her and connected it to the concentrator. LN D stated R3's family member sat in the recliner with a stoic (a person who can endure pain or hardship without showing their feelings or complaining) expression. R3 was not unresponsive but not coherent, LN D obtained vital signs and R3's oxygen saturation was coming back up, so LN D stepped out to call the provider. LN D revealed R3 stated no pain, during rolling back and forth to place sling under her, or with back and forth to clean her up, R3 complained of no pain. LN D revealed for at least three to four days after the fall R3 did not complain of pain. LN D stated she was present when R3 got the Xray and all she noticed was R3 took a deep breath at one point. LN D revealed CNA E told LN D R3 became unresponsive, so CNA E lowered her to the floor from the wheelchair The facility's reviewed 08/2022 Abuse Prevention Program policy, documented the residents have the right to be free from neglect. The facility failed to provide a safe environment, free from neglect for R3 when a CNA used a lift alone, left R3 alone, suspended in the lift, and with lack of sufficient oxygen, and R3 fell and fractured her humerus. On 06/19/23 at 05:25 PM, Administrative Staff A was provided the Immediate Jeopardy Template and notified the failure to provide a safe environment free from neglect, placed R3 in immediate jeopardy. The facility identified and implemented the following corrective actions completed 05/11/23: 1. Administrator received verbal concern for R3's family member pertaining to shoulder pain following an incident while utilizing a facility lift in the late afternoon of 05/10/23. Investigation into the alleged incident began with education to staff members in the areas pertaining to abuse, neglect, facility lift use, and completed at approximately 11:30 PM on 05/10/23. Staff members on shift of incident 05/05/23 interviewed and statements obtained. Immediate alert of education of mechanical lift use, abuse, and neglect delivered to all staff on 05/11/23 at 09:15 AM. Review of the incident determined immediate suspension of staff member CNA E due to the concern of leaving the resident room while positioned in a sit to lift which led to termination of employment on 05/11/23. 2. Audits initiated for areas pertaining to neglect and lift use concerns on 05/11/23. Social Services Designee interviewed all residents with a BIMS of ten or higher to investigate any potential abuse, neglect, or lift safety concerns of other residents. 3. Education of policies, facility lift procedures and the following completed: A) Abuse, Neglect, and Exploitation Policy completed with staff members on 05/10/23 B) Falls, fall risk, and managing falls completed at approximately 11:30 PM on 05/10/23 with staff members. C) Safe lifting including facility protocol with staff members and mechanical lifts education completed at approximately 11:30 PM on 05/10/23. D) Using the resident care plan policy education completed at approximately 11:30 PM on 05/10/23. E) Instant alert notification sent to all certified staff members at 05/11/23 at 09:15 AM. 4. Audits consisting of abuse, neglect, and lift use will monitor for potential areas of concern until lesser frequency is determined during Quality Assurance Meeting. A) Abuse, Neglect, and Exploitation will be reviewed three times a week for two weeks, then one time a week for four weeks. a. A random sample of five residents of BIMS ten or higher to be completed on scheduled audit. b. Abnormal findings to be reported with immediate action plan as needed. B) Lift use audit to ensure enforcement of facility protocol to be completed five times a week for one week, three times a week for one week, and once a week for four weeks. a. Care plan audit to review all resident transfer status and mechanical lift use 05/11/23. b. To review consistency of staff education of mechanical lift use, audits began 05/16/23 following the resident care plan review to ensure accuracy of use, per schedule with randomized sample. C) All certified staff members received immediate alert via electronic notification of education of mechanical lift use, abuse, and neglect on 05/11/23 at 09:15 AM. 5. Plan of correction and education reviewed with Administrator, DON, and Medical Director in an ad hoc Quality Assurance Meeting 05/11/23. Results of audit findings will be brought to the quality assurance meeting on 06/22/23. The surveyor verified the implemented corrective actions while onsite on 06/20/23. Due to the implemented corrective actions prior to the surveyor entrance, the deficient practice was deemed past noncompliance at a J scope and severity.

The facility reported a census of 58 residents, and identified 15 residents at risk for elopement, with 4 residents sampled for elopement. Based on observation, interview and record review the facility failed to provide adequate supervision to prevent elopement for 1 (#1) of the 4 sampled residents, who left the facility without staff knowledge. The resident was gone from the building for 25 minutes, and was found sitting on the curb of a busy street by bystanders after the resident fell and received abrasions to the knee. Furthermore, the facility failed to maintain 3 of the 9 exit doors and alarms in working condition, to prevent elopement of resident ' s from the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - The medical record face sheet documented resident #1 with [DIAGNOSES REDACTED]. to be dangerous, uncomfortable or unsafe, such as wide-open spaces, uncontrollable social situations and unfamiliar places) with panic disorder. The quarterly minimum data set (MDS), dated [DATE], documented the resident ' s brief interview for mental status score of 9, indicating moderately impaired cognition, had delusions with no wandering exhibited, and required supervision for activities of daily living including walking in the corridor and locomotion on or off the unit with a steady gait at all times and no mobility device used, had impaired vision with [DIAGNOSES REDACTED]. The annual (MDS), dated [DATE], documented no change from the previous assessment. The care area assessment, dated 8/7/15, for activities of daily living documented the resident ambulated without the use of an assistive device, had no falls in the last review period, and needed supervision when out of his/her room due to psychiatric [DIAGNOSES REDACTED]. The resident took several psychotropic medications that increase the risk for falls. The care plan, dated 11/25/14, identified the resident with memory problems and wandered throughout the facility with a wanderguard (bracelet alarm device) on at all times. Staff were to remove the resident from unsafe situations and staff were to monitor the wanderguard function daily. Staff were to give the resident verbal reminders not to ambulate or transfer without assistance, to observe the resident frequently and place the resident in a supervised area when out of bed. The update, on 8/23/15 (after elopement), directed staff to monitor the resident ' s whereabouts frequently, keep wanderguard in place and check for placement every shift, and to perform reality orientation and re-direction when the resident attempted to exit the building. The elopement risk assessment, dated 6/25/15 (before the elopement), documented the resident was disoriented, forgetful with a short attention span, independent in ambulation and had a history of [REDACTED]. The fall risk assessment, dated 8/6/15 (before the elopement), documented a score of 14, indicating the resident was a high fall risk. The nurses note, on 8/23/15 at 6:45 PM, documented a visitor approached the nurse at 6:45 PM to inform staff that he/she believed one of the residents from the facility was outside the facility on the street, sitting on the curb. Both facility nurses went to follow-up on this. Once outside in front of the building, the north CMA came outside and stated the resident was up the street, and had last been seen him/her on the north hall at the nurse desk at 6:00 PM before the shift change report. The resident was seen going out the door by another resident and when that resident was questioned about it stated, He/She walked out when a delivery man walked in and the alarm never went off. The resident was found up the street approximately a block away and was sitting on the curb with 2 bystanders comforting him/her. Emergency Medical Services (EMS) arrived, assessed the resident and found a new abrasion on the left knee from a fall in the grass. EMS transported the resident back to the facility and when the resident entered through the front door (the same door the resident had reportedly gone out), the alarm triggered due to the wander guard on the right ankle. The page/call light monitor screen (located at the nurse ' s desk) revealed the resident exited the front door at 6:35 PM. A page was triggered and sent to all pagers, but no alarm sounded when the resident exited the front door. The resident was placed on 15 minute checks due to the elopement, increased confusion, and wandering with falls. The resident was encouraged to remain on the hall where his/her room was located and not wander to the lobby or south hall, with frequent reminders given due to his/her short attention span and confusion. Observation of the resident on 9/1/15 and 9/2/15, at random intervals from 7:00 AM to 6:45 PM revealed the resident frequently wandered the halls of the facility independently and came in close proximity of exit doors, which required staff to re-direct the resident. A wanderguard bracelet was visible on the resident ' s right ankle. On 9/1/15 at 8:20 AM, administrative nursing staff B demonstrated the door the resident eloped through as the front door of the facility. The facility bordered on that side by a three lane road, which is divided into the two directions of traffic in the center by a large median, which also functions as a deep waterway ditch bordered by road-side rails. The resident was found sitting on the curb of this street, approximately one block north of the facility parking lot. There was no sidewalk along the street. Staff B stated the facility reviewed the pager system log for 8/23/15, which revealed the resident left the facility through the front door at 6:35 PM and returned at 7:00 PM, but the alarm was not re-set until 7:19 PM. This would allow any resident at risk for elopement to exit the facility during that time without staff knowledge. Staff B also stated that there were 8 staff working at the time of the elopement on 8/23/15, 5 of the 8 staff were not wearing a pager at all and 3 of the 8 staff were wearing a pager, but did not respond to the wanderguard page at 6:35 PM. Staff B stated the expectation was that all staff should have had a pager on, and responded to the wanderguard page at 6:35 PM. On 9/1/15 at 3:47 PM, the outside food delivery person D reported he/she delivered a pizza to the facility on [DATE] at around 6:30 PM. He/she saw three residents around the area of the door when entering the building, but could not describe them. He/she used the handicapped button after pushing the green button to enter the building. To exit the building, he/she entered the door code and handicapped button. Pressing the handicap button allows the door to be held open for an extended time to enter or exit. He/she did not ever see a resident go out the door during the delivery and was only in the building a minute or two. When leaving the building, he/she got into his/her car to leave, and did not notice a resident outside walking at that time, but did notice that when he/she got into his/her car, which faced the building, the exit door was still open, stating the handicap button must make the door stay open a long time and somebody could certainly go out during the time the door is held open. On 9/1/15 at 4:08 PM, direct care staff F reported working the night the resident eloped from the facility. Staff F did have a pager on, and stated it was their second night working in this facility. On 8/23/15, staff were getting exit door pages and resident call light pages showing on the facility pagers from a non-related facility. Staff F was told to just ignore it, it happened all the time. Staff F did not see the wanderguard page because the pagers were going nuts. At the time the wanderguard page went off, staff F was in a resident ' s room doing care, and training. The pagers were going off so much and half the time it was not for this facility, so staff F quit looking to see what the pages were. Staff F did not realize there was a wanderguard page until after it was over because all staff working got called into the DON (director of nursing) office for questioning that night. Staff F did not know a resident was gone until the resident returned. Staff F stated they were new enough that they would not have even known which resident to look for. Staff F did not know which residents were elopement risks. Staff F stated the resident did wander up and down the halls, walked near exit doors all the time and had to be re-directed. On 9/1/15 at 4:35 PM, direct care staff G reported staff are supposed to carry a pager from the time of clock in to the time of clock out. Staff G worked the night the resident eloped, and had a pager on at first but was told to switch halls. Staff G had returned the south hall pager and had not gotten a pager for the north hall yet when the elopement happened. When staff G reported to the north hall, at 7:00 PM, staff said a resident eloped and the police were bringing the resident back. Staff G did not hear a door alarm and did not know a resident was out of the facility. Staff G stated the front door alarm would often glitch, sounding when no resident was near the alarm. Staff G stated that the facility staff got so conditioned to the alarm sounding that the staff who wore pagers, did not take the wanderguard page seriously. Staff G stated the door pages were not resetting half the time, so the page for doors would stay up on the monitor for an hour or two at a time, and staff got too used to it, and ignored it. Staff G did not think the resident was an elopement risk, but did fall a lot. On 9/1/15 at 5:01 PM, direct care staff H reported he/she worked on 8/23/15, the night the resident eloped. Staff H was wearing a pager, saw the wanderguard page, but was in another resident ' s room providing care and did not feel like they could leave during resident care. Neither of the staff in the room checked to see if anyone else responded to the wanderguard page. The wanderguard alarm is really soft and cannot be heard down the hall where staff work and provide resident care. When the resident came back, he/she was confused, more so than usual, and staff H found out later that the resident also had a UTI (urinary tract infection) at the time. The resident usually wandered the halls and had a wanderguard on the ankle. When the resident went near the door, staff H usually distracted the resident to get him/her away from the door. On 9/1/15 at 6:12 PM, licensed nursing staff I reported he/she worked the night of the elopement. He/she had just come on shift at 6:00 PM that night, and at the time of the elopement at 6:35 PM, still did not have a pager on. A visitor to the facility approached staff I and the other nurse, at 6:45 PM, and said they saw a resident outside the facility. Staff I left the facility with the visitors in their car so the visitor could show staff I where the resident was, which was one block north of the facility on a very busy street. The resident was sitting on the curb and 2 bystanders had pulled their cars to the side of the road to block the resident from traffic so cars had to go around the resident. One of the bystanders had seen the resident fall in the grass and stopped to make sure he/she was okay, and called 911, who responded. The resident was gone from the building 25 minutes, from 6:35 PM to 7:00 PM. Staff I confirmed the wanderguard alarm was not reset until 7:19 PM, but was not able to explain why. Staff I felt the alarm did not sound when the resident went out, because when it sounds, it is constant until it is reset by the code at the door. However, when staff I went to the front door to look for the resident, the alarm was not sounding. The pages went out and showed on the monitor at the nurse ' s desk that there was an elopement at the front door, but no audible alarm was heard. The resident gets very confused, falls frequently, and had a UTI at the time. When the resident returned to the facility he/she stated he/she was going to a neighboring town where he/she was from. The resident ' s family member visited that day, and the resident does not understand why the family member leaves and the resident stays behind. The facility was also getting pages for an elopement at a neighboring facility that night (pages that had nothing to do with the doors and residents of the facility). Some staff do not carry the pagers. Staff I had to educate staff in the past about not carrying the pagers. The excuse from the aides was usually they prefer to look at the board (monitor at the nurse ' s desk). Staff I stated there were elopement books (a book containing identifying information on each resident considered at risk for elopement from the facility) at the nurse ' s desk that were not up to date. The facility had an elopement book located at each of the two nurse ' s desks. Review of the two books, on 9/2/15 at 10:00 AM, revealed the resident ' s profile was located in the south hall book, not the north hall book where the resident resided. On 9/2/15 at 7:56 AM, direct care staff J reported he/she worked the night the resident eloped on 8/23/15 and was wearing a pager. Staff J did not see a page come across the pager from the wanderguard for the elopement out the front door. Staff J was very busy and just did not answer the pages that were coming across the pager. Staff J was answering lots of call lights and was overwhelmed with that work. Staff J had the pager in a pocket, but was not looking at it. Another staff member approached staff J at some point and said somebody had told the nurse the resident was out on the street, so they needed to look for the resident. Right after that, EMS came through the door with the resident. Staff J did not ever hear the audible alarm. Staff stated he/she was supposed to use the pager to answer call lights, and delete the pages as they are answered so the memory in the pager did not fill up (16 pages). If the memory is full, it will not get pages on it anymore. The facility also received pages from another facility down the street. That is partly why all of the staff ignores the pagers, because a lot of the pages do not even belong to the facility, so staff get frustrated and ignore the whole thing after a while. That night we were getting wanderguard pages from the other facility before and after our own elopement, so the staff got desensitized to seeing an elopement on the pager from seeing the other facilities elopement page. Staff J had no idea the resident was out of the building. The resident wore a wanderguard and does wander a lot all over the facility, and goes up to the doors. The resident was very confused and a fall risk. The resident fell that night, and skinned up his/her knee. On 9/2/15 at 9:59 AM, licensed nursing staff K reported there was an elopement book, one for each end of the facility, north and south. Staff K stated nursing staff were supposed to use the book in the event of a possible elopement, but it was not current at all. Staff K did not know who was responsible for keeping it current. All staff should have a pager on while working, should clear the memory at the beginning of their shift, and respond to each page no matter what. If a door alarm paged, like the elopement page, all staff should respond to that. The CMA (certified medication aide), RA (restorative aide), and bath aide all should carry a pager and respond to all pages, especially a wanderguard page. On 9/2/15 at 10:21 AM, licensed nursing staff L reported working on 8/23/15, when the resident eloped and was talking with the other nurse when a visitor approached at 6:50 PM and said someone was outside sitting on the curb down the street from the facility, and it looked like one of the facility residents. The visitor said there were cars pulled over on the side of the street with the resident, people standing around him/her and the ambulance was there. Staff L immediately stopped all staff and had them start looking for the residents who were wanderers. Then staff L and the other nurse went out the front door to look, and saw the resident sitting down the street on the curb, just like the visitor said. Staff L stayed at the facility while the other nurse went to see what was going on. Staff L did not have a pager on, it was on the medication cart, where staff L always kept it. Staff L did not ever keep the pager on as staff had been told to do. Staff L did not ever see the wanderguard page or know the resident was out of the building. Staff L did not know that the CNAs did not carry pagers until that night. Staff L confirmed the wanderguard alarm did not get re-set until 7:19 PM, because it was so quiet it was not bothering anybody and nobody thought to do it. Staff L stated that during the time the alarm was not re-set, from 6:35 PM to 7:19 PM (44 minutes), any resident with a wanderguard could go through the front door without staff knowledge because it would not pick up the alarm for their bracelet since the alarm was still going off from the elopement. Also, any other at risk resident without a bracelet could have gone out too during that time, and staff would not have known. Staff L stated the street out front was usually really busy and dangerous. There was nowhere for the resident to walk other than on the street or along the side of the street in the grass, which was not conducive to a resident who was a fall risk. Staff L stated the resident did fall while out of the building and the injury was an abrasion to the knee. On 9/2/15 at 7:52 AM, administrative staff A reported the facility had a new pager system installed into the south end of the facility on 7/11/15 along with 2 of the 3 current wanderguard alarms the facility currently had. After that installation, there had been reports of the facility staff receiving pages that belonged to a facility down the street that was un-related to this facility. The alarm company was notified of this, explained that the pager system had been configured incorrectly, causing pages from one of their other customers to produce on the facilities pagers. The problem was fixed by the alarm company on 8/27/15. On 9/2/15 at 11:00 AM, administrative nursing staff B stated lots of things failed the night of the elopement including poor leadership, licensed staff not doing their job of making sure direct care staff had pagers on and the licensed nursing staff failed in their expectation of carrying a pager as well. A lot went wrong that night. Staff B stated the facility system for handling a resident elopement was broken. In addition, on 9/1/15 at 8:30 AM, administrative nursing staff B triggered the front door wanderguard alarm with a bracelet to demonstrate the alarm and staff response to the alarm. The alarm was barely audible from approximately 2 feet distance of the alarm mechanism mounted on the door. Licensed Nursing Staff M responded to the front door, stating he/she saw the alarm on the pager monitor at the nurse ' s desk and responded, however, the pager he/she was carrying did not show the elopement page. The handicapped button on the front door was pushed at this time, to open the door from the outside, and the door remained open for approximately 25 seconds before automatically closing. Review of staff and pagers at that time revealed the following findings: 1.) Three direct care staff were not carrying pagers. Direct care staff J stated he/she often takes his/hers off and leaves it at the nurses desk in order to give resident ' s showers, then forgets to go back and get it. Staff J does not think he/she needed to keep it on at all times, because other staff have theirs. 2.) Two direct care staff were carry pagers with dead batteries and not showing any pages. 3.) One licensed nursing staff and 1 direct care staff were carrying pagers that did not show the elopement page. Direct care staff N reported his/her pager had been turning on and off, blacking out and not showing all the pages since the pager was picked up this morning, but the battery icon showed with ½ battery life remaining. Staff N began the shift at 6:00 AM, and turned in the pager for maintenance staff to look at it at 9:10 AM, after carrying it for 3 hours, knowing it was not working correctly. Furthermore, a tour of the security of the facilities 9 exit doors, beginning 9/1/15 at 9:34 AM, with staff revealed the following: 1.) Observation of the northeast door revealed the keypad code posted by the door, with a key pad/mag lock, and no wanderguard alarm on the door. The door was opened using the posted code and held open for 4 minutes with no audible alarm noted and no staff response to the opened door. Direct care staff C, who was standing at the door with a pager when opened, stated the door alarm should be sounding and it should be paging as an open door on the pager, but confirmed it was not. The light on the inside keypad turned green as soon as the door code was entered and changed back to red, indicating the lock had re-engaged after 5 seconds, even though the door remained open. The door was released for it to shut and it became hung up on the threshold and did not shut. When the door was pushed open again, allowing it to swing wide open and closed, again it got stuck and did not shut or lock, leaving a visible 1 inch gap in the door to the outside. During this time, the alarm did not sound. 2.) Observation of the backdoor revealed the keypad code posted by the door with a key pad/mag lock on the door and a wanderguard alarm on the door. The door was opened using the posted code, no alarm sounded that the door was opened and no page was sent to the pager of the door being opened. Administrative staff A stated the alarm should have sounded on the door and a page should have been sent to the pagers, but confirmed it did not. 3.) Observation of the laundry door (at the end of a resident hallway, is a door with a button that says push to exit , through that door is a foyer, that included a door to the laundry area and an exit door identified by staff as the laundry door) revealed the keypad code posted by the door with a key pad/mag lock and no wanderguard alarm on the door. The door was opened and no audible alarm sounded or page sent to the pagers for 4 minutes. After 4 minutes, the alarm sounded and a page was sent that the door was opened. Administrative staff A stated the alarm should have sounded and a page should have sent at the time the door opened, not after 4 minutes. 4.) Observation of the courtyard gate revealed the gate was unsecured. The courtyard could be accessed through 2 different exit doors from the facility, both with the code posted and numerous residents observed using the posted code to enter into the courtyard unsupervised. On 9/1/15 at 10:56 AM, administrative staff A reported he/she was not aware of the problems with the alarms on the northeast, back or laundry doors, the northeast door becoming stuck when opened and not securely closing, or the courtyard gate was unsecure. Staff A confirmed a resident could go out these areas without staff knowledge under the current conditions of the doors and alarms and stated this was concerning for the resident safety and unacceptable. Review of the work history report, provided by the facility as the log for the door alarm checks, revealed the checks were scheduled weekly on Saturdays; however, the logs were not completed weekly as follows: on 7/1/15 there was an 11 day interval from the previous door check on 6/25/15; on 7/12/15 the door check was logged for the week of 7/11/15 and 7/18/15, and on 8/8/15 there was a 13 day interval from the previous check on 7/26/15. On 9/1/15 at 2:27 PM, maintenance staff O stated it was his/her responsibility to do a daily check of the doors to see if they open and close and that was not logged or documented anywhere. At that time, staff O pushed on the bar to see if the mag-lock is engaged. Regarding the northeast door, staff O was aware it hung up and had known that for 2 years now based on his/her own maintenance experience with the door. Staff O had repaired the door in the past and the door would quit working again after it was repaired and this pattern had repeated for the past two years. Staff O also performed weekly checks of the magnetic lock alarms. Staff O last performed the check of the magnetic door locks on 8/23/15, and reported there were no concerns at that time. Staff O stated he/she was not aware the door alarms on the northeast and back doors were not working, but the delay on the laundry door alarm was his/her fault. Staff O had set the timer to the longest delay possible last week when staff were moving a resident ' s possessions in through that door so the alarm would not keep sounding when it was held open for long periods of time. Then, staff O forgot about re-setting the alarm for that door to an appropriate time. The facility failed to provide adequate supervision to prevent the elopement of this resident, who was outside the facility without staff knowledge for 25 minutes walking along a busy street and obtained abrasions to the knee from a fall during this time. The facility provided policy for elopement, dated September 2012, documented staff shall evaluate, investigate and report all cases of missing residents. Upon admission and quarterly, each resident will be evaluated for elopement and wandering risk. Based upon the evaluation the resident will be deemed not at risk or at risk for elopement and wandering. Interventions will be initiated, reviewed and modified. For residents requiring increased monitoring of wandering, the charge nurse will initiate the elopement/wandering form for a specific period of time identified in the care plan or physicians orders for attempted elopement or wandering not conducive to the safety of the resident or other residents in the community. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 9/4/15 at 1:29 PM when the facility placed appropriate signage at entrance and exit doors alerting visitors regarding residents exiting the facility; fixed all non-functioning door alarms; fixed all non-functioning doors; secured the courtyard gate; updated the elopement policy and pager policy and provided in-service to all staff regarding the use of pagers and elopement procedures; updated a policy for and educated maintenance staff regarding exit doors and door alarm maintenance for the facility. This deficient practice remains at the scope and severity of an E.

The facility census totaled 50 residents, with 5 included in the sample. Three of the 5 sampled residents were reviewed for falls. Based on interview and review of the closed record, the facility failed to develop and implement interventions after each fall to ensure the environment remained as free of accident hazards as possible and failed to provide adequate supervision for 1 of 3 sampled residents with falls. (#2). Resident, #2 sustained injuries to the head as well as cognitive changes with possible relation to the falls and required further evaluations. Findings included: - Review of the annual MDS (Minimum Data Set-a required assessment) dated 9/8/12, identified resident #2 with a BIMS (Brief Interview for Mental Status) score of 14/15 (indicated intact cognition), minimal depression, no behaviors, independent in bed mobility, transfers, walking both in the room and on the unit, and all ADLs. It also identified the resident did not have falls. Review of the quarterly MDS dated [DATE] identified the resident with a BIMS of 14/15, minimal depression, no behaviors, independent in bed mobility, transfers, walking in both the room and on the unit and with all ADLs. It also identified the resident did not have any falls. Review of the Fall CAA dated 9/20/12 identified the resident ambulated and transferred using a 4-wheeled walker, It also identified the resident as steady most of the time, but had unsteady problems with transitioning and changing positions. That put the resident at risk for falls. Review of the care plan, dated 6/20/12, revealed the resident at risk for falls. It directed staff to check the resident every 1-2 hours for safety and positioning, involve the resident in meaningful activities, to place the call light within reach, and to remind the resident to call for help before mobilizing as needed. Review of the nurse's notes revealed on 12/21/12 at 3:05 a.m., staff found the resident lying on the floor, face down. The resident had a half-dollar sized hematoma (bump) with a small laceration to the back of his/her head. The resident's neurochecks were within normal limits at the time of the fall, but 15 minutes later became decreased. The facility staff notified the physician on call of the change in level of consciousness and the facility sent the resident into the hospital emergency room for evaluation and treatment. The resident returned to the facility, and staff identified they educated the resident about using the call light for help with ambulating. This was not a new intervention, as the care plan dated 6/20/12 identified staff were to be reminding the resident to use the call light for ambulation. On 12/21/12 at 7:40 p.m., the nurse's notes revealed the staff again found the resident on the floor, face down. This time the resident was not wearing socks or shoes. The resident had a half dollar size bruise to the back of his/her head with a small laceration from the previous fall and as a result from this fall, then had two bruises to the back of the head. When the facility staff notified the family, they insisted the resident be sent to the emergency room for an evaluation, which the facility did. Upon the resident's return from the emergency room , staff put a personal body alarm on the resident, to be used at all times. On 12/27/12 at 8:00 a.m., staff found the resident on the floor next to the bed. The resident denied knowing how he/she got there. The investigation lacked information regarding the personal alarm, or when the last time someone saw the resident, if the bed was in the high position, or in what position staff found the resident. The investigation identified that staff implemented 15 minute checks. On 12/30/12 at 3:45 a.m., staff found the resident on the floor. The investigation did not identify where on the floor staff found the resident, or if the 15 minute checks were still in place, or the personal body alarm. The staff documented there was slight redness to the back of the resident's head. The staff documented they planned to toilet the resident every 2 hours, and to awaken the resident to toilet if he/she was asleep. On 12/31/12 at 10:15 a.m., staff lowered the resident to the floor during a transfer from the bed into a recliner as the resident lost his/her balance. Staff identified they planned to start using a mechanical lift for all transfers. Review of a nurse's note, dated 12/31/12 at 3:15 p.m. revealed the facility staff attempted to have the resident sent to a local emergency room , because the resident's condition declined. The facility staff identified the resident needed continuous oxygen, decreased independent mobility, constant tremors, decreased level of consciousness, and decreased mental status since the previous 24 hours. During a conversation with Physician C's office, the nurse for Physician C identified the resident's status as "no different status wise as (he/she) was 5 days ago." The facility staff explained to the nurse the changes noted in the resident within the 24 hours, including that the resident had mental status changes after a fall "last night when (he/she) hit (his/her) head, and another fall this a.m." Later, after review, Physician C gave the facility an order to send the resident to the hospital for evaluation. On 1/28/13 at 4:21 p.m., Licensed Nurse A stated that the resident had a fall twice on his/her shift one day in December. Nurse A stated that the nurses worked 12 hours and that was "a bad night." Nurse A said that after the second fall, he/she implemented a tabs alarm (personal body alarm) on the resident, but it did not last long, but he/she could not remember why it was stopped. During an interview on 1-28-13 at 4:52 p.m., Direct Care Staff F reported that the resident had not had any falls that he/she could remember. During an interview on 1-28-2013 at 4:59 p.m., Direct Care Staff G stated the resident had "a couple of falls toward the end when (he/she) was weaker." Staff G stated the resident had a cushion alarm but the resident continued to keep trying to get up without assistance. Staff G could not remember any other interventions that the facility tried other than the alarm. On 1-28-13 at 5:04 p.m., Direct Care Staff H identified the resident had 2 falls and that staff placed the resident on 15 minute checks for a short period. That was the only intervention staff H could remember. The facility failed to develop and implement interventions after each fall that a resident experienced to ensure the environment remained as safe as possible. The facility staff also failed to provide adequate supervision to prevent additional falls. The resident had several falls, 3 of which involved injuries to the head, and experienced changes in level of consciousness, which required further evaluation in an emergency room .

The facility census totaled 50 residents, with 4 residents included in the sample. Based on interview and the closed record review, the facility failed to ensure the medication regimen for 1 of 4 sampled residents remained free of significant medication errors. The facility administered an incorrect dose of an anti-rejection medication, [MEDICATION NAME], and the resident experienced side effects and required a hospitalization . (#2) Findings included: - Review of the electronic, closed record revealed resident #2 with an admission date of [DATE]. It also identified the resident with the [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set-a required assessment) dated 9/8/12, identified the resident with a BIMS (Brief Interview for Mental Status) score of 14/15 (indicated intact cognition), minimal depression, no behaviors, independent in bed mobility, transfers, walking both in the room and on the unit, and all ADLs (Activities of Daily Living). It also identified the resident did not have falls. Review of the quarterly MDS dated [DATE] identified the resident with a BIMS of 14/15, minimal depression, no behaviors, independent in bed mobility, transfers, walking in both the room and on the unit and with all ADLs. It also identified the resident did not have any falls. Review of the ADL CAA (Care Area Assessment-a further assessment) dated 9/20/12 identified the resident at times had increased weakness and wore glasses to correct visual impairment. It further described the resident as independent with ADLs, required minimal assistance from staff at times when weakness/pain occurred. Finally, the CAA identified the resident experienced chronic pain due to a back condition. Review of the Fall CAA dated 9/20/12 identified the resident ambulated and transferred using a 4-wheeled walker. It also identified the resident as steady most of the time, but had issues with occasional unsteadiness with transitioning and changing positions, and that put the resident at risk for falls. Review of the ADL care plan, dated 11/23/11, revealed the resident as independent in most ADLs, to assist the resident whenever the resident asked. It identified the resident preferred to take a shower on Monday, Wednesday and Thursday evenings, directed staff to encourage the resident to remain independent in ADLs, to encourage the resident to participate in ADLs as much as able, for staff to provide assistance as needed to complete hygiene needs, and identified the resident ambulated independently. Review of the liver transplant care plan, dated 6/4/12, directed staff to administer [MEDICATION NAME] (an anti-rejection drug) per doctor ' s order. "This drug should be administered under supervision of experienced physicians in immunosuppressive therapy and management of renal, cardiac, or hepatic transplant patients and administered in equipped facilities with adequate lab and supportive medical resources. The physician responsible for maintenance therapy should have complete information needed for patient follow-up." On 6/18/12, staff included the intervention to ensure staff obtained the following laboratory tests: CBC with diff (Complete Blood Count with differential-the type and number of different cells in the blood), CMP (Complete Metabolic Profile-a test to determine kidney and liver diseases), GGTP (Gamma-glutamyltransferase or gamma-glutamyl transpeptidase, a test that monitors liver disorders), Mg (Magnesium-monitors the level of the metal in the blood), Phos (Phospherous-monitors the level in the blood), [MEDICATION NAME] (an anti-rejection medication) level, CMV PCR (Cytomegalovirus, quantitative--monitors [MEDICAL CONDITION] load to monitor [MEDICAL CONDITION] infections) laboratory is drawn every Monday and Thursday before giving [MEDICATION NAME]/sirolimus. On 6/22/12, staff added the intervention for staff to monitor the resident for signs and symptoms of liver rejection, which included a fever over 100.4 degrees Fahrenheit, jaundice (yellowing of skin or eyes), darkening of urine, clay-colored stools, and abdominal pain over the liver. Review of the fall care plan, dated 6/20/12, revealed the resident at risk for falls. It directed staff to check the resident every 1-2 hours for safety and positioning, involve the resident in meaningful activities, to place the call light within reach, and to remind the resident to call for help before mobilizing as needed. Review of the resident's electronic chart revealed the physician hospitalized the resident on 11/29/12 due to the side effects the resident experienced from taking the anti-rejection medication [MEDICATION NAME]. The resident experienced confusion and lethargy, as well as high laboratory blood levels of the medication [MEDICATION NAME]. The resident returned to the facility on [DATE]. The physician wrote an order for [REDACTED]. On 12/6/12, the resident's laboratory levels rose again, and the physician admitted the resident back to the hospital. On 12/14/12, the resident returned to the facility. At that time, the physician wrote the order for staff to administer [MEDICATION NAME] 0.5mg daily to the resident. Review of the December 2012 MAR indicated [REDACTED]. Staff signed they administered the order for the daily doses of [MEDICATION NAME] 0.5mg, but there were also two signatures on the order for [MEDICATION NAME] 0.5mg every other day. Observation revealed staff circled one of the signatures, but the back of the MAR indicated [REDACTED]. Review of the nurse's notes revealed that the staff failed to notify the resident's physicians to notify them of the error in administration of the correct dose of medication. The resident started to experience symptoms of toxicity of the anti-rejection medications, including severe confusion and lethargy. The resident experienced 5 falls from 12/14-12/31 and by 12/31/12 required 2 staff and a mechanical lift for transfers and continuous oxygen. Laboratory results of the resident's medication levels showed the resident's blood levels were high. Physician C gave the facility staff an order on 12/24/12 to send the resident to the hospital for direct admit, but that did not occur. By late 12/31/12, the resident no longer responded to verbal stimuli. On 1/1/13, the facility had the resident flown to a hospital where the resident required intubation (a tube placed into the resident's lungs to breathe for the resident). On 1/28/13 at 4:21 p.m., Licensed Nurse A stated the resident had an order for [REDACTED]. Nurse A identified the results of the test determined if the resident needed his/her anti-rejection medications changed. Nurse A identified the laboratory would fax the results to the facility, the nurse would then fax the information to Physician B's office, who worked as the resident's transplant physician. Once Physician B reviewed the results, then Licensed Nurse E (who worked with Physician B) would call the facility and give the new order to the nurse. The nurse would then call the pharmacy to give the new order for the medication change. The pharmacy then sent out the new dose of medication. On 1/29/13 at 11:10 a.m., Physician C, who worked as the resident's primary physician, identified the resident as very sick and said the resident experienced "chronic rejection" of the liver. Physician C said that he/she was aware the facility made an error in the dosage administration of the anti-rejection medication. On 1/29/13 at 3:18 p.m., Physician B stated that his/her main concern with the care the resident received included the mistake in administration of the resident's anti-rejection medications--when the facility staff gave the resident too much. Physician B said the extra doses of medication certainly harmed the resident. Physician B said the resident had been very ill and needed the facility to watch the administration of these medicines very closely. The facility failed to ensure a resident who received an anti-rejection medication received the medication as ordered to ensure the medication level remained within therapeutic levels. The staff administered extra doses of the medication and the resident required a hospitalization due to a toxic level of the medication.

The facility census totaled 45 residents, with 30 residents included in the sample, and 1 of those residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled residents(#60) who entered the facility with pressure ulcers did not develop additional pressure ulcers, and failed to provide the timely necessary treatment to promote healing. The facility failed to adequately reposition the resident, and the failed to provide timely, consistent treatment and services to promote healing which resulted in the resident developing 3 additional avoidable, unstageable pressure ulcers, and failed to prevent the worsening of current pressure ulcers. Findings included: - Review of resident #60's admission MDS (Minimum Data Set) assessment dated [DATE] revealed it identified the resident admitted to the facility on [DATE] with a BIMS (Brief Interview for Mental Status) score of 1. The assessment identified the resident as totally dependent of 2 staff members for bed mobility, transfers, toilet use and personal hygiene. It identified the resident had a urinary catheter, and as always incontinent of bowel. It identified the resident had a feeding tube, and received 51% or more of intake by an artificial route. The assessment identified the resident as at risk for developing pressure ulcers, had one or more pressure ulcers, 1 unstageable (according to the 2009 Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline by the National Pressure Ulcer Advisory Panel identified an unstageable ulcer as full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined) pressure ulcer with slough and/or eschar, with dimensions of 5.0 cm (centimeters) long x (by) 4.0 cm wide x 0.5 cm deep. The assessment identified slough as the most severe type of tissue, and had no other unhealed or healed pressure ulcers. It identified staff used a pressure reducing device for the bed, and staff provided a turning and reposition program, nutrition/hydration interventions, pressure ulcer care, applications of nonsurgical dressings and ointments/medications. Review of the CAAs (Care Area Assessments) Summary identified pressure ulcers triggered for a further assessment. The record lacked any indication staff completed the CAAs to assist in developing interventions for the resident's current condition. Review of the resident's care plan identified the resident (from a problem date of 5/17/12) as incontinent of bowel, and directed staff to apply skin barrier every 1-2 hours and as needed. It also identified the resident (problem start date of 5/17/12) had actual skin breakdown related to decreased mobility, decreased nutritional intake and decreased fluid intake. It directed staff to treat the affected areas per the physician's orders [REDACTED]. On 7/24/12, staff updated the care plan to identify hospice performed the scheduled wound care treatments, and the nursing home staff needed to perform as needed dressing changes when the dressing became loose or fell off. Review of a Weekly Wound Measurement for Pressure Ulcer (stage I to Stage IV) identified an unstageable coccyx wound on 5/8/12 with measurements of 5.0 cm (centimeters) long x (by) 4.0 cm wide x 0.5 cm deep with a large amount of serous drainage. On 5/17/12, the wound measured 17 cm x 6 cm x 1 cm with a large amount of drainage. On 5/23/12, the wound measured 17.0 cm x 6.0 cm with no depth or drainage. Staff continued to measure the wound until 6/12/12 when it measured 4.4 cm x 5.5 cm x 0.1 cm. The documentation lacked any further measurements made by the facility until 6/27/12 (15 days later) where it measured 7.9 cm x 6.8 cm x 0.1 cm (3.5 cm x 1.3 cm larger). On 7/17/12, the wound measured 5.3 cm x 7.5 cm x 0 cm. Review of an order started on 5/8/12 identified for the coccyx/buttock wound directed staff to place calcium alginate to the major coccyx wound, cover the surrounding abrasion with xeroform (a type of dressing), cover the entire area with bordered gauze, and change every other day. This order continued until 5/10/12. Review revealed another order started 5/11/12 for the coccyx wound directed staff to cleanse with normal saline, apply 3 alternating layers each starting with normal saline then pixi dust (a type of treatment), then cover with a foam dressing and ABD (type of dressing), held with [MEDICATION NAME] tape daily for 14 days. Documentation revealed the order was discontinued on 5/25/12. The wound had no other treatment order specific to it. The orders for a wound initiated on 5/16/12 directed staff to apply skin prep to the peri wound then use xeroform or equivalent product to apply [MEDICATION NAME], poly ox, and normal saline mixture to the wound to insure adequate application. The order failed to specify which ulcer to apply the dressing to. The facility's measurements also indicated the resident had a pressure area to the left scapula with initial measurements on 5/8/12 of 3.0 cm x 2.0 cm and no depth. The Weekly Pressure Sore Record form staff started to use in July, 2012 identified the wound developed in house on 4/23/12, different than developing in the hospital as reported by staff. The wound on 7/17/12 measured 7.2 cm x 6.0 cm with eschar. Review of an order started 6/20/12 for the left shoulder directed staff to apply Fibracal (a type of treatment) to the wound bed, and cover with a [MEDICATION NAME] border. It directed staff to change 2 times weekly and as needed. Staff discontinued this on 7/25/12. Review of another order started 6/1/12 directed staff to apply a [MEDICATION NAME] border to the left shoulder and change every 7 days and as needed. Staff discontinued this on 7/25/12. Review of a third order started 5/10/12 revealed an open area to the left hip and left "subscapular" (below or on underside of scapula/shoulder blade). It directed staff to clean with normal saline, apply dusting of [MEDICATION NAME] powder, and cover with a dressing of choice and change every 5 to 7 days. The facility discontinued this order on 7/3/12. The 3 different treatment orders for the left shoulder all continued to be active for staff to follow from 6/20/12 to 7/3/12. Skin documentation on 6/6/12 (29 days after admission) identified the resident developed a pressure area to the right scapula with a measurement of 1.7 cm x 1.6 cm with no other description noted. Staff failed to measure the wound again until 6/27/12 which had a measurement of 10.7 cm x 9.8 cm. The Weekly Pressure Sore Record for the right shoulder/scapula wound identified it developed in the facility on 5/16/12 (different than the facility documented on the previous skin documentation form.) The skin documentation sheet on 7/17/12 identified the measurements for that wound as 5.0 cm x 7.0 cm with eschar covering at least part of the wound. Review of the only order specifically addressing the right scapula started 6/20/12 for the application of [MEDICATION NAME], "poly-ox" powder to yellow slough, apply normal saline, then cover with a foam dressing. It directed staff to change daily for 14 days. Staff discontinued the order on 7/4/12. Review of the facility's skin documentation forms also indicated the resident developed an ulcer to the left heel on 6/6/12 (29 days after admission) with measurements of 1.9 cm x 1.0 cm. On 6/27/12 it had increased to a measurement of 3.0 cm x 1.7 cm x 0 cm. Review of the Weekly Pressure Sore record revealed, on 7/17/12 the left heel ulcer measured 1.0 cm x 1.7 cm x 0 cm with eschar. The form identified the wound developed in the facility on 6/9/12 (3 days after the facility had indicated it developed on the other form). The ulcer to the left heel had no treatment order to address it specifically until 6/20/12 when the order directed staff to apply skin prep to the medial left heel daily and off load pressure. Staff discontinued this order on 7/25/12. Documentation revealed the resident also developed a pressure ulcer to the right thigh/hip on 6/6/12 (29 days after admission) with measurements of 1.7 cm x 1.3 cm x 0 cm. Staff failed to assess and measure the wound again until 6/27/12 when the wound increased in size to 1.9 cm by 3.0 cm. The Weekly Pressure Sore Record form revealed the area developed in house, and on 7/17/12 it measured 2.5 cm x 1.3 cm x 0 cm. Review of an order started 7/3/12 directed staff to apply a dressing to the right hip and cover with a foam border dressing 2 times per week. Staff discontinued this on 7/25/12. Review of the physician and hospice orders revealed an order dated 7/3/12 for skin prep to the periwound (area directly surrounding the wound), [MEDICATION NAME] (type of wound treatment) approximately the size of a nickel, applied to center of eschar, then apply a [MEDICATION NAME] dressing. It directed staff to change the dressing 3 times weekly and as needed. It directed staff to cover the right hip area with a foam border dressing 2 times weekly and as needed per the hospice's protocol. The order addressed only the right hip for treatment. Review of the current skin care order with clarification dated 7/25/12 directed staff to apply skin prep to the peri wounds. Apply [MEDICATION NAME] approximately the size of a nickel to the center of the eschar, then apply a [MEDICATION NAME] dressing. It directed staff to change the dressing 3 times weekly and as needed, but did not indicate which wounds this applied to in the order. Observation at 9:46 A.M. on 7/23/12 revealed Direct Care staff I and Direct Care staff H confirmed the resident had been incontinent of bowel and gathered supplies to provide care. Staff H assisted the resident to lay on his/her side as staff I provided perineal care. At that time, observation revealed clean dressings to each of the resident's scapulas, and a soiled dressing on the resident's coccyx, but partially removed with the wound exposed. Staff I wiped BM (bowel movement) up toward and into areas of the wound attempting to clean the incontinent episode. Staff H confirmed the nurse needed to change the dressing, and with soiled gloves from providing incontinent care, Staff I removed the dressing and blotted the wound with a perineal wipe, then applied moisture barrier over the resident's groin and backside. The staff members finished care, repositioned the resident for comfort and left the room. During an interview with Licensed Nursing staff K at 10:09 A.M. on 7/23/12, he/she reported the resident had his/her dressings changed by hospice staff every Monday, Wednesday and Friday, and hospice staff was scheduled to come in to the facility that day, but Staff K wanted to keep the wound covered until someone came. At 10:25 A.M. Direct Care staff H assisted the resident to his/her side, while staff K viewed the wound. Staff K picked up a dry disposable cloth, and sprayed it with "No Rinse" Perineal wash with aloe. Staff K cleansed the wound with the cloth, then, with the same soiled gloves, applied a new dressing. At 3:25 P.M. on 7/24/12, observation revealed Direct Care staff L and Direct Care staff M assisted the resident with an incontinent episode. Both staff confirmed the dressing needed changed, and would report it to the nurse. The staff applied a clean brief, positioned the resident for comfort and left the room. At 4:43 P.M. on 7/24/12, over an hour later, Licensed Nursing staff N confirmed no one reported the dressing needed changed. At 4:48 P.M. Staff N observed the area and confirmed the dressing needed to be replaced, and confirmed the dressing protected the area and helped with healing. During an interview at 3:58 P.M. on 7/24/12, Licensed Nursing staff F reported the resident had a multiple unstageable pressure areas and had high risk for more pressure ulcers. Staff F reported the resident's skin would redden, even just to turn for dressing changes, and when staff figured that out, they started to turn the resident every hour. Staff F did not know of the dressing coming off that day. Staff F reported he/she used soap and water and/or wound cleanser on the wound, but should not use the perineal wash. Staff F reported the nursing staff had extra wound cleanser available for staff to use anytime. During an interview at 2:40 P.M. on 7/25/12, Administrative Nursing staff C reported he/she thought staff repositioned the resident at least every 2 hours before the resident received the other 3 areas (right hip, right scapula, and left heel). Staff C reported the staff could not use a different mattress at that time for medical reasons, and the resident could not tolerate any additional supplement at that time. Staff C confirmed staff identified 3 wounds on June 6th, and thought staff had attempted to avoid pressure on the areas that already had sores. This applied more pressure to the right side. Staff C confirmed he/she expected weekly measurements of the wound, but confirmed staff failed to measure the wounds for two weeks in July. Staff C confirmed the aide removing the dressing and cleansing it while wearing soiled gloves and, leaving the wound open for over an hour increased the risk for infection. On 7/26/12 at 10:54 A.M., Administrative Nursing staff C confirmed the resident had pressure areas to the coccyx, right hip, and both shoulders, and also had an area to the heel. Staff C reported hospice declared the heel wound healed the previous day. Staff C reported staff started to reposition the resident every hour after the wounds developed to the right hip, right scapula and left heel in June, 2012. Staff C reported the nurses monitored by having the aides sign a paper each hour that they repositioned the resident. Staff C reported he/she planned to provide the sheet the staff filled out on day hourly repositioning initiated. Review of that form provided by Staff B revealed a date of 6/20/12, 14 or more days after staff identified the 3 wounds on the right hip, right scapula and left heel. During an interview with Consultant P at 12:50 P.M. on 7/25/12, he/she reported, when the resident first started receiving hospice services, the resident had an area on the sacrum. Staff P reported the resident had poor nutritional status, and staff turned the resident every two hours. Staff P reported the hospice and nursing did not feel that was adequate, so staff started helping the resident to reposition every hour. Consultant P confirmed they had a struggle getting the resident turned as often as needed, but education helped to make that issue better. Consultant P reported he/she preferred staff to use wound wash which hospice provided to clean the wound, or a little soap and water. Consultant P reported he/she felt leaving the wound open for over an hour provided the potential for it to dry out and allow more bacteria to enter the wound. Consultant P also reported the perineal wash made it more difficult for the medication to get through to the wound. Consultant P confirmed contaminating the wound with BM did not promote healing. During an interview with Consultant Q on 7/26/12 at 11:35 A.M., he/she reported the resident had multiple problems including a spinal cord injury and inadequate nutrition, and confirmed the resident had pressure ulcers. Consultant Q reported he/she viewed the wounds on 7/26/12 and did have a concern regarding the wound to the coccyx and potentially needing to change wound care management and/or the type of dressings the resident received. Consultant Q confirmed the hospice did the primary care/management of the wound, and nursing staff attempted to follow the recommendations, but reported he/she felt like the staff needed more training on some procedural things. Consultant Q reported he/she did encourage repositioning the resident, and reported he/she thought the 3 wounds that occurred in June did come from staff avoiding the areas that had pressure ulcers at that time, and having the resident lie more on his/her right side. In regards to the observations, Consultant Q confirmed contaminating the wound with BM did not promote healing, felt perineal cleanser was more suited for intact skin, and preferred staff to use a water, normal saline, or wound cleanser solution to clean the area. Consultant Q, reported he/she preferred to have the wound redressed as soon as possible if the previous dressing came off, and confirmed, even though the resident was at high risk for decline, and did have declining health, staff needed to strive to do the best for the resident. Review of the facility's Wound Care Policy, last revised April 2009 revealed, "The purpose of this procedure is to provide guidelines for the care of wounds to promote healing." The policy directed staff to wash and dry hands thoroughly prior to applying gloves and removing a dressing from the body, and directed staff to wash hands again prior to cleansing and dressing the wound." The facility failed to provide timely and consistent treatment and services to prevent the worsening of pressure ulcers present on admission, and failed to revise and implement interventions to ensure the resident did not experience additional pressure ulcers.

The facility had a census of 48 residents, with 9 residents selected for sample. Three sampled residents experienced falls or required assistance with transfers. The facility identified 14 residents as cognitively impaired and independently mobile. Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident/hazards for 14 cognitively impaired independently mobile residents when staff failed to store chemicals in areas inaccessible to the residents. Based on observation, interview and record review, the facility failed to provide 2 of 3 residents sampled for falls/transfers with adequate supervision and assistive devices (gait belts) to prevent accidents. (#104 and #109) Findings included: - Environmental tour of the South Nursing Unit on 12/20/11 at 2:30 p.m. revealed an unlocked, unoccupied resident room on the Southwest hallway. The room appeared to be undergoing renovation/remodeling, with missing floor tiles and general disarray within the room. The contents of this unlocked room included: o A one gallon jug of " Self Stick Tile Primer " sitting on floor by the doorway. The product container included the warning " Caution - avoid eye and skin contact ... ...do not take internally ...Keep Out Of Reach Of Children". o A one quart container of Lacquer Thinner. The product container included the warning, " Danger ...Poison ...May be fatal or cause blindness of swallowed. Vapor harmful". o A one gallon container of " DIF Fel Wallpaper Stripper " . The product container included the warning, " Avoid contact with eyes and skin, product contains a chemical known to the state of California to cause cancer. Keep Out of Reach of Children. " o An 18 ounce spray container of " Zip Clean Evaporator Coil Cleaner " . The product label included the warning to Keep Out of Reach of Children. During an interview on 12/20/11 at 3:15 p.m., Administrative Staff A confirmed the door to the room on the South hallway currently under renovation should have been locked and the chemicals within the room should not have been accessible to residents. The facility provided a list which identified a total of 14 facility residents as cognitively impaired and independently mobile. The facility's 2008 Safety and Supervision of Residents policy stated, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities." The facility failed to ensure the environment remained free of accident/hazards. The facility failed to store chemicals in areas inaccessible to 14 cognitively impaired independently mobile residents. - According to the 11/28/11 [DIAGNOSES REDACTED]. Resident #104's 10/14/11 quarterly MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 10 which indicated moderately impaired cognition. The resident required extensive assistance of 1 person for bed mobility and transfers. He/she had functional limitations in range of motion in both upper and lower extremities. The resident used a walker and wheelchair for mobility. Resident #104's 8/5/11 CAAS (care area assessment summary) related to falls stated, "Resident attempts to transfer self without the assistance of staff. Resident must be reoriented frequently and ensure tabs alarm is in place at all times...Resident transfers with assist of 1 at all times. The resident takes daily Zoloft (antidepressant), scheduled and prn (as needed) Percocet (pain medication)....Resident has a medical [DIAGNOSES REDACTED]." The resident's 10/21/11 fall risk assessment score of 19 identified him/her "at risk" for falls. Review of the clinical record revealed the resident had 3 non injury falls from 11/22/11 to 12/2/11. Resident #104's 12/2/11 updated nursing care plan for falls had the following interventions: * Non-injury fall on 11/23/11 - Resident placed in Broda chair. * Educate staff and resident about use of alarms and proper use of equipment. * I will be in staff view when I am not in bed. * Provide non skid socks to help prevent fall. * Provide personal items within reach so that I do not try to get up and get them myself. * Provide visual checks every 30 minutes through the night and whenever I am in my room during the day. * Offer toileting assistance upon rising, before and after meals, at bedtime and as needed. * Provide extensive assistance of 1 with transfers. * I use pressure alarm and tabs alarm at all times. * Encourage and remind me to call for assistance with transfers. The plan of care summary (guide for nurses aides) kept in the ADL (activities of daily living) book used by the CNAs (certified nursing assistants) for resident #104 identified the resident required 1 assist with ambulation, used a pressure alarm, and a high/low bed with a bedside mat while in bed. The facility's 2009 policy for Safe Lifting and Movement of Residents stated, "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents....Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices." During an observation on 12/20/11 at 8:22 a.m., direct care staff C and D transferred resident #104 from a Broda chair (reclining chair) to a recliner in the living room area of the South hall. Direct care staff C and D supported the resident under his/her arms as he/she stood and pivoted. Staff placed the pressure alarm under the resident in the recliner and placed a tabs alarm to the resident's clothing. Staff did not use a gait belt during the transfer. An observation on 12/20/11 at 10:46 a.m., direct care staff C and E transferred the resident from the recliner to the Broda chair using a gait belt. Further observations on 12/20/11 at 4:22 p.m. revealed direct care staff F and G transferred resident #104 from the recliner to the Broda chair by supporting the resident under the arms and did not use a gait belt. Staff wheeled the resident to his/her room and transferred the resident to the toilet and off the toilet in the same manner without using a gait belt. The resident held on the the grab bar by the toilet, however, staff supported the resident under the arms during the transfers and had to cue and assist the resident to move his/her legs during the transfers. During an interview on 12/20/11 at 5:01 p.m., direct care staff G stated the resident usually required 2 assist for transfers and staff should use a gait belt. He/she stated even though the care plan indicated the resident required 1 person assist for ambulation, he/she would not feel safe doing this considering the resident's present abilities. An interview on 12/21/11 at 10:04 a.m. with direct care staff H revealed resident #104 required 2 staff assist at times, depending on his/her day. He/she stated staff can usually transfer the resident with 1 assist and a gait belt, but sometimes they may need 2 assist for transfers depending on how the resident felt. During an interview on 12/21/11 at 10:59 a.m., licensed nurse I stated resident #104 required 2 staff assistance for all ADLs. He/she stated the resident had a pressure/tabs alarms, used a high/low bed with a mat, used a Broda chair, and staff kept him/her in their site at all times when not in bed. Licensed staff I confirmed resident #104 should be transferred with a gait belt and 2 staff assist or may use the sit to stand lift if needed. The facility failed to provide resident #104 with adequate supervision and assistive devices (gait belts) to prevent accidents. - According to the 11/11/11 [DIAGNOSES REDACTED]. Resident #109's admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 1 which indicated severe cognitive impairment. The resident required extensive assistance of 2 persons for transfers, walking in room, and walking in corridor. He/she had no functional limitations in range of motion and used a wheelchair for mobility. Resident #109's CAAS (care area assessment summary) for falls stated, "Frequent monitoring, re-orientation required. History of falls at home resulting in hospitalization and subsequent surgery. Resident unstable on his feet, requires assist for most ADLs (activities of daily living)....Traumatic brain injury with generalized anxiety, resident frequently incontinent of bowel/bladder. Resident frequent pain to hand/shoulder. Agitation and calling out present on a daily basis. Cognition severely impaired." The resident's 10/31/11 fall risk assessment score of 18 identified the resident "at risk" for falls. Review of the clinical record revealed the resident had 3 non-injury falls from 11/1/11 - 11/25/11. Resident #109's nursing care plan updated on 12/19/11, had the following interventions related to fall prevention: * Check the resident every 1-2 hours for safety and repositioning. * Place call light within reach. * Remind to call for help before mobilizing. * Floor mat to be placed at beside while I am in bed. * Tabs alarm and pressure alarm should be in place at all times. Interventions related to ADLs included: * I am unable to perform my ADLs. * OT to evaluate and treat as ordered. * Provide assist of nursing staff as needed to complete ADLs and hygiene needs. * PT to evaluate and treat as ordered. The 11/14/11 plan of care summary (guide for nurses aides) kept in the ADL (activities of daily living) book used by the CNAs (certified nursing assistants) for resident #109 indicated the resident required assistance of 2 persons with gait belt for transfers, ambulated x 2 assist with gait belt, and used a wheelchair. The facility's 2009 policy for Safe Lifting and Movement of Residents stated, "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents....Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices." During an observation on 12/20/11 at 4:37 p.m., direct care staff F and G prepared resident #109 for the evening meal. The resident stood from his/her bed to ambulate to the toilet. Staff stood by him/her during ambulation, however, the resident had unsteady gait and leaned to the right. The resident regained his/her balance as staff walked with him/her to the toilet without using a gait belt. During an interview on 12/21/11 at 10:41 a.m., licensed nurse I stated staff should use a gait belt with resident #109 during transfers and ambulation. The facility failed to provide resident #109 with adequate supervision and assistive devices (gait belts) to prevent accidents.

The facility had a census of 47 residents, with 3 residents reviewed for skin integrity. Based on observation, interview, and record review, the facility failed to ensure that one sampled resident (#3) did not develop a pressure ulcer in the facility and failed to provide a position change for one dependent, sampled resident (#4). Resident #3 developed a 3.0 cm (centimeter) by 3.2 cm blister on the right heel, with eschar present in the middle of the blister. The facility failed to conduct weekly skin assessments, as per facility policy, on this dependent resident to identify the resident's compromised skin integrity. In addition, the facility failed to provide wound care, as ordered by the resident's physician and failed to provide preventative devices to promote healing of the pressure ulcer. The resident experienced harm due to the development of the facility acquired pressure ulcer on the right heel. Findings included: - Staff admitted resident #3 to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/6/11, the resident's physician ordered for staff to perform weekly skin assessments. Staff recorded on the resident's 5/19/11 Braden assessment (tool used to identify residents at risk for the development of a pressure ulcer) the resident with a score of 14 (which indicated the resident at moderate risk for the development of a pressure ulcer). The resident's care plan, reviewed on 7/20/11, directed staff to use a pressure relieving mattress, provide repositioning every 2 hours, provide extensive assistance of 2 with bed mobility, and the nurse to perform weekly head to toe skin assessment. The care plan failed to include any interventions for protection/prevention of the resident's feet or heels. Review of the resident's clinical record revealed a skin assessment, dated 7/21/11, with no skin issues identified. The resident's significant change MDS (Minimum Data Set), dated 7/26/11, identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff with bed mobility and transfers, walking in the room and/or corridor did not occur, required limited assistance of 1 staff with locomotion on and off the unit, required extensive assistance of 2 staff with toileting, and used a wheelchair. The assessment recorded the resident at risk for the development of a pressure ulcer, currently did not have pressure ulcer, utilized a pressure reduction device in the chair and in the bed, and was on a turning/repositioning program. Staff recorded on the 7/27/11 CAAS (Care Area Assessment Summary) for pressure ulcers, the resident required extensive assistance of 2 staff with transfers. The resident spent time in either the bed or the chair for the majority of the day. Staff recorded the resident had a pressure relieving mattress in place. Staff recorded in the 9/19/11 nursing notes, at 10:39 PM, the resident's skin intact. Staff recorded in the resident's 10/11/11 care plan the resident used a pressure relieving mattress, used a pressure relieving cushion in the wheelchair, and planned for a nurse to perform weekly head to toe skin assessments on the resident. Staff recorded in the 10/11/11 nursing notes, at 5:33 AM, " Resident has blister to right heel purple in color with 2 white areas to center, skin surrounding blister blanches. Cleaned and applied foam pad to protect, wrapped in Kerlix, heel protectors at night. Dr notified. Area measures 3.0 cm (centimeter) x 3.2 cm, no depth." On 10/11/11, the resident's doctor ordered for staff to apply [MEDICATION NAME] border dressing to the blister on the resident's right heel, change every 7 days and as needed. Hospice staff recorded on the 10/11/11 skilled hospice notes the resident's right heel blister present, measured 3.0 x 2.5 cm, and [MEDICATION NAME] border placed on blister. Review of the resident's clinical record revealed a documented skin assessment, dated 10/14/11, 2:49 AM, which read, "...Resident continues with blister like area to heel currently with treatment, measures 2.1 cm x 3.1 cm, no depth, purple/black in color with 2 small white areas in the center..." The resident's clinical record lacked evidence of a facility skin assessment performed from 7/21/11 to 10/14/11. Staff recorded on the resident's 10/18/11 Braden assessment (tool used to identify residents at risk for the development of a pressure ulcer) the resident with a score of 12 (a score of 10 to 12 indicated the resident at high risk for the development of a pressure ulcer). Hospice staff recorded on the 10/19/11 skilled hospice notes the resident's right heel blister present, with dressing in place to the right heel, and measured 2.5 cm by 2.5 cm. On 10/25/11 at 1:25 PM, observation revealed direct care staff F and P transferred the resident from the wheelchair to the resident's bed. These direct care staff positioned the resident on the resident's back, in bed, with no right heel bootie in place. Observation revealed a cushioned heel bootie in the resident's room on top of the heating unit. At 4:27 PM, observation revealed the resident still in bed on the resident's back, with no protective device in place on the resident's right foot. At 4:33 PM, direct care staff R and Q assisted the resident to sit on the side of the bed and assisted the resident to stand with the sit to stand lift. At that time, direct care staff R removed both of the resident's socks. Observation revealed the right heel lacked a dressing in place and had a darkened area on the right heel which measured approximately 3 cm in diameter with a surrounding white colored area, surrounding the darkened area, which measured approximately 0.5 cm. Observation revealed the resident's heel bootie remained on top of the heater. After inspection of the right heel area, direct care staff R reapplied the resident's socks and applied the bootie to the resident's right foot. On 10/26/11 at 2:57 PM, observation revealed the resident asleep in bed with the right heel resting directly on the mattress. Observation revealed the resident's bootie on the floor beside the resident's bed. 10/26/11 at 3:07 PM, licensed staff D stated the resident needed to wear a protective bootie on the resident's right foot while in bed. On 10/26/11 at 8:30 AM, licensed staff B stated, "Skin assessments should be done weekly." At that time, this licensed staff verified the last documented skin assessment conducted on the resident performed on 7/21/11. This licensed staff stated, "Our staff probably thought hospice was doing the skin assessments. That is about the time (the resident) went on hospice." When questioned, this direct care staff lacked knowledge of how the resident developed the pressure ulcer. On 10/26/11 at 3:14 PM, licensed staff B stated, "(The resident) should be wearing a protective bootie on (the resident's) right foot while in bed." On 10/27/11 at 8:10 AM, observation revealed the resident in the wheelchair at the south nurses' desk. Direct care staff T removed the resident's right shoe and right sock and verified the resident lacked any type of dressing to the right heel. The facility's pressure ulcer risk assessment policy, revised 10/10, recorded, "...1. Risk Assessments. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring...c. Nurses will conduct skin assessments at least weekly to identify changes... The facility's pressure ulcer treatment policy, revised 10/10, recorded, "...1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s). b. Managing tissue loads. c. Pressure ulcer care..." The facility failed to ensure this resident did not develop a pressure ulcer. This resident experienced harm from the development of a facility acquired pressure ulcer to the right heel, with eschar present in the middle of the blister. The facility failed to conduct weekly skin assessments, as per facility policy, on this dependent resident to identify the resident's compromised skin integrity. In addition, the facility failed to provide wound care, as ordered by the resident's physician and failed to provide preventative devices prevent the development of and to promote healing of the pressure ulcer. - The clinical record revealed staff admitted resident #4 to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident ' s annual MDS (Minimum Data Set) dated 8/3/11, recorded the resident with a BIMS (Brief Interview for Mental Status ) score of 14 (a score of 13 to 15 indicated cognition intact), no behaviors coded, required limited assistance of 1 staff with bed mobility and transfers, did not walk in the room and/or corridor, required set-up supervision with locomotion on and off the unit, used a walker or wheelchair, at risk for developing a pressure ulcer, used pressure reducing device in the chair and the bed, and on a turning/repositioning program. Staff recorded in the resident's most current care plan, dated 7/7/11, the resident used a pressure relieving cushion in the wheelchair. Staff recorded in the resident's 8/12/11 CAAS (Care Area Assessment Summary) the resident alternated between ambulating in the hallways via a wheelchair and sleeping in bed. The resident had a history of [REDACTED]. Staff recorded the resident transferred with assistance of 1 staff and sat in the wheelchair most of the day. Staff recorded on the resident's 10/19/11 Braden assessment (tool used to identify residents at risk for the development of a pressure ulcer) the resident with a score of 14 (a score of 14 indicated the resident at moderate risk for the development of a pressure ulcer). On 10/25/11 at 8 AM observation revealed the resident in wheelchair in the dining room. At 8:37 AM, observation revealed the resident in a wheelchair by south nurses' desk, with a sensor pad alarm in place and the lap buddy in place. At 9:55 AM, observation revealed direct care staff P and S transferred the resident from the wheelchair to the toilet with the use of a gait belt. Observation revealed the resident had no open areas on the buttocks. At that time, observation revealed the seat of the resident's wheelchair lacked any type of cushioning present. On 10/25/11, at 10:00 AM, direct care staff S stated, "I got (the resident) up at 5:45 AM." This direct care staff verified the resident lacked a timely position change since 5:45 AM. This licensed staff added, "We try to reposition (the resident) every 2 hours. We try to do that to all the resident who need help with positioning. It is really hard to get to everyone since we only have 1 sit to stand lift." Staff failed to provide the resident a change of position for 4 hours and 55 minutes. On 10/25/11, at 4:41 PM, direct care staff R stated, "We try to reposition residents every 2 hours." On 10/26/11,at 3:30 PM, licensed staff B stated, "...I thought (the resident) had a cushion in the seat of (the resident's) wheelchair. The facility's prevention of pressure ulcers, revised 10/10, recorded, "...General Preventative Measures...3. For a person in a chair: a. Change position at least every hour; b. Use foam, gel or air cushion as indicated to relieve pressure..." The facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for this resident identified at risk for the development of a pressure ulcer, as the facility failed to provide a position change for 4 hours and 55 minutes and failed to provide a pressure relieving cushion in the resident's wheelchair, as care planned.

The facility had a census of 47 residents, with 3 residents reviewed with accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 2 of these sampled residents (#4 and #5) and failed to ensure 1 of these sampled resident's (#3) environment remained free of accident hazards. Findings included: - Review of resident #4's clinical record revealed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's most current care plan, reviewed on 7/7/11, directed staff to provide non-skid socks to help prevent falls, provide visual checks every 30 minutes throughout the night and whenever the resident was in the resident's room during the day, intervention dated 2/1/11 for staff to apply a pressure alarm and personal alarm at all times and staff needed to position the alarms for the resident's safety as the resident could disarm the alarms, and encourage the resident to use the call light to call for assistance with transfers. The resident's annual MDS (Minimum Data Set), dated 8/3/11, recorded the resident with a BIMS (Brief Interview for Mental Status) score of 14 (a score of 13 to 15 indicated cognition intact), required limited assistance of 1 staff with bed mobility and transfers, did not walk in the room and/or corridor, required set-up supervision with locomotion on and off the unit, used a walker or wheelchair, had 2 or more non-injury falls and 1 injury fall (major injury) since admission or prior assessment. Staff recorded in the resident's 8/12/11 CAAS (Care Area Assessment Summary) for falls the resident transferred self without the assistance of staff, the resident must be reoriented frequently, insure the personal alarm is in place at all times, and the door alarm is working properly. The resident transferred with assistance of one staff at all times. Staff recorded in the 9/6/11 nursing notes, at 3:15 AM, staff found the resident sitting on the floor by the side of the resident's bed. Staff noted the resident's alarm was in the off position and noted dried blood on the bed. When staff assessed the resident, staff noted a lot of blood on the left side of the resident's neck. Upon further inspection, staff found a spot on the left side of the resident's head, right behind the resident's ear which measured 3 inches long and raised about 3 inches around. Staff noted a gash that appeared to deep and bleeding badly. Staff applied pressure to the wound. The resident stated the resident hit the resident's head on an area protruding from the wall by the vents in the resident's room. When ambulance personnel arrived, the resident stated the resident had hit the resident's head on the TV stand that was to the right side of the resident's bed. Staff sent to the resident to the hospital for stitches and returned at 5:06 AM with 7 staples in place over the laceration to the left side of the head. Staff recorded in the 9/12/11 nursing notes, at 12:32 PM, the resident tried to stand up by self in the bathroom. The bath aide asked the resident to sit down, but the resident would not sit down and started to fall. The aide supported the resident to keep the resident from falling. In the process of losing the resident's balance, the resident brushed the resident's head against the wall and sustained a very small scrape with no bleeding present. Staff recorded in the 9/12/11 nursing notes, at 2:50 PM, staff found the resident in the resident's room, laying face down on the floor beside the resident's bed. The resident's alarm sounded. Staff went into the resident's room and found the resident on the floor. The resident stated the resident tried to set the urinal on the floor when the resident slipped out of bed. Staff assessed the resident and found no injuries. Staff implemented an intervention to remove the resident's urinal out of resident's room completely, educated resident that the resident needed to use the bathroom, use the call light, and staff could assist with the urinal, if needed. Staff recorded on the 10/5/11 nursing notes, at 10:49 AM, staff found the resident face down on floor beside the resident's bed, with a pool of blood under the resident's nose. Staff recorded the resident's nose was bloody and swollen. The resident required 4 staff members to assist the resident to bed. Staff implemented an intervention to place a PVC bed in the resident's room with a mattress beside the resident's bed. Staff scored the resident with a score of 19 (a score of 10 or higher indicated the resident at high risk for falls) on the resident's 10/21/11 fall risk assessment. Staff recorded in the 10/21/11 nursing notes, at 6:06 PM, the resident's alarm sounded, staff responded right away, and found the resident on the floor. The resident stated, " I snuck into my room and was trying to turn my TV down and fell ." Upon assessment, staff identified no injuries. On 10/25/11 at 8 AM observation revealed the resident in wheelchair in the dining room with a personal alarm attached to the back of the resident's shirt and the wheelchair. On 8:37 AM, observation revealed the resident in a wheelchair by south nurses' desk, with a sensor pad alarm in place and a lap buddy in place. On 10/25/11 at 10:00 AM, direct care staff S stated, "The resident has a low bed, has a sensor pad alarm in the wheelchair, and we keep (the resident) in eye sight... (The resident) has a sensor alarm in bed." On 10/25/11 at 10:08 AM, direct care staff S and P transferred the resident from the toilet to the resident's wheelchair, applied the lap buddy, and attached the personal alarm to the back of the resident's shirt and the wheelchair. Observation revealed the resident lacked a pressure alarm in the wheelchair, as care planned. On 10/25/11 at 11:16 AM, 11:58 AM, and 12:53 PM, revealed the resident sat in the wheelchair with a lap buddy in front of the resident and a personal alarm attached to the back of the resident's shirt and the wheelchair. On 10/25/11 at 4:54 PM, observation revealed the resident in the wheelchair, with a lap buddy in place and a personal alarm attached to the resident's shirt. On 10/26/11, at 3:30 PM, licensed staff B verified the facility failed to develop new interventions after the resident's falls on 9/6, the second fall on 9/12, and 10/21/11. The facility's falls-clinical protocol, revised 10/10, recorded, "...1...the staff..will identify pertinent interventions to try to prevent subsequent falls..." The facility's assessing falls and their causes policy, revised 10/10, recorded, "...When a resident falls, the following information should be recorded in the resident's medical record:...6. Appropriate interventions taken to prevent future falls..." The facility failed to provide adequate supervision and assistive devices to prevent accidents. The resident experienced 5 falls from 9/6/11 through 10/21/11, 3 with injuries and experienced harm as one of these injuries required staff to send the resident to the hospital for 7 staples. The facility failed to ensure the resident had a pressure alarm and a personal alarm in place at all times, as care planned, to alert staff of the resident's movements. In addition, the facility failed to develop new intervention, to prevent additional falls, following the falls on 9/6/11, the 9/12/11 fall at 12:32 PM, and on 10/21/11. - Review of resident #5's clinical record revealed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. Staff scored the resident a 13 (a score of 10 or higher indicated the resident at high risk for falls) on the resident's 10/7/11 fall risk assessment. The resident's 10/7/11 initial care plan indicated the resident at high risk for falls with interventions to refer the resident to occupational therapy, place the resident in a room near the nurses' station, remind the resident to call for help before mobilizing, and to placer the call light within the resident's reach. The resident's admission MDS (Minimum Data Set), dated 10/14/11, identified the resident with a BIMS (Brief Interview for Mental Status) score of 4 (a score of 0 to 7 indicated severe cognitive impairment), delirium and disorganized thinking continuously present, required extensive assistance of 1 staff with bed mobility, required extensive assistance of 2 staff with transfers, required extensive assistance of 2 staff with walking in the room, required set-up assistance with locomotion on and off the unit, used a walker and wheelchair, and had experienced 2 falls since admission, one with injury and one without injury. The resident's 10/25/11 care plan directed staff to refer the resident to occupational therapy as needed, place the resident in a room near the nursing station, remind the resident to call for help before mobilizing, place the call light within the resident's reach, analyze falls to determine pattern/trends, keep the resident' bed in the lowest position with the brakes locked, observe frequently and place in supervised areas when out of the bed, provide proper, well-maintained footwear with non-skid soles, and provide the resident an environment free of clutter. Staff recorded in the 10/9/11 nursing notes the resident fell on [DATE] around 11:45 PM when the resident was up in the wheelchair in the hallway, the resident got self up and tripped over the sandals the resident wore. The resident sustained [REDACTED]. Staff identified no additional injuries upon assessment. Staff implemented an intervention following the fall for the resident to wear more supportive shoes. Staff recorded on the care plan interventions for the resident to wear different shoes with better support, implemented 15 minute visual checks, and applied a personal body alarm. Staff recorded in the 10/11/11 nursing notes at 12:37 AM, staff found the resident on the floor in the resident's room laying on the resident's left side at approximately 11:45 PM. Staff assessed an abrasion to the resident's forehead, a purple bruise to the right side of the resident's cheek along the jaw line, a large skin tear to the resident's right hand which staff cleaned and applied steri-strips, a small abrasion to the resident's left knee with no bleeding noted. Staff initiated neurological checks and assisted the resident back to bed. Staff placed the resident's alarm back on the resident, out of sight, raised the bed rails, lowered the as much as possible and placed a mattress on the floor beside the bed and removed the night stand from the bedside to assist in protecting the resident. The intervention implemented by staff following the fall included to place the alarm back on the resident out of sight, keep the bed as low as it will go, place a mattress on the floor next to the resident's bed, and place the side rails in the up position. Staff recorded in the 10/15/11 nursing notes at 2:22 AM, the resident came out of the resident's wheelchair and went down to the resident's hands and knees. Staff witnessed the resident's fall. Staff did not document any type of injury from the fall. Staff implemented 15 minute visual checks and ensure the resident's personal alarm in place at all times. Staff recorded in the 10/16/11 nursing notes at 6:05 AM, the resident's alarm sounded and staff found the resident laying on the floor in the TV room. The resident had a small abrasion to left forehead. Staff assessed the resident and found the neurological assessment within normal limits. Staff implemented 15 minute visual checks. Staff recorded in the 10/23/11 nursing notes at 4:56 AM, the resident's alarm sounded in the resident's room, and staff found the resident laying on the floor in front of the resident's recliner at 12:15 AM. The resident had a small bump on the resident's forehead. Staff applied a cool moist cloth. Staff identified no open areas or other apparent injuries upon assessment. Staff recorded to continue with the 15 minute checks. Staff recorded interventions following this fall which included adaptive equipment, a bed alarm, and 15 minute visual checks. Staff failed to develop new interventions to prevent additional falls, as staff had already implemented these interventions following previous falls. Staff recorded in the 10/24/11 nursing notes at 8:13 PM, at 8:25 PM, staff found the resident on the floor in front of resident's dresser/TV cabinet laying on the resident's left side. Staff assessed the resident and found no apparent injuries. Staff recorded the resident removed the personal alarm and needed a pressure alarm, however, staff failed to locate a pressure alarm in the building. Staff recorded interventions following this fall to include adaptive equipment and a bed and wheelchair alarm. Staff failed to develop new interventions to prevent additional falls, as staff had already implemented these interventions following previous falls. Staff recorded in the 10/24/11 nursing notes at 9:45 PM, the resident personal alarm sounded. Staff found the resident on the floor, laying in the middle of the room on the resident's left side. Staff identified no injuries upon assessment. Staff assisted the resident back to bed, lowered the resident's bed, placed the personal alarm on the resident, and placed a mat beside the resident's bed. Staff initiated neurological checks. Staff failed to develop any new interventions to prevent addition falls. On 10/25/11, at 9:30 AM, observation revealed the resident in a wheelchair at the south nursing station, with a personal alarm attached to the back of the resident's shirt. Observation revealed the resident wore sandals as footwear. On 10/25/11 at 10:52 AM, observation revealed direct care staff G pushed the resident in the wheelchair into the shower room. After staff undressed the resident, observation revealed a ruby colored bruise noted to the resident's left upper back and a greenish bruise to the left shoulder, purplish bruise to back of right hip, and the resident's left eye was purplish in color, around the entire left eye. At that time, observation revealed when the direct care staff attempted to lock the resident's wheelchair break, the right side wheelchair brake failed to lock. Upon completion of the shower and dressing the resident, the direct care staff applied sandals to the resident's feet. On 10/26/11 at 3:00 PM, observation revealed the resident asleep in a recliner in the resident's room, with a personal alarm attached to the resident's shirt and the back of recliner. Observation revealed the brake on the right side of the wheelchair remained broken. On 10/26/11 at 11:05 AM, when questioned about interventions to prevent the resident from falling, direct care staff H stated, "Most of (the resident's) falls occur on the night shift. (The resident) has a high low bed. (The resident's) personal alarm broke yesterday. (The resident) has an alarm in the bed and wheelchair." On 10/26/11, at 3:30 PM, licensed staff B verified the facility failed to develop new interventions after the resident's falls on 10/15, 16, and 24/11 and verified the interventions staff implemented, after these falls, were already in place and not new interventions. The facility's falls and fall risk, managing policy, revised 12/07, recorded, "...4. If falling recurs despite initial interventions, staff will implement additional or different interventions..." The facility's falls-clinical protocol, revised 10/10, recorded, "...1...the staff..will identify pertinent interventions to try to prevent subsequent falls..." The facility's assessing falls and their causes policy, revised 10/10, recorded, "...When a resident falls, the following information should be recorded in the resident's medical record:...6. Appropriate interventions taken to prevent future falls..." The facility failed to provide adequate supervision and assistive devices to prevent accidents. The resident experienced 7 falls from 10/9/11 through 10/24/11, 4 falls with injuries. The resident's initial care plan's interventions were not appropriate due to the resident's decreased cognitive status. Also, the facility failed to provide proper footwear, as care planned following the resident's fall on 10/9/11. In addition, the facility failed to develop new interventions, to prevent additional falls, following the falls on 10/15, 16, and 24/11. - Review of the clinical record of resident #3 revealed staff admitted the resident to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's 7/26/11 MDS (Minimum Data Set) recorded the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff with bed mobility and transfers, walking in the room and/or corridor did not occur, required limited assistance of 1 staff with locomotion on and off the unit, required extensive assistance of 2 staff with toileting, and used a wheelchair. The resident's 10/11/ care plan directed staff the resident required extensive assistance of 2 staff with transfers and to keep the resident's environment clean and free of clutter. On 10/25/11 at 10:34 AM, observation revealed the toilet paper holder broken with only one side attached to the bathroom wall, below the grab bar. At that time, direct care staff P and S transferred the resident off the toilet with the sit to stand lift into the wheelchair. At that time, licensed staff F instructed these direct care staff to hold the resident's right arm toward the resident's body to prevent contact with the broken and sharp edge of the toilet paper holder and stated, "(Broken toilet paper holder) could cause a skin tear." The facility failed to ensure this resident's environment remained free of accident hazards, as the broken toilet paper holder, with a sharp edge, created the potential for skin tears.

The facility census totaled 43 residents with 38 included in the sample. Based on observation, interview and record review the facility failed to adequately assess the cause of falls, failed to implement new fall prevention interventions, failed to monitor the effectiveness of interventions and failed to provide supervision for 3 of 5 residents (#23, #32 and #50) sampled for review of accidents. Resident #50 fell numerous times suffered a fractured hip and laceration to the outside of the left eye which required sutures. Findings included: - Review of resident #50's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/14/11 identified the resident with moderately impaired cognition skills, required limited assistance with bed mobility, personal hygiene, and locomotion in the wheelchair, extensive assistance with transfers, walking, dressing, and toilet use, with two or more falls since admission. The further assessment CAAS (Care Area Assessment) were not dated and remained blank. The care plan located in the resident's computerized record contained the following interventions added on 8/5/10 "remind to use call light for assistance." On 2/1/11 staff added "use pressure alarm and tabs alarm at all times." On 2/7/11 staff added "recent hip fracture, perform frequent visual checks to ensure safety, offer assistance to the toilet upon rising, before and after meals, at bedtime and as needed. During the night offer assistance to the toilet every three hours, provide limited assist of 1 with transfers." Review of the events section in the resident's computerized record revealed the resident fell on [DATE], 1/15/11, 1/28/11, 2/1/11, 2/4/11, 3/10/11, 3/19/11 and 4/2/11. During interview on 4/12/11 at 1:00 p.m. administrative nurse B stated they did not know about all the residents falls and only found 3 fall investigations. They expected staff to add new fall prevention interventions to the care plan book located at the nurses station, but reported they did not think staff had been doing that. The care plan located in the computer, the copy printed out and the care plan for the nurse aides all identified the resident as at risk for falls but lacked new fall prevention interventions for 6 of the 8 times the resident fell . Review of the nurse's notes revealed on 1/15/11 at 2:49 p.m. the resident attempted to transfer themselves from the wheelchair to the recliner. They failed to lock their brakes and fell to the floor. On 1/24/11 the resident complained of leg pain, they sent the resident to the physician's office where an X-ray revealed a fractured hip. The resident underwent [REDACTED]. On 1/28/11 at 4:18 p.m. staff found the resident on the bathroom floor. The resident said they were trying to use the bathroom. On 2/1/11 at 3:15 p.m. the resident said they were on their way to the toilet to dump a urinal, they spilled the urinal and when they tried to wipe it up they leaned forward and fell out of the wheelchair. On 2/21/11 at 6:40 p.m. during dressing the resident lost their balance and staff lowered them to the floor. The incident caused bruising and abrasions down the right side of the resident's body. On 3/10/11 at 1:26 p.m. the resident attempted to transfer themselves to the toilet and fell . On 3/19/11 at 1:05 p.m. staff found the resident sitting on their buttocks between the recliner and the bed. Staff documented "the resident had a call light in reach but refused to use it. The resident has been told over and over again to not transfer self. The resident turns off the alarm so staff does not know when they transfer." On 3/23/11 the resident underwent [REDACTED]. A repair made 8 months prior after the resident fractured the left upper arm suffered from falls prior to admission. On 4/2/11 at 12:40 p.m. documentation revealed the resident got stuck in the mud outside while smoking, another resident tried to help the resident get unstuck, the resident fell out of wheel chair on to the ground. Staff allowed the resident to go to the outside courtyard with another resident and unsupervised by the staff. Observation on 4/7/11 at 1:28 p.m., 1:45 p.m., 2:15 p.m., 3:22 p.m. and again on 4/11/11 at 8:51 a.m. 1:00 p.m., 1:55 p.m. 2:40 p.m. revealed the resident in their room alone in an electric recliner watching TV or sleeping with the alarm attached to the recliner. On 4/7/11 at 3:37 p.m. and 4:10 p.m. and again on 4/11/11 at 10:51 a.m., 11:05 a.m., 12:30 p.m. the resident wandered about the facility independently in their wheelchair visiting with staff and other residents with the alarm attached to the back of their wheelchair. Only two nurse aides and one nurse worked this side of the building with 3 halls and a total of 20 residents. On 4/12/11 at 7:00 a.m. observation revealed staff loading the resident onto the facility van with the left side of their face bandaged with gauze. The van driver said the resident fell . On the same day at 10:03 a.m. the resident returned to the facility with a dressing to the outside of their left eye. Their left eye was red and swollen. The resident said they received 4 stitches. When asked the resident could not report how they fell . During interview on 4/12/11 at 4:26 p.m. nurse GG stated the resident fell out of the electric recliner that morning. "The resident pushes it and decides to stand and then falls." Nurse GG did not know if staff completed an assessment to ensure the resident could safely use the electric recliner. Nurse GG thought the administrative nurses should update the care plan after each fall. Review of the resident's computerized record revealed no assessment to ensure the resident could safely use the electric recliner. During interview on 4/13/11 at 7:58 a.m. administrative nurse B stated they did not think the resident fell out of the recliner and the night shift nurse reported they found the resident by the wheelchair next to the bed. Nurse B reported they had not assessed the electric recliner to ensure the resident could safely operate it. Nurse B identified the resident as very non-compliant with the alarms and took them off frequently. The facility failed to investigate the cause of each fall, failed to update the care plan with new fall prevention interventions, failed to assess if the resident could safely use the electric recliner, and failed to provide adequate supervision to prevent future falls for a resident with a history of falls. The resident fell and suffered a fractured hip and in another fall received a laceration to the side their face which required sutures. - Review of the annual MDS (minimum data set) assessment dated [DATE] identified resident #23 with no history of falls. The CAAs (care area assessments, required further assessments) for the annual assessment remained blank. Review of the significant change assessment MDS (a required assessment) with the ARD (assessment reference date) date of 3/7/11 identified the resident with the BIMS (brief interview for mental status ) with a score of 9 out of 15. A score of 9 identified the resident as moderately impaired. The assessment identified the resident did not walk in their room, no impairment in range of motion, used a wheelchair and no falls since admission. CAAs (care area assessments, required further assessments) completed 3/15/11 for falls identified the resident with impaired balance and no specific supporting documentation. Analysis of findings revealed the resident at risk for falls related to cognitive impairment, decreased mobility and psychotropic medication use. Review of the plan of care for Falls dated 2/19/10 identified the resident at risk for falls related to cognitive impairment, decreased mobility and psychotropic medications. Interventions revealed instructions for staff to "provide frequent visual checks to ensure my safety. Keep my call light within easy reach at all times. Encourage me to use call light if I feel weak or light headed. Provide adequate lighting. Keep my bed in low position. Ensure I am wearing nonskid foot wear when I am out of bed. Keep my environment clean and free of clutter. Clean spills immediately". Review of the medical record revealed the resident sustained [REDACTED]. Staff failed to revise the plan of care to address the resident's low/high blood sugars and continued falls. Interview with nurse N on 4/13/11 at 11:12 p.m., revealed when there is a fall or any change to the care plan, the nurses write it in the care plan book at the nurses' desk. Review of the care plan book at the nurses desk revealed a date of 11/11/10 with an X by fall risk. That book contained no information regarding the recent falls. Nurse N provided an additional care plan book that also lacked mention of the resident's falls. Review of the Post Fall Observation form dated 3/17/11 identified the resident fell in their room, and had either been in bed or the wheelchair before the fall. FSBS (fasting blood sugar) was 41, lethargic, diaphoretic and semi-non-responsive. Measures initiated to prevent falls were fasting blood sugars prn (as needed). A nurse's progress note dated 3/18/11 at 8:52 p.m., revealed "resident found lying on the floor in room. No injuries noted resident diaphoretic, skin cool, clammy, disoriented and lethargic. At 7:35 p.m. blood sugar taken 49, glucagon injection given, blood sugar 57 at 7:40 p.m. Orange Juice with sugar given, blood sugar at 7:49 p.m. 94. Resident more alert and states (gender) is feeling better. peanut butter sandwich given. Blood sugar at 8:10 p.m. 115. Skin warm and dry will continue to monitor." A nurse's progress note dated 3/19/11 revealed the resident continued on fall follow-up with neuro (neurological ) check WNL (within normal limits), "Resident has dime size bruises to right temple, small scratch to left eyebrow, denies pain at this time. Door to bedroom left open this shift for resident's safety". A nurse's progress note on 3/31/11 at 5:21 a.m., revealed "resident found sitting in doorway ROM (range of motion) WNL (within normal limits) for this resident, resident denies pain Blood Sugar 291, no bruising bumps or lacerations noted, doctor faxed with update and will ask 1st shift to call emergency contact later this morning." The resident fell again on 4/12/11 at 12:15 p.m. The nurse's notes revealed "resident found laying on floor in room. Resident states (gender) was ambulating from bathroom to (gender) bed and (gender) legs gave out causing (gender) to fall. No injuries noted. ROM WNL times 4 extremities. No pain or discomfort voiced. Resident states (gender) hit (gender) head on the floor. Neuros started and WNL. fax to doctor attempted to call power of attorney and no answer. will cont to monitor". Interview on 4/12/11 at 2:30 p.m., with the resident revealed they "fell at noon today" when going to the bathroom. The resident reported they used the wheelchair to go to the bathroom and when they stood up to get on the toilet, they fell . The resident reported when their blood sugar gets low, they "feel funny" and don't have feeling in their legs. The resident reported they have had several strokes and used to be more independent with walking without problems but now used a wheelchair. The resident reported during one fall last month they hit their head, but did not when they fell on this day. The resident reported staff do not do any exercises with them and they received no therapy. Interview with nurse H on 4/12/11 at 2:45 p.m., revealed the resident had falls when their blood sugar gets low, but the resident refused to to let staff monitor the blood sugar four times a day and staff only can check it one time a day. The nurse reported the resident also refused to have therapy. Observation revealed the resident kept the door to their room closed at all times. Staff failed to revise the plan of care after each fall to address the resident's refusals, and how staff would monitor the resident to prevent further falls. Interview with administrative nurse B on 4/12/11 at 2:40 p.m., revealed their unawareness of the requirement to investigate causal factors of falls to prevent further falls. The facility lacked investigations into the resident's continued falls. The facility failed to determine causal factors of the resident's continued falls and failed to develop and implement a plan of care to ensure staff provided supervision to prevent further falls. - Review of resident # 32's admission MDS (Minimum Data Set, a required assessment) 3.0 with an assessment reference date of 3-10-11 identified the resident with a BIMS (Brief interview mental status) score of 10/15 (moderate impairment) and required extensive assistance of one staff member for transfers. The MDS identified the resident with impairments on the left upper and lower extremities related to a CVA (Cerebral Vascular Accident, a rupture or occlusion to a blood vessel that leads to the lack of oxygen in the brain (www.thefreedictionary.com/CVA)) and the resident used a wheelchair for locomotion and propelled self. The MDS also identified the resident as unsteady and only able to stabilize with human assistance during transitions. Review of the resident's CAT (care area triggers) dated 3-10-11 identified the need for a further assessment for falls. The CAA (care area assessments), a further assessment used to document supporting reasons for identified risk factors, dated 3-10-11, documented the resident's risk for falls was related to psychotropic medication use, CVA with left [DIAGNOSES REDACTED] (weakness), and poor decision making skills. Review of the resident's Fall Risk Assessment, dated 3-6-11, identified the resident at high risk for falls. The assessment included referrals to the facility's fall prevention program, OT (Occupational Therapy), and PT (Physical Therapy). Record review revealed current orders dated 3-20-11 and 4-12-11 for a PT consult. The resident's record lacked evaluations and documentation from OT and PT. During an interview on 4-12-11 at 3:44 p.m. administrative nurse B revealed they had thought about having the resident start therapy due to their frequent falls. Administrative nurse B reported they did not realize the resident had 2 orders for PT and confirmed the facility's staff failed to implement the therapy orders the physician ordered. Review of the resident's care plan dated 3-23-11, identified the resident as a fall risk related to the resident's cognitive impairment and post CVA with left sided weakness. The care plan instructed the staff to provide "frequent visual checks to ensure safety, use a pressure pad alarm at all times, and provide extensive assistance with all transfers." Record review revealed the resident had a total of 7 falls in 37 days at the facility. Record review revealed the resident fell on [DATE] in their room, 3-9-11 in their bathroom, 3-20-11 in their room, 3-22-11 in their room, 4-2-11 in their room, 4-12-11 in their bathroom, and 4-13-11 outside in the front of the building. The resident reported to the facility staff, after the fall on 3-7-11, left mid abdominal pain with a bump, abrasion and redness noted to the area. The resident was treated and released from the hospital for a [DIAGNOSES REDACTED]." After each fall, the facility staff initiated the "fall prevention program." Interview on 4-13-11 at 4:32 p.m., administrative nurse B reported there was no fall prevention program in place and the facility staff haven't received training about this program. During an interview on 4-6-11 at 9:34 a.m., the resident reported they were unable to reach the call light string in their bathroom due to their left sided weakness. On 4-12-11 at 2:26 p.m. the resident reported they had fallen off of the toilet this morning while trying to reach the call light string. Observation on 4-12-11 at 2:26 p.m. revealed the call light string in the resident's bathroom was tied to the handle on the toilet. The resident reported that they were still unable to reach the call light string in the bathroom due to their left sided weakness. The facility failed to ensure the resident's environment remained free of accident hazards and implement effective interventions. Observation on 4-7-11 at 3:20 p.m. revealed the resident's tab alarm on their wheelchair with the clip hanging down and dangling between the back of the seat of the wheelchair and not attached to the resident. Observation on 4-7-11 at 4:42 p.m. revealed again the resident's tab alarm dangled down under their wheelchair. Observation on 4-11-11 at 8:32 a.m. revealed the resident's tab alarm cord hung down onto the floor. Observation on 4-11-11 at 11:46 p.m. revealed the resident's tab alarm cord touching the floor. Observation on 4-12-11 at 2:22 p.m. revealed the resident's personal alarm was not on their wheelchair and not attached to their clothing. Observation on 4-13-11 at 8:57 a.m. revealed the resident's pressure alarm beeping in their room while the resident propelled them self down the hallway in another part of the building. Observation on 4-13-11 at 9:12 a.m. revealed nurse aide S replaced the battery in the resident's tab alarm and stated "why do you keep hiding you're your tab alarm, you need to stop doing that" and then attached the tab alarm onto the resident's clothing. The resident reported "I'm not hiding it. I don't like the alarm because it scares me when it goes off." Interview on 4-12-11 at 1:46 p.m., administrative nurse B confirmed the facility failed to thoroughly investigate falls, initiate and update interventions, and failed to identify environmental hazards. The facility failed to ensure the resident's environment remained free from accident hazards and failed to provide adequate supervision to prevent further accidents. The facility failed to re-assess, plan, and implement the resident's fall prevention interventions to prevent further falls and possible injuries.

The facility census totaled 46 residents with 3 residents reviewed for accidents. The facility reported 8 residents required the use of a sit-to-stand lift for all transfers. Based on observation, record review and interview the facility failed to adequately supervise 3 of 3 sampled residents (#1002, #1004, and #1019) to ensure staff applied the sit-to-stand lift slings according to the manufacturers recommendations to ensure safe transfers to prevent accidents to the extent possible. This deficient practice had the potential to affect 5 additional residents who also required the use of the sit-to-stand lift for transfers. Findings included: - Review of resident #1002's quarterly MDS (minimum data set) with an ARD (Assessment Reference Date) of 3/18/11 identified the resident with cognitive impairment, required extensive assist of 2 with transfers. The care plan dated 3/30/11 instructed staff to use l or 2 person assist with transfers. On 6/14/11 at 10:25 a.m. observation revealed the resident sat in their high back wheelchair. The sit-to-stand lift sat in front of them. Nurse E and nurse aide D placed the sling over the resident and hooked the leg straps loosely along side the resident then raised the resident to a full standing position. The sling cut into the resident's arm pits during the transfer. This unsafe transfer placed the resident at risk for accidents. Review of the manufacturer's instructions and picture on a tag attached to the sling revealed the following directions: "Use only on Innvocare Model RPS 350 stand up lift. Maximum height 2 " above lift surface. Not intended for full standing position during transfer. " The facility's sit-to-stand lift was a Lumex LF2090 model number. The picture showed the straps were to go under the persons' thighs and between their legs and then fasten to the lift. The picture also showed the person remained in a sitting position for transfers. On 6/15/11 at 10:05 a.m. nurse aide D when asked about the placement of the leg straps for the sit-to-stand lift sling, reported "that's the way we always do it." Nurse aide C reported they had been here about one month and they only learned to use the lift from other nurse aides who worked with them. During an interview on 6/15/11 at 3:45 p.m. administrative nurse F reported new staff were shown the lift by other aides working the floor. Nurse F reported the facility had no formal training in place regarding how to use the mechanical lifts. Nurse F was unaware of the manufacturer ' s recommendations and when shown, confirmed the lift slings were not recommended for their Lumex Model. The facility failed to adequately supervise the transfers of a resident who required a sit-to-stand lift to ensure staff applied the sling jackets according to the manufacturer's recommendations and failed to provide staff with the appropriate sling recommended for the facility's sit-to-stand brand and model to ensure staff transferred the resident in a safe manner to prevent accidents to the extent possible. - Review of resident #1004's admission MDS (Minimum Data Set) with an ARD of 1/10/11 identified the resident with severe cognitive impairment, experienced short-term and long-term memory problems, resisted care 4-6 days per week and required extensive assist of 2 with transfers. The care plan dated 2/2/11 instructed staff to use a sit-to-stand lift with 2 person assist for all transfers. On 6/15/11 at 9:55 a.m. observation revealed nurse aide D and C placed the sit-to-stand lift in front of the resident and placed the sling around the resident fastening the top straps to the lift bars and the bottom straps hung on both sides of the resident and nurse aide D and C fastened them to the lift. Nurse aide D then raised the resident to a full standing position. As the lift stood the resident up the sling cut into the resident's skin under their armpits and pulled the resident's shoulders into a crunched position, placing the resident at risk for an accident by transferring the resident in an unsafe manner. The staff then proceeded to move the resident to the bed and lower them back to a sitting position on the bed. On 6/15/11 at 10:05 a.m. nurse aide D when asked about the placement of the leg straps for the sit-to-stand lift sling, reported "that's the way we always do it." Nurse aide C reported they had been here about one month and they only learned to use the lift from other nurse aides who worked with them. Review of the label on the sling jacket instructed staff to only use the sling on an Innvocare (name brand) lift with a model number RPS 350. The facility's sit-to-stand lift was a Lumex LF2090 model number. The picture showed the straps were to go under the persons' thighs and between their legs and then fasten to the lift. The picture also showed the person remained in a sitting position for transfers. The label also instructed the staff that the sling was not intended for a full standing position and should only be raised about 2". The sling was designed to allow the person to remain in a sitting position during transfers. During an interview on 6/15/11 at 3:45 p.m. administrative nurse F reported new staff were shown the lift by other aides working the floor. Nurse F reported the facility had no formal training in place regarding how to use the mechanical lifts. Nurse F was unaware of the manufacturer ' s recommendations and when shown, confirmed the lift slings were not recommended for their Lumex Model. The facility failed to adequately supervise the transfers of a resident who required a sit-to-stand lift to ensure staff applied the sling jackets according to the manufacturer's recommendations and failed to provide staff with the appropriate sling recommended for the facility's sit-to-stand brand and model to ensure staff transferred the resident in a safe manner to prevent accidents to the extent possible. - Review of resident #1019's admission MDS (minimum data set) dated 5/19/11 identified the resident with cognitive impairment and required extensive assist of 2 persons with transfers. The care plan dated 5/23/11 instructed staff to provide extensive assist of 2 with a sit-to-stand mechanical lift. On 6/15/11 at 11:20 a.m. nurse aide G reported "I'm able to get a lift and are now ready to transfer (resident's name)." Nurse aide G placed the sling around the resident's back and hooked the top straps to the lift bar appropriately but took the bottom straps of the sling and placed them along the outer side of the resident's body and hooked them to stationary bars in the front of the lift. The staff again failed to place the bottom straps under the resident's legs as the instructions and pictures showed on the label to ensure the resident was securely in the sit to stand lift. The straps dangled as nurse aide G and medication aide P lifted the resident to a full standing position, which caused the resident's shoulders to raise up while the sling cut into the residents armpits. This unsafe transfer placed the resident at risk for accidents. The label on the sling jacket instructed staff to only use the sling on an Innvocare (name brand) lift with a model number RPS 350. The facility's sit-to-stand lift was a Lumex LF2090 model number. The picture showed the straps were to go under the persons' thighs and between their legs and then fasten to the lift. The picture also showed the person remained in a sitting position for transfers. The label also instructed the staff that the sling was not intended for a full standing position and should only be raised about 2". The sling was designed to allow the person to remain in a sitting position during transfers. During an interview on 6/15/11 at 3:45 p.m. administrative nurse F reported new staff were shown the lift by other aides working the floor. Nurse F reported the facility had no formal training in place regarding how to use the mechanical lifts. Nurse F was unaware of the manufacturer's recommendations and when shown, confirmed the lift slings were not recommended for their Lumex Model. The facility failed to adequately supervise the transfers of a resident who required a sit-to-stand lift to ensure staff applied the sling jackets according to the manufacturer's recommendations and failed to provide staff with the appropriate sling recommended for the facility's sit-to-stand brand and model to ensure staff transferred the resident in a safe manner to prevent accidents to the extent possible. - During an interview on 6/15/11 at 3:45 p.m. administrative nurse F reported new staff were shown the lift by other aides working the floor. Nurse F reported the facility had no formal training in place regarding how to use the mechanical lifts. Nurse F was unaware of the manufacturer ' s recommendations and when shown, confirmed the lift slings were not recommended for their Lumex Model. The failure to have the proper sling for the sit-to-stand lift, and a lack of training on the use of the sit-to-stand lift had the potential to affect the other 5 residents for whom staff utilized the sit-to-stand lift.

The facility census totaled 43 residents with 5 residents sampled for pressure sores. Based on observation, interview and record review the facility failed to ensure, 4 of the 5 residents (#7, #14, #21 and #36) sampled for pressure sores received the necessary treatment and services to promote healing and prevent new pressure sores from developing. The facility failed to routinely assess the pressure sore, failed to notify the supervisor of the developing sore (as their policy planned) and failed to administer physician ordered treatments. Resident #7 redeveloped an avoidable pressure sore on their buttock. Findings included: - Review of the computerized physician orders [REDACTED]. (The resident had a history of [REDACTED]. The resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/11 identified the resident with severe cognitive impairment, required extensive assistance from staff for bed mobility, transfers, dressing, personal hygiene and toilet use. The MDS also identified the resident at risk for pressure sore development but with no current pressure sores. The annual MDS with an ARD of 3/18/11 identified the resident with one stage 2 pressure sore that started on 2/23/11. The staff failed to document the measurements on the MDS. The Care Area Triggers (CAT) dated 3/18/11 triggered cognitive loss, dementia, activities of daily living function, and pressure ulcers. The Care Area Assessments (CAA) failed to contain any further assessment and remained blank. The care plan dated 3/23/11 contained the interventions of "provide extensive assistance with one staff member for bed mobility, place a pillow between the resident's knees and under their ankles. Provide incontinent checks with repositioning every 2 hours during the night." The facility's policy for the prevention of pressure ulcers stated: "pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Immediately report any signs of a developing pressure ulcer to the supervisor. The facility should have a system/procedure to assure assessments are timely and appropriate. Immediately report any signs of a developing ulcer to the supervisor. The policy also contained the preventive measures of change the position of the resident at least every two hours or more frequently if needed. If a pressure ulcer is present positioning the resident on the existing ulcer should be avoided." Review of the current nurses notes revealed on 2/23/11 at 9:55 a.m. nursing staff documented the resident developed a pressure ulcer on their right buttock and a sore on their perineal area. The pressure sore on the buttock measured 6 centimeters (cm.) by 2 cm. The nurse contacted the physician and received an order for [REDACTED]. Review on 4/12/11 of the current treatment administration record (TAR) revealed the documentation for the administration of Collagen and dry dressing of choice remained blank. Nursing staff documented they administered the [MEDICATION NAME] ointment to the resident's perineal area three times a day. Review of the last skin assessment in the computer charting revealed staff completed it on 3/24/11 at 1:28 p.m. Further review of the TAR revealed instructions for staff to complete weekly skin assessments on Monday. The documentation for the skin assessments remained blank. The staff failed to complete routine skin assessments. Observation on 4/7/11 at 1:26 p.m., 2:22 p.m., 2:47 p.m. and 3:33 p.m. revealed the resident in bed on their back. The same day at 3:57 p.m. staff repositioned the resident by pulling the resident up in bed. But staff left the resident positioned on their back and at 4:37 p.m. the resident remained on their back. On 4/11/11 at 8:58 a.m. nurse aides C and D assisted the resident to bed. Observation of the resident's buttocks during incontinent care revealed one red sore, approximately 2 cm. by 2 cm. without a dressing, on the right buttocks. The nurse aides applied [MEDICATION NAME] ointment to the red sore and the resident's perineal area. The staff placed the resident onto their back in the bed, placed a pillow under the resident's ankles and but failed to place a pillow between thier knees as care planned. At 9:57 a.m., 10:32 a.m., and 10:52 a.m. the resident remained on their back. At 11:21 a.m. nurse aide C assisted the resident up into the wheelchair for lunch. After lunch the same day at 12:51 p.m. nurse aide D assisted the resident back to bed and again positioned the resident onto their back. The resident moved their legs but remained on their back at 1:30 p.m., 1:56 p.m., 2:39 p.m. and 4:00 p.m. At 4:50 p.m. nurse aides E and F assisted the resident out of bed into the wheelchair. On 4/12/11 at 10:28 a.m. the surveyor requested nurses H and X to assess the resident's buttocks. The observation revealed two red areas on the resident's buttocks. Nurse H stated the the sores only had the top layer of skin off and were not open. They measured the top area as 5 cm. by 6 cm. and did not measure the lower red area. The nurses cleaned the area with wound cleaner, applied the Collagen and covered both areas with OpSite. Nurse H stated the resident would not allow them to position them onto their side. The nurses did not attempt to position the resident onto their side and left the resident positioned on their back when they left the room. During interview on 4/12/11 at 3:49 p.m. administrative nurse B stated nursing staff failed to inform them of the pressure sore that developed on 2/23/11 and confirmed staff failed to assess the pressure sore weekly. On 4/13/11 at 2:00 p.m. observation with nurses Y and X revealed no dressings on the open sores, with [MEDICATION NAME] ointment on the sore and the resident's perineal area. After the nurses cleaned the ointment off the sore, nurse Y confirmed it as open and measured it as 2.3 cm by 6.1 cm. The red areas observed the day before had combined into one open sore. After applying the physician ordered dressings the nurses positioned the resident onto their left side with pillows. The resident remained in that same left side position resting comfortably in bed at 2:45 p.m. The facility failed to routinely assess the resident's pressure sore, failed to notify the supervisor of the developing ulcer, failed to apply the physician ordered treatment and failed to position the resident off of their back. The resident redeveloped an avoidable pressure sore on their buttocks. - Review of resident #36's physician orders [REDACTED]. Observation of the dressing change on 4/13/11 at 9:18 a.m. revealed nurse Y picked up scissors from the top of the treatment cart as they gathered supplies for the treatment. The nurse failed to place a barrier on the over bed table before placing supplies used for the treatment on the table. Nurse Y placed the measuring paper directly onto the table without a barrier and then placed the measuring paper directly onto the open sore. Nurse Y used the scissors without cleaning them off to cut the Alginate dressing and placed the dressing directly onto the open sore. During interview after the treatment nurse Y acknowledged they failed to follow good infection control practices by failing to clean off the scissors before the treatment started, then using the scissors to cut the dressing they applied directly onto the open sore. Also by failing to place a barrier on the over bed table to place the treatment supplies they contaminated the measuring paper by placing it on the unprotected table. They contaminated the resident's open sore when they placed the measuring paper on it. The facility failed to provide the necessary treatment and services to promote healing and prevent infection for a resident with a pressure sore. - Review of the significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/29/10 revealed resident #14 required total assistance of two persons for bed mobility, with one stage 3 pressure ulcer that required dressing changes. The required CAAs (care area assessments) remained blank for this assessment. Review of the quarterly MDS assessment dated [DATE] identified the resident with 2 stage 2 unhealed pressure ulcers. The resident had pressure ulcers on their mid back area and on the left heel. Review of the plan of care dated 3/9/11 for pressure ulcers included the goal for the pressure ulcer will heal without complications. The plan identified pressure ulcers on the left heel and low back. An intervention dated 2/4/10 instructed staff to "avoid transferring me with the sit to stand lift as this stretches the area on my back and prevents healing. Use the full mechanical lift and extensive assist of 2 with transfers. The care plan also included the use of an air mattress, cushion in the wheelchair, and to keep the resident's skin clean and dry. An intervention added on 3/22/11 instructed staff to provide incontinent checks with position changes every 2 hours, weekly skin assessments and to treat the left heel as ordered. Observation on 4/7/11 at 1:30 p.m., revealed the resident lying supine (on their back) in bed on an air mattress with pressure relieving boots on both feet. Observation on 4/11/11 at 7:15 a.m., revealed the resident seated at the dining room table with a soft splint boot on their left foot. At 7:35 a.m. staff served the resident their breakfast. The resident ate independently and consumed all of the meal and fluids. Observation on 4/11/11 at 9:51 a.m, revealed nurse aide C and nurse H transferred the resident to bed from the wheelchair with the sit to stand lift. As they raised the resident, the straps of the lift fit tightly under the resident's arms and pulled up on the skin on the resident's back around the pressure ulcer. The resident remained in that position while the staff changed the resident's incontinent brief. Observation revealed a dressing on the resident's back which the nurse reported "is an open area" and that they changed the dressing in the afternoon. Observation revealed a red tinge on the dressing. The staff lowered the resident into bed and covered the resident. The nurse was called to another resident's room and reported they would change the dressing to the resident's heel later. The nurse aide failed to place the heel protectors on the resident's feet and left the room. The aide reported it was their usual practice to use the sit to stand lift for transfers for the resident. The aide further reported they lacked awareness of the intervention on the care plan to not use the sit to stand lift for transfers. Nurse H reported the only time staff were to use the sit to stand lift for the resident was to transfer the resident to the shower. All other transfers, staff were to use the full sling lift. Observation on 4/11/11 at 10:22 a.m., revealed the resident remained in bed without the heel protectors in place. The resident remained in bed supine without the heel protectors until staff assisted the resident up for lunch at 11:30 a.m. Again staff used the sit to stand lift to transfer the resident from bed to the wheelchair. Observation on 4/11/11 at 11:34 a.m., staff wheeled the resident into the dining room for lunch with heel protectors in place on both feet. Observation on 4/11/11 at 2:11 p.m. revealed nurse H provided the dressing change to the resident's left heel, with assistance from nurse aide F. Nurse H removed the dressing and reported improvement in the area. The area looked dark red but not open. The nurse provided the treatment as ordered and placed both heel protectors following the dressing change. The nurse had already changed the dressing to the mid back area. Review of the Weekly Wound Report identified the mid back pressure area with a date of onset in 4/2008 and the current use of a foam dressing and air mattress with measurements of 4.3 x 1.7 x 0.3 cm (centimeters) on 2/3/11. On 3/12/11 the mid back area measured 5.3 x 3.8 x 0.2. cm. The weekly wound report identified the left heel with onset on 3/2/11 as a blister 2.8 x 2.6 x 0.3 cm air bed and booties used. On 3/16/11 the nurse identified the area as a stage 3 (full thickness tissue loss) with heavy drainage and the wound bed with 50% slough (yellow or white tissue that adheres to the ulcer bed) and 50% dark red tissue. On 4/6/11 the mid back ulcer area measured 5.4 X 2.4 X 0.2 cm with dark red tissue and 20% pale pink tissue. The left heel ulcer measured 2.5 x 2.5 cm, with 60% pale pink tissue and 40% slough. The left heel measurement showed improvement in the condition of that ulcer. On 4/13/11 at 2:00 p.m., nurse Y reported they measured the resident's mid back area at 2.4 x 2.4 cm, during the weekly wound monitoring conducted on that day. The nurse also confirmed staff were not to use the sit to stand lift for transfers except to the shower room. The nurse also reported the resident rubbed their left heel on the bed and the floor that caused the area to start as a blister. The facility failed to provide consistent care in a manner that promoted healing of pressure ulcers regarding transfers and the application of heel protectors. - Review of resident #21's medical record revealed an admission MDS (Minimum Data Set, a required assessment) dated 2/23/11 which showed the resident with short and long term memory problems, disoriented, severely impaired cognitive skills, required extensive to total assist for all ADLs (activities of daily living), and range of motion impairment of bilateral (both) upper and lower extremities. The MDS identified the resident at risk of developing pressure ulcers and with the presence of one ulcer at a Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer or blister), and two ulcers at a stage 4 (full thickness loss with the exposure of bone, tendon, or muscle). Review of resident #21's care plan, with the last review date of 3/1/11 revealed an identified problem of 'Skin breakdown: I am at risk for further skin breakdown related to incontinence, severe cognitive impairment, decreased mobility and history of skin breakdown. I have actual skin breakdown on bilateral iliac crest (upper hips) and posterior spine (back). I have a recently healed pressure ulcer on my left lateral shoulder'. Interventions included, 'nurse to perform weekly head to toe skin assessment'. It lacked any intervention related to position of the head and neck. Observations on 4/5/11 at 4:00 p.m. and 4/6/11 at 11:40 a.m. revealed the resident sat in the w/c, near the nurse's station, (gender) head bent down toward the left with no padding to prevent contact of the jaw and clavicle (collarbone) regions. When spoken to by survey staff FF, the resident opened (gender) eyes in response but made no effort to raise (gender) head. During an interview on 4/12/11 at 10:55 a.m., nurse M reported resident #21 obtained pressure ulcers on the cheek and collarbone after admission to the facility. Nurse M further reported the facility tried positioning and pillows to help prevent the resident from leaning her head down against the collarbone but the resident moved (gender) head until the pillow or cushion slipped out of place. The weekly wound measurement form dated 2/25/11 documented the presence of three pressure ulcers located on the left iliac crest, PSIS (spine), and right iliac crest. The weekly wound measurement form dated 3/16/11 documented the left iliac crest area healed and showed the development of a Stage 2 ulcer present on the coccyx. The weekly wound measurement dated 3/30/11 documented the development of two more pressure ulcers at Stage 2 on the left clavicle and the left jaw. Review of a physician's referral from dated 4/4/11 signed by a wound specialist documented, "New ulcers have developed left jaw and clavicle area. One ulcer left iliac crest healed, Remaining open." The facility failed to provide effective measures to prevent the development of two new pressure ulcers for one resident admitted with pressure ulcers.