Every finding on record at I O O F Home and Community Therapy Center

Based on clinical record review, electronic health record review, Centers for Medicare and Medicaid Services Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, facility policy, resident, and staff interviews, the facility failed to complete the Minimum Data Set (MDS) assessments to accurately reflect the tobacco status for 1 of 1 resident (Resident #6) reviewed for smoking. The facility reported a census of 76 residents.Findings Include:Resident #6's MDS assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. MDS Section J Health Conditions indicated Resident #6 did not utilize tobacco. MDS Section V Assessment Administration documented they certified the accompanying information accurately reflets resident assessment information for this resident and they collected or coordinated collection of this information on the dates specified. To the best of their knowledge, the information was collected in accordance with the applicable Medicare and Medicaid requirements. They understood that this information is used as a basis for ensuring that resident receive appropriate and quality care, as a basis for payment from federal funds. They further understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that they may be personally subjected to or may subject their organization to substantial criminal, civil, and/or administrative penalties for submitting false information. They also certified that they are authorized to submit this information by the facility on its behalf. Staff A, Registered Nurse (RN) signed the completed Section J Health Conditions on 5/30/25A physician visit Patient Plan dated 5/6/25, listed Resident #6 smoked 1 pack per day. A Smoking and Safety assessment dated [DATE] identified Resident #6 used tobacco and smoked independently. The Smoking and Safety assessment documented Resident #6 refused to wear the smoking apron after education provided. A Progress Noted dated 5/30/25 at 11:02 AM, documented Resident #6 frequently went outside to smoke. The Care Plan Report initiated 2/5/26 identified Resident #6 as a smoker. The Care Plan report directed staff as follows:1. Resident 6 can smoke unsupervised. 2. Education provided related to use of a smoking apron.3. Instruct Resident #6 on smoking risks and hazards and smoking cessation aids.4. Instruct Resident #6 on the facility policy for smoking.5. Notify the nurse if violations of the facility policy for smoking.6. Smoking assessment to be completed quarterly and as needed. The Care Plan Report lacked direction for storage of Resident #6 cigarettes and/or lighter. On 3/16/26, the facility provided a Resident List identifying Resident #6 as a smoker. On 3/18/26 at 2:10 PM Staff B, Certified Nursing Assistant (CNA), identified Resident #6 as a current smoker. On 3/18/26 at 2:26 PM the Director of Nursing (DON) verbalized the facility staff follow the RAI manual when completing the MDS. The DON verbalized she identified the error on the MDS dated [DATE], for Resident #6 but didn't know if she spoke to Staff A about it. The DON acknowledged the MDS was not accurate. The DON verbalized she expected the MDS to be coded accurately for each resident's status. On 3/18/26 at 3:33 PM, Resident #6 verbalized he is a smoker. Resident #6 verbalized he kept his cigarettes and lighter in his coat pocket located at the door to go out to smoke. Resident #6 stated he smoked in the smoking area or his car. On 3/18/26 at 3:35 PM the DON verbalized Resident #6 is supposed to keep cigarettes/lighter locked at the nurse's station or in his personal car. The DON identified Resident #6's coat near the smoking area door and reported they didn't find cigarettes/lighter in his pockets. The undated Smoking - Permitted with Limitations facility policy revealed the following:a. Residents will be assessed for independent smoking ability with the COMS-Smoking Safety Evaluation in the electronic health record, at the time of admission if they self-identify as a smoker, and with the MDS assessments.b. Cigarette lighters and matches are not allowed in resident rooms. They will be turned into the charge nurse and/or activity personnel, when not being used.The LTC RAI 3.0 User's Manual Version 1.20.1 October 2025 documented the RAI process had multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require assessments accurately reflect the resident's status. Section J Health Conditions instructed to code yes if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on clinical record review, facility document review, and staff interview the facility failed to send notice to the State Long Term Care Ombudsman for hospitalization s for 3 of 3 residents (Residents #2, #27 and #64) reviewed. The facility reported a census of 71 residents. Findings include: 1. Resident #2's Census List reviewed on 3/11/25 reflected she discharged to the hospital on 12/24/24 and returned to the facility on [DATE]. The General Nurses Note written on 12/24/24 at 3:15 PM identified an ambulance took Resident #2 to the hospital. The General Nurses Note written on 12/24/24 at 9:59 PM documented the hospital admitted Resident #2 to the hospital for outpatient observation. The N ADV Clinical Admission Note completed on 12/26/24 at 1:30 PM reflected Resident #2 returned to the facility. The Notice of Transfer Form to Long Term Care Ombudsman for December 2024 lacked documentation of Resident #2's transfer to the hospital. 2. Resident #27's Census List reviewed 3/13/25 identified he transferred to the hospital on 11/20/24 and returned to the facility on [DATE]. The General Nurses Note written on 11/20/24 at 7:30 AM reflected Resident #27 transferred to the hospital by ambulance. The N ADV Clinical Admission Note written on 11/22/24 at 2:16 PM identified Resident #27 returned from the hospital. The Notice of Transfer Form to the Long-Term Care Ombudsman report for November 2024 lacked documentation of Resident #27's transfer to the hospital. 3. Resident #64's Census List reviewed 3/13/25 indicated she transferred to the hospital on 1/19/25 and returned to the facility on [DATE]. The General Nurses Note written on 1/19/25 at 2:15 PM reflected Resident #64 transferred to the hospital. The General Nurses Note written on 1/19/25 at 6:32 PM identified Resident #64 admitted to the hospital. The N ADV Clinical Admission Note completed on 1/27/25 at 1:52 PM reflected Resident #64 returned to the facility. The Notice of Transfer Form to the Long-Term Care Ombudsman report for January 2025 lacked documentation of Resident #64's transfer to the hospital. In an interview on 3/12/25 at 2:50 PM Staff A, License Practical Nurse/ Admissions Coordinator, reported she added the residents to the Ombudsman's report each month who have discharged . She reported she didn't know that anything else needed to be on the report such as hospitalization s so she missed putting the residents on the list.

Based on record review, staff interview the facility failed to complete a discharge Minimum Data Set (MDS) for 1 of 5 residents reviewed (Resident #2) for discharge. The facility reported a census of 71 residents. Findings include: Resident #2's Census List reviewed on 3/11/25 reflected she discharged to the hospital on 12/24/24 and returned to the facility on [DATE]. Resident #2's MDS log reviewed 3/11/25 reflected a quarterly MDS assessment on 10/11/24 with a Entry MDS assessment on 12/26/24. The list lacked an assessment completed for her discharge on 12/24/25. The electronic health record listed the next tracking/discharge due as: Discharge - assessment reference date (ARD) 12/24/24, 63 days overdue. During an interview on 3/13/25 at 9:49 AM the MDS Coordinator reported she didn't know Resident #2 discharged to the hospital and if she could complete a late MDS. During an interview on 3/13/25 at 9:57 AM the Director of Nursing (DON) explained the MDS Coordinator would complete a late discharge MDS for Resident #2 that day to comply. She added she expected the MDS assessment get completed timely.

Based on observation, record review, staff interviews and policy review the facility failed to ensure 1 of 3 residents with a facility acquired pressure ulcer were provided with proper assessment and treatment to prevent pressure ulcers while living at the facility (Resident #66). The facility reported a census of 71 residents. The facility fixed the concern on 3/7/25, prior to the survey start through the following action plan: a. 2/27/25: The Director of Nursing (DON), or Assistant Director of Nursing (DON) if the DON is absent, would double check all new admission/readmission orders. b. 2/28/25: The facility checked all residents to ensure no other residents affected. c. 3/7/25: Anytime a resident has an order to wear any device fitted on a resident extremity (such as a brace), the standing order will be for the nurse to remove or loosen the device and check the skin twice a day. d. 3/7/25: Unit managers to check details of any new device/brace orders entered in the electronic health record (EHR) to ensure nurse will check the skin under the device twice a day. e. 3/7/25: Each nursing station will have skin monitoring forms for the Certified Nurse Aides (CNA). The facility conducted a meeting to remind staff of how to use the form. Findings include: Resident #66's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive impairment. Resident #66 required total assistance from staff for toileting, showering, bathing, and dressing. Resident #66 couldn't stand, transfer to the toilet or walk. The MDS included diagnoses of cancer, hypertension (high blood pressure), anemia (low blood iron levels), diabetes mellitus, bacteriuria (bacteria in the urine), and a left hip fracture. The MDS reflected Resident #66 had a risk for developing pressure ulcers/injuries. At the time of assessment Resident #66 didn't have one or more unhealed pressure ulcers/injuries. Resident #66 received an antihyperglycemic medication during the lookback period. The N ADV Clinical Admission Note dated 12/31/24 at 1:45 PM indicated Resident #66 had a knee immobilizer on her upper leg and a bilateral Podus boots (specialized boots used to prevent pressure to the heels and hip rotation) to be worn at all times. The functional note listed Resident #66 as non-weight bearing (NWB) on the left lower extremity and used an immobilizer on her left leg. Resident #66's Hospital Clinical Summary dated 12/31/24 listed her transfer orders for restricted activities as toe-touch weight bearing to her left lower extremity with a knee immobilizer on at all time. Remove/loosen brace for twice daily skin checks. Resident #66's January 2025 Treatment Administration Record (TAR) lacked the restricted activities order for the toe-touch weight bearing, the knee immobilizer, and the removal of the brace twice daily for skin checks. The TAR did include an order dated 12/31/24 to apply Eucerin Advanced Repair cream to both of her legs every morning and night for dryness. The Doctor Visit Form dated 1/9/25 reflected the facility requested to get a second immobilizer due to Resident #66 complaining of extreme pain to her leg. The provider responded the fracture appeared stable, continue with care - NWB, toe-touch weight bearing for balance. No knee range of motion (ROM), may do quad sets with knee brace on. The Doctor Visit Form dated 1/20/25 listed the reason for visit as follow-up visit with orthopedics. The doctor's instructions directed NWB to left lower extremity, follow-up in 6 weeks, keep left knee immobilizer on at all times (may remove for hygiene, showers, and home physical therapy (PT) exercises. The additional comments included to avoid falls, ice, and elevation. The 2/6/24 Encounter Note completed by Staff F, Advanced Registered Nurse Practitioner (ARNP) documented Resident #66 used an immobilizer. The assessment of the skin reflected it as dry, with no unusual rashes, lesions, or excessive bruising. The note reflected the leg had normal color with the immobilizer intact to her left lower extremity. The Doctor Visit Form dated 2/24/25 listed the reason for visit as follow-up with orthopedics. The doctor's instruction section included to continue toe-touch weight bearing to her left lower extremity for 6 weeks, follow-up in 6 weeks, and additional PT orders. Resident #66's February 2025 TAR included the following orders: a. Eucerin Advanced Repair Cream dated 12/31/24 - apply to bilateral lower extremities every morning and bedtime for dryness. b. Hinge Brace on left knee at all times dated 2/25/25, discontinued 2/26/25. c. Per provider dictation on 2/24/25 Left leg hinged knee brace to be worn at all times dated 2/26/25: Can be removed for showers only. The Incident Report dated 2/25/25 at 1:45 PM identified Resident #66 had a skin issue that measured 8 centimeters (cm) by (x) 3 cm x 0.1 cm with a small amount of red drainage. The provider gave an order for cephalexin (antibiotic) 500 milligrams (mg) 4 times a day for 7 days for wound healing. The report listed the root cause as wearing left leg immobilizer at all times until 2/24/25. The untitled handwritten document dated 2/25/25 written by Staff C, Certified Nurse Aide (CNA), documented she did care on Resident #66 daily and she didn't see any open areas on her when Staff D, CNA, gave her a bath the week before. She added Resident #66 didn't have her brace on at the time and she didn't see any open areas. Staff C reported that day as the first time she ever saw an open area to her lower leg. The untitled handwritten document dated 2/26/25 by Staff B, Registered Nurse (RN), documented on 2/24/25 she removed Resident #66 boot and socks to lotion her lower extremities (legs). At that time, she saw her legs dry and scaly but she didn't notice any open wounds. The untitled handwritten document dated 2/26/25 by Staff D documented on 2/19/25 she gave Resident #66 a bath and removed her leg brace from her leg and applied lotion to them, she didn't see a sore. The 2/27/24 Encounter Note completed by Staff F, Advanced Registered Nurse Practitioner (ARNP) documented Resident #66 had a new skin concern the nursing staff found on 2/25/25. The note described the area as an unstable pressure ulcer on her left lower extremity caused by the bar of her knee immobilizer. The area measured 8 cm x 3 cm x 0.1 cm with cellulitis from the knee to the ankle. The wound had a small amount pink drainage. The wound had 70% slough (dead, non-viable tissue that forms on the surface of a wound), 25% eschar (dead tissue that appears dry, thick, and leathery, often appearing tan, brown, or black) and 5% granulation tissue (a type of new, temporary tissue that forms in response to an injury or wound). During an interview on 3/12/25 at 2:38 PM the Director of Nursing reported she didn't have documentation that the facility staff completed twice a day assessments for the removal of the immobilizer. A letter written by Staff F dated 3/13/25 reflected Resident #66 had an unstageable pressure ulcer to her left lateral lower extremity. The nursing staff noted the wound on 2/25/25. Staff F suspected the appearance and quick deterioration of the wound is secondary to the underlying comorbidities (multiple diagnoses), including type 2 diabetes and a history of chondrosarcoma s/p (has a history of chondrosarcoma, a rare type of tumor that usually begins in the bones, and went through a form of treatment, like surgery, radiation, or chemotherapy), and current immobility secondary to left femur fracture being conservatively managed and known poor nutritional intake. Resident #66 has thick scales of hyperkeratosis (a condition characterized by thickening of the outermost layer of skin (stratum corneum) due to an overproduction of keratin, often appearing as calluses, corns, or rough patches) on her left lower extremity that likely masked any developing concerns with tissue integrity. During an interview on 3/13/25 at 11:35 AM the Administrator explain he expected the staff to document on the TAR the completion of twice a day removal and skin assessment of Resident #66's immobilizer.

Based on observation, policy review, and staff interview the facility failed to maintain safe holding temperatures of 135 degrees Fahrenheit for hot foods and under 41 degrees Fahrenheit for cold foods to prevent foodborne illness. The facility reported a census of 63. Findings include: Premeal temperatures taken on 3/19/24 at 11:42 AM revealed the pureed vegetables and gravy were not heated to an internal temperature of 135 degrees Fahrenheit ( F) before being served to residents. The vegetables reached a temperature of 125.7 F and the gravy 134.7 F directly before being plated. Post meal temperatures taken at 12:32 PM revealed the following foods did not maintain the internal holding temperature of 135 F: a. Pureed vegetables (on unit): 125.1 F b. Ground Pork (on unit): 100.0 F c. Pork loin (on unit): 102.0 F d. Sweet potatoes (on unit): 128.0 F e. Gravy (on unit): 120.0 F An observation on 3/19/24 at 12:47 PM revealed the steam table was not plugged in on the back unit. The pork loin was placed on the counter, not on the steam table. An observation on 3/21/24 on the back unit from 7:48 AM to 8:26 AM revealed the milk set directly on the counter for the duration of the breakfast meal. The post meal temperature was 58.5 F. The undated facility policy titled Safe Food Preparation: Final Cooking Temperatures instructed staff to cook fresh, frozen, or canned fruits and vegetables to a hot holding temperature of 135 F to prevent the growth of pathogenic bacteria. It further delineated the use of a steam table to heat food as unacceptable. The undated facility policy titled Food Distribution: Tray line and Alternative Meal Preparation and Service Area instructed staff to avoid risks including holding foods in danger zone temperatures which are between 41 F and 141 F and using steam tables to heat food. It further instructed staff to reheat hot pureed, ground, or diced foods that have fallen below 141 F to reach 165 F for 15 seconds prior to serving. The undated facility policy titled Food Service and Distribution instructed staff to avoid food handling risks including food left on trays or countertops beyond safe time and/or temperature requirements. During an interview on 3/21/24 at 8:45 AM the Food Services Supervisor reported he expected foods to be cooked to the correct initial temperature indicated on the menu chart. Altered consistency foods must be brought back to temperature in the oven and then placed on the steam table. He expected anything not up to temperature upon cooking to go back into the oven before going on the steam table. He reported anything on the steam table needs to be 135 F or above for service. He explained milk must be on ice to keep below 41 F and cold items that can spoil must be kept under 41 F. He confirmed staff must follow the policies and have been trained on them.

Based on observation, policy review, and staff interview the facility failed to keep the kitchen area clean, use gloves appropriately for assembling and serving meals, keep hands off the drinking surfaces of glasses, keep bare hands off of foods, and keep serving utensils clean in order to serve meals under sanitary conditions. The facility reported a census of 63 residents. Findings include: During an observation of the kitchen on 3/18/24 at 11:10 AM, food particles were present on the floor throughout the kitchen and on the bottom shelf of the steam table where resident insulated lids were stored. Food particles continued to be present during an observation on 3/19/24 at 11:13 AM. An observation on 3/20/24 at 11:06 AM revealed food particles on the floor and steam table along with crumbs on the counter near the clean plates, bread crumbs coating the counter near the toaster, and paper and a cleaning cloth on the floor near the dish washing station. During an observation of the noon meal on 3/18/24 from 11:52 to 12:38, Staff A, Environmental Aide, Staff B, Certified Nursing Assistant (CNA), Staff C, Certified Medication Aide (CMA), and the Food Services Supervisor (FSS) served 12 glasses to 7 residents in the main dining area handling the cups with fingers on the drinking rim surface of the glasses. During a continuous observation of puree preparation on 3/19/24 from 11:01 AM to 11:40 AM, Staff D, Dietary Staff failed to measure out portion sizes prior to pureeing the pork, mixed vegetables, and sweet potatoes. He then failed to measure the volume of the pureed pork, mixed vegetables, sweet potatoes, and cake after altering consistency. He divided the food into containers for the front and back dining rooms without measuring for the requisite number of residents. During a continuous observation of the puree preparation on 3/20/24 from 11:02 AM to 11:39 AM Staff E, Dietary Staff failed to measure the volume of the ground beef, pureed steak, and pureed cake after altering consistency. She divided the food into containers for the front and back dining rooms without measuring for the requisite number of residents. An observation of the noon meal preparation on 3/19/24 revealed the following: A. At 12:07 PM The FSS failed to secure the scoop for the sweet potatoes. The handle he touched with his bare hands fell into the dish. The affected food was then served to residents and the scoop was not replaced. B. At 12:16 PM Staff D wore gloves and touched a butter knife to spread butter onto a sandwich. He then failed to change gloves and touched the bread, meat, and cheese and assembled the sandwich. C. At 12:16 PM Staff H, Dietary Staff wore gloves to assemble a sandwich. He failed to change gloves after he touched the spatula to flip the sandwich and then used his hands to assist in turning it. He failed to change gloves after closing the lid of the cheese container and then touched the sandwich to plate it. D. At 12:20 PM The FSS used tongs to remove the lid from a pan. He then used the tongs to take a burger patty out and then to place the lid back on. E. At 12:26 PM Staff H wore gloves and opened a chip bag. He failed to change gloves and then touched a hot dog and chips in the bag. F. At 12:38 PM Staff D wore gloves and untied and opened a bread bag. He failed to change his gloves and then touched bread. He failed to change his gloves after he opened the lid to the cheese container and then touched the cheese. An observation of the noon meal preparation on 3/20/24 revealed the following: A. At 11:58 AM Staff I, Dietary Staff wore gloves and took bread out of a bag. He then touched plates, the oven handle, and his glasses. He failed to change gloves and then retouched the bread. B. At 11:59 AM Desserts were transported uncovered to the back units. C. At 12:18 PM Staff G, Dietary Staff grabbed the food lid with her bare hand and placed it face down on the counter. She replaced the lid on the food with her bare hands and placed serving tongs on top of the food lid. She proceeded to serve 8 residents with the tongs. In an interview on 3/19/24 at 11:01 AM Staff D explained he eyeballs the number of slices and amounts of food to puree. He makes sure there is enough left for the residents on normal diets and goes from there. The undated facility policy titled Safe Food Preparation: Cross-Contamination instructed staff to clean and sanitize work surfaces and food-contact equipment between uses. The undated facility policy titled Food Distribution: Tray Line and Alternative Meal Preparation and Service Area instructed staff to avoid risks including handling food with bare hands or improperly handling equipment and utensils. The undated facility policy titled Food Distribution instructed staff to cover all foods transported through public corridors. The facility lacked a policy on handling of dishes, puree procedures, and use of gloves in food preparation. During an interview on 3/21/24 at 8:45 AM FSS indicated his expectation of the puree process was for staff to start with one more serving than needed, puree the food, divide it into the two serving tins for the front and back units, and use the indicated scoop size from the menu book to serve the food. He further acknowledged that he had not considered the reduction in volume. He voiced he was not aware of the pureed diet portion sizes chart. He reported he expected staff to clean as they go and clean the whole area after each shift. He confirmed staff must wear gloves when handling ready to eat foods or assembling a sandwich. They are not to touch multiple surfaces when wearing gloves. He expected staff to use tongs to get bread or chips out of bags. They are not to use the same tongs to get both items. Staff are not to touch any food bare handed. He explained they are to handle the bottom half of cups and not on the rim where residents put their mouths. He confirmed staff must follow the policies and have been trained on them. 42134 2. During an observation on 3/18/24 at 12:26 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #45. During an observation on 3/18/24 at 12:32 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #13. During an observation on 3/18/24 at 12:33 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #66. During an observation on 3/18/24 at 12:39 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #2.

Based on facility record review and staff interviews, the facility failed to provide satisfactory evidence that they identified their own high risk, high volume, and problem-prone quality deficiencies, and made a good faith attempt to correct them. The facility reported a census of 63 residents. Findings include: Review of the facility records, revealed repeated deficient practices identified during the facility's previous survey completed on 12/15/22, during a complaint and facility reported incident survey completed on 8/11/23 and current survey investigations. During an interview on 3/21/24 at 10:28 AM, the DON reported QA meets monthly and go over each department's areas, audit and concerns. She reports prior deficiencies from previous surveys are talked discussed at the meeting. Each month will go over the concerns and the corrective actions in place. The QAPI Plan dated August 2023 directed the facility will examine and improve care or services in areas that are identified as needed attention. It directs the committee meets monthly to go over the plan, interventions and continue to monitor the effectiveness.

Based on record review, staff interview, and policy review the facility failed to ensure 1 of 3 residents reviewed for catheters (Resident #37) Care Plan was updated to inform and instruct staff of the reason and how to care for his catheter. The facility reported a census of 63 residents. Findings include: Record review of Resident #37's Progress Notes on 2/28/24 revealed a new order for catheter. Record review of Resident #37's Telephone Order dated 2/28/24 revealed a new order for a catheter. Record review of Resident #37's current Care Plan on 3/19/24 did not include that he had a catheter. During an interview on 3/20/24 at 1:40 PM the MDS Coordinator revealed she would Care Plan if a resident would have a catheter placed while living at the facility, she stated she would put it on the Care Plan as soon as she found out about it. Review of an undated facility policy, Care Planning Comprehensive Care, lacked instruction on when to update Care Plans for changes in nursing care needs.

Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual the facility failed to ensure 2 of 4 residents (Resident #37 and #57) Significant Change Minimum Data Set (MDS) assessments were completed within 14 days of identifying a significant change occurred. The facility reported a census of 63 residents. Findings include: 1. Record review of Resident #37's Hospice Certification and Plan of Care dated 2/27/2024 documented he went on Hospice services on 2/27/24. Record review of Resident #37 Progress Notes revealed on 2/27/24 a hospice nurse came to the facility and signed Resident #37 up for hospice services. Record review on 3/19/24 of Resident #37's Significant Change MDS dated [DATE] revealed the MDS was not completed. Record review of the current RAI Manual dated 10/2023 on page 2-25 instructed the following: A Significant Change MDS is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Significant Change MDS date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A Significant Change MDS must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing. 42134 2. Clinical record review for Resident #57 revealed a certification for hospice services beginning on 2/19/24. The MDS for Resident #57 was signed as complete on 3/13/24. This is outside the required 14-day time frame. During an interview on 3/20/24 at 1:40 PM the MDS Coordinator explained she thought she had 14 days after a significant change was identified to set an Assessment Reference Date. She further explained she thought she had an additional 14 days to complete the MDS assessment. She acknowledged the MDS for Resident #57 was outside the 14 days required time frame. She stated the facility did not have a policy for MDS completion, they follow the RAI Manual.

Based on record review and staff interview the facility failed to ensure all diagnoses that were present on admission were on the Preadmission Screening and Resident Review (PASRR) upon admission to the facility for 1 of 1 residents (Resident #49). The facility reported a census of 63 residents. Findings include: Record review of Resident #49's PASRR dated 11/29/2023 documented resident had one (1) mental health diagnosis, major depressive disorder. Record review of Resident #49's current diagnosis upon admission to the facility on the, Transfer/Discharge Report dated 11/30/2023 included six (6) mental health diagnosis: pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), delusional disorders, major depressive disorder, other symptoms and signs involving cognitive functions and awareness, adjustment disorder with mixed disturbance of emotions and conduct, and anxiety disorder due to known physiological condition. During an interview with the Social Worker on 3/20/2024 at 12:10 PM revealed Resident #49's PASRR did not include all of his current diagnosis and she just submitted a new PASRR to the local agency with all of his mental health diagnosis to review. During an interview with the Social Worker and Admission Coordinator on 3/20/24 at 12:41 PM revealed they do not currently have a process in place to compare and review new resident admission diagnosis and what's on the PASRR to ensure they match, but they are going to start now.

Based on observation, staff interview, resident interview, resident council minutes, food temperature logs and facility policy review the facility failed to store, prepare, distribute and serve food in accordance with the professional standards for food service safety. This failure resulted in an Immediate Jeopardy to the health, safety and security of the residents. The facility identified a census of 67 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 10, 2023 on August 10, 2023 at 5:19 PM. The Facility Staff removed the immediacy on August 10, 2023 through the following actions: a. Assurance the facility contracted dietary personnel had been educated on proper food storage, preparation and procurement. b. Kitchen shut down and thoroughly cleaned and sanitized. c. Termination of management contracted dietary personal. d. On August 10th, the facility ordered and brought in pizza for the residents. The evening meal was served with paper plates, cups and sanitized silver ware. Resident diets were followed as ordered. e. Three more professional grade fly traps were ordered on 8/10/23. The scope was lowered from a L to F at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: An observation on 8/9/23 at 5:15 p.m. revealed the following in the kitchen: a. Multiple flies which landed on food, utensils, dishes, cookware, food prep and service areas and the people in the kitchen. b. No temperature book available per Staff D, a contracted cook/dietary staff who confirmed she failed to check food temperatures. c. Meal served had been tater tot casserole, which was not on the menu. The casserole portion of the meal had been ground in the food processor per Staff D which had been planned to have been served to all residents. The directive of the ground casserole portion came from Staff E, the contracted cook/dietary staff. d. As Surveyor stood beside the hot service table noted flies as they swarmed around my person and landed on the food and the food service and preparation area and utensils. e. Noted sticky fly traps which hung from the ceiling above a clean prep area just inside the kitchen door which contained clean dishes, glassware and condiments also above the hand washing station to the right of the ice machine. Both fly traps contained multiple dead flies adhered to the trap. An observation on 8/9/23 at 6 p.m. revealed Staff F, contracted dietary staff/dietary manager as she gloved her hands and began to prepare and cook grilled cheese sandwiches. The contracted staff member proceeded to touch her person, clothes, surface areas in the kitchen and food items. The staff member failed to remove her gloves until directed by the facility Administrator who had been present in the kitchen. During an interview on 8/9/23 at 6:50 p.m. Staff F confirmed there had always been that many flies in the entire kitchen area since she started working 3 months prior. An observation at the same time revealed continued flies on food, utensils, plates, silverware, glasses and various serving and prep areas in the kitchen. Facility photos revealed the following on 8/9/23 as timed below: a. 5:57 p.m. - A cell phone plugged in an outlet and sat on a clean surface area in the kitchen next to clean pitchers, glasses and condiments and a fly trap that hung above the same area with multiple flies adhered to the surface area and the same type of fly trap that sat directly on top of a paper towel dispenser above a hand washing station to the right of the ice machine in the kitchen. b. 5:58 a.m. - A fly that rested on a cloth hot pad located on a food serving surface area, a fly on the surface area attached to the front of the stove with an uncovered grill cheese sandwich within inches, a fly on the surface area of a food prep table. c. 6:01 p.m.- The only sanitation bucket located by the 3 stall sink in the back room of the kitchen. At 6:01 p.m. Staff F tested the sanitation level of the bucket which registered 0. (normal = 150-400) The observation had been confirmed by the facilities Administrator. d. 6:22 p.m. - A fly on the handle of a metal cart that contained clean serving bowls, cooking utensils and plate covers. e. 6:25 p.m. - Dust, dirt, debris and food on the floor under the metal storage racks in the dry food pantry. f. 6:42 p.m. - Dust, dirt and debris on the floor behind the stove in the kitchen. g. 7:03 p.m. - A drain on the floor under the sink located on a food prep area in the middle of the main kitchen, behind the food service area and in front of the stove with a large amount of build up of grease, old food, a bowl and lid. The drain had been plugged by a soiled white cloth. An observation on 8/10/23 at 12:00 p.m. revealed the dietary department's contracted Regional Director in the kitchen as he used his bare hands to squeeze butter out of 2 separate small plastic containers directly onto 2 bread slices. Once the Director noted the Surveyor had been present he went to a handwashing sink in the dishwashing area, washed his hands and left the kitchen. The contracted Regional Director left the bread unattended. Upon Surveyor's exit of the kitchen at 12:15 p.m. the Director had not returned. An observation as the same time as above revealed Staff G, contracted cook/dietary staff with gloved hands as she touched her person, kitchen surface areas and serving utensils as flies swarmed around and landed on those same items. Facility photos revealed the following photos taken on 8.10.23 as timed below: a. 12:04 p.m. - A fly that rested on a cloth hot pad located on a food serving surface area. b. 12:08 p.m. - The same fly trap that hung above a clean serving/surface area in the kitchen that contained clean coffee mugs, condiments and various other kitchen items. c. 2:44 p.m. - A build up of dust, dirt and debris on the floor in the walk in refrigerator in the kitchen area. 2:45 p.m. - Ricotta Con Latte Whole Milk all natural cheese best if used by 7.25.23, an unmarked and unlabeled plastic baggie and a large bowl of cut up mixed fruit with the appearance of cantaloupe and muskmelon. 2:46 p.m. - A large bag of shredded lettuce not labeled or dated which began to turn brown along the edges. d. 2:46 p.m. - A build up of dust, dirt and debris on the floor located in the walk in freezer located in the kitchen area. 2:47 p.m. - A bag of what appeared to have been pre-made round frozen chocolate chip cookies not dated or labeled, a bag that contained unknown white round objects, opened and not dated or labeled and an opened bag with a hole in it which contained brown/tan round frozen items with the appearance of chicken nuggets, not labeled or dated. e. 2:48 p.m. - Dust, dirt, food and debris on the floor under the metal storage racks in the dry food pantry remained. f. 2:49 p.m. - Thickened orange juice stored in the dry food area not dated, various types of dry cereal stored in large clear plastic containers located on the counter in the kitchen not dated or labeled. g. 2:50 p.m. - A plastic covered open cardboard container of au gratin potatoes not dated located on a food service area counter. h. 2:51 p.m. - In the refrigerator located beside the serving table in the kitchen a bowl of what appeared to have been lettuce labeled BT (unknown what BT meant) and dated 2.27.23 (outdated) and an opened savory roasted beef base not dated. 2:52 p.m. - A bowl of onions not covered, labeled or dated, a large bag of opened wilted lettuce not dated or labeled, a half of a squeeze bottle of a thickened brown/tan food item with the appearance of caramel not dated or labeled and an opened stick of butter in a plastic baggie not dated. 2:53 p.m. - A large, clear, plastic storage container of what appeared to have been a cold bean salad not dated or labeled. 2:55 p.m. - A large, clear, plastic storage container of what appeared to have been pickles not dated or labeled. 2:55 p.m. - A large, clear, plastic storage container of what appeared to have been cooked chicken or turkey dated 8.2.23 at 1:35 p.m. outdated and not labeled. i. 2:56 p.m. - A fly located on a tub of clean dishes. j. 2:57 p.m. - An undated container of peanut butter on the serving counter in the kitchen, a fly on a large sheet of wax paper stored on a bottom shelf in the kitchen area and a build up of dust, dirt and debris on the floor along the wall and floor between the ice machine and prep table in the main kitchen area. k. 2:59 p.m. - A build up of food debris on a shelf to the right of the serving table that contained lids to meal plates/trays and plates. l. 5:39 p.m. - A build up of dust, dirt and debris on a running osculating fan that blew directly on clean dishes in the dishwashing area. During an interview on 8/11/23 at approximately 10:15 a.m. Staff B, Certified Nursing Assistant (CNA) provided pictures of moldy food served to residents. The staff member indicated 2 residents ate the moldy blueberry muffin before she retrieved the rest of the muffins served to other residents. A photo dated 5/28/23 at 8:43 a.m. revealed a blueberry muffin with white mold along the upper surface area. During an interview on 8/10/23 at 11:18 a.m. Staff H, CNA confirmed he noticed flies in the dining room and they seemed to have always flown around. The staff member looked at the picture of the bucket of sanitizing agent identified above and confirmed the test strip registered 0. The staff member also verbalized his biggest concern at the facility had been the cleanliness of the kitchen and they failed to serve what had been identified on the menu. During an interview on 8/10/23 at 11:32 a.m. Staff I, Certified Medication Aide (CMA) indicated she spent about 1/2 of her time in the day in the dining room and noticed an abundance of flies in that area as well as the kitchen. The staff member stated she felt the entire kitchen needed to have been wiped out. During an interview on 8/10/23 at 2:14 p.m. Staff A, CNA confirmed she ate at the facility and at times the food had been served cold. The staff member looked at the picture of the bucket of sanitizing agent identified above and confirmed the test strip registered 0. During an interview on 8/9/23 at 2:56 p.m. Resident #4 confirmed the facilities food as cold a majority of the time and with no flavor. During an interview on 8/9/23 at 2:56 p.m. Resident #5 confirmed the facility served cold food. Resident Council Minute forms revealed the following resident concerns as dated: a. 6.5.23 (no time documented) - Cold baked potatoes served 6/4/23 for the evening meal. b. 8.8.23 (no time documented) - Food temperatures still not corrected. According to Service Line Checklist forms the facility staff failed to check temperatures for the meals documented below as dated: a. 8/2/23 - The dinner meal. b. 8/3/23 - All meals. c. 8/8/23 - The dinner meal. A Food: Preparation policy, revised 9/2017 included the following procedures: a. All staff practiced proper hand washing techniques and glove use. b. Dining services staff had been responsible for food preparation procedures that avoided contamination by potentially harmful physical, biological and chemical contamination. c. All utensils, food contact equipment and food contact surfaces would be cleaned and sanitized after every use. The Environment policy revised 9/2017 identified all food preparation areas, food service areas and dining areas would have been maintained in a clean and sanitary condition. A Pest Control policy revised 9/2017 identified a program established for the control of insects and rodents for the dining services department. The procedures included the following: a. All food preparation, service and storage areas would have been monitored regularly for any signs of pest/vermin.

Based on observation, clinical record review, staff interview, resident interview, Nurse Practitioner (NP) interview and facility policy review, the facility failed to ensure staff maintained a safe and secure environment for 1 of 3 residents reviewed, (Resident #1). The facility identified a census of 67 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 2/17/23 indicated Resident #1 had diagnosis that included alzheimer's disease, anxiety and depression. The assessment indicated the resident rarely made self understood or understood others, had severely impaired cognitive skills, continuous inattention and fluctuating disorganized thinking. The resident exhibited physical, verbal and other behaviors 1 to 3 days out of the look back period of 7 days. The resident required limited assistance of one staff member with transfers, supervision with ambulation and sustained 2 falls without injury. A Care Plan addressed the following Focus and Intervention areas as dated: a. Dependent on staff with emotional, intellectual, physical, and social needs related to cognitive deficits. (initiated 3/22/17) b. I required more assistance with my activities of daily living due to a diagnosis of dementia and alzheimer's disease. I had a history of a stroke from 2017. My abilities fluctuated throughout the course of the day based on cognition. (initiated 3/31/17) c. Impaired cognitive function and impaired thought processes related to dementia and alzheimer's. 1. Resident to resident altercation 10/28/19 and 11/1/19. d. At risk for falls related to dementia, wandering, use of psychotropic medications, inability to voice wants/needs and a decline in condition as my disease progressed. 1. Found on the floor in the lobby. (initiated 10/17/22) 2. On floor and hit head on table. (initiated 12/24/22) 3. Sat on recliner, missed and slid to floor with no injuries. (initiated 12/6/22) 4. On floor near bedroom door without injuries. (initiated 2/5/23) 5. On floor in room with a cut in her mouth. (initiated 3/18/23) An Incident Report form dated 4/24/23 at 4:20 p.m. included the following documentation: The nurse had been called to weather b way. Found resident as she sat up on her buttock and clutched the right knee and cried out in pain. A 2 centimeter (cm) skin tear noted full thickness on her right outer knee. Range on motion (ROM) hindered on the right leg. Staff reported resident argued over an item with another resident which resulted in the fall. The resident lost balance while she grabbed an incontinence pad. A Notes section of the Incident Report included the following entry dated 4/25/23: Per staff a Certified Nursing Assistant (CNA) had been by the resident while she held onto the incontinence pad. The CNA turned around and the resident lost her balance and fell . A Major Injury Determination Form signed by an Nurse Practitioner (NP) 4/25/23 indicated the fractured hip as a major injury. During an interview on 8/3/23 at 10:36 a.m. a contracted NP confirmed she would have expected staff to have followed through with the facility policy and assured the disagreement/tug of war with an incontinent pad had been over before staff cared for another resident. The NP confirmed the fall could have been prevented if the staff member would have disarmed/separated the disagreement. According to a written statement dated 4/23/23 (no time documented) Staff A, CNA documented the following: I, Staff A witnessed Resident #1 and another resident (in the CCDI (chronic confusion or a dementing illness) unit) as they pulled on an incontinent pad. She thought the tug of war had been over so she walked away. The staff member then turned around because she heard commotion. As she turned around she witnessed Resident #1 as she fell towards the table and landed on her right side. The resident hollered so she called the nurse on the walkie talkie. During an interview on 8/3/23 at 12:17 p.m. Staff B, CNA confirmed she witnessed 90% of the fall. As she walked into the medication room she noticed the resident walked with the incontinent pad as the other resident stood by a table located right outside the nurse's station/medication room. The resident began to fall as another resident also held onto the incontinent pad. The staff member ran to the resident as she laid on her right side on the floor. The resident tried to get up so the staff member knelt down as the resident leaned against her person for support. At that time, she noted the gash on the resident's knee and described the gash as deep without much blood. The resident continued to yell ow, ow, ow. Staff A went to get Staff C, Registered Nurse (RN) who entered the unit and performed vitals. The resident tried to get up off the ground so the staff transferred the resident into a wheel chair. The staff member described the facility policy with resident to resident altercation as you always separated the residents and called for the nurse. The staff member described both residents involved as aggressive. During an interview on 8/3/23 at 10:03 a.m. Staff C, Registered Nurse (RN) indicated she had not been physically in the CCDI unit when the resident fell . Staff called on the walkie and said hurry back to the unit related to a bad fall. When she entered the CCDI the resident had been positioned in the dining area on the floor between the 2 tables. The other resident involved stood at a table. The staff member stated as the resident sat on the ground she kept stating ooh as she held onto her knee. The resident had been verbal without having made sense. The Nurse assessed the resident and described the leg as not externally or internally rotated but the resident failed to let go of the knee. Staff A, B and C then gently picked up the resident and sat her in a wheel chair. The staff member indicated the resident cried out with movement however not a ton. The staff member described the gash on the resident's knee as full thickness related to the location directly on the knee. The staff member cleansed the area and noted it swelled about 15 minutes post fall. A facilities Risk Management policy dated 12/8/22 directed facility staff that in the event of a resident to resident altercation staff should have immediately separated the residents involved.

Based on observation, resident interview, staff interview, resident council minutes and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes, (Resident #4 and #5) The facility identified a census of 67 residents. Findings include: During an interview on 8/9/23 at 2:56 p.m. Resident #4 confirmed she timed her call light on for 1/2 hour to 45 minutes at times as she used her watch. The resident indicated that it really made her feel unimportant. The resident also stated recently she had been on the toilet for a lengthy period of time and it caused her legs to go to sleep and tingly. A Device Activity Report dated 8/9/23 at 3:39 p.m. identified the resident's call light on longer than 15 minutes as follows from 8/8/23 thru 8/9/23: a. 8/8./3 at 7:16 a.m. - 16 minutes and 11 seconds. b. 8/9/23 at 7:21 a.m. - 26 minutes and 31 seconds. During an interview on 8/9/23 at 3:36 p.m. Resident #5 stated she had not known what to think due to the fact when she put on her call light no one answered. The resident described staff as kind however they propelled her to her room and just left her. The resident indicated she timed her call light on for about 45 minutes around noon as she utilized her watch located on her left wrist which caused frustration and a feeling of having been upset. A Device Activity Report dated 8/9/23 at 3:39 p.m. identified the resident's call light on longer than 15 minutes as follows from 8/8/23 thru 8/9/23: a. 8/8/23 at 5:28 a.m. - 22 minutes and 48 seconds. b. 8/9/23 at 11:10 a.m. - 22 minutes and 37 seconds, at 6:48 p.m. - 16 minutes and 12 seconds. A Device Activity Report dated 8/9/23 at 3:39 p.m. identified the call light on from room [ROOM NUMBER] bed 2 as follows: a. 8/8/23 at 12:22 p.m. - 20 minutes and 30 seconds. b. 8/9/23 at 6:54 a.m. - 26 minutes and 31 seconds. During an interview on 8/10/23 at 11:18 a.m. Staff H, CNA confirmed staff as unable to answer resident call lights within 15 minutes because of staffing and when we are short. The staff member indicated there had not been enough walkie talkie's for all staff which is where the call system ran through and there had only been 1 computer screen on East side of the building and none on the West. During an interview on 8/10/23 at 11:32 a.m. Staff I, Certified Medication Aide (CMA) indicated she knew call lights had been identified through walkie talkies and a screen at the nurse's station however there had been times there were not enough walkies for everyone. Additionally, staff turned off their walkie's at times. According to the facilities Call Light System policy (not dated) the purpose identified the policy established guidelines for the operation and staff response to the call light system. The policy aimed to ensure prompt and effective communication between residents and staff to have met their needs and ensured their safety and well-being.

Based on document review, interviews, and review of facility policies, the facility failed to consider and respond to grievances and recommendations from the Resident Council for 7 (June, July, August, September, October, November, and December 2022) of 7 months of council minutes reviewed. Specifically, the facility was unable to demonstrate that responses were provided to the council regarding their verbalized and documented concerns involving dietary, housekeeping/laundry, and nursing services. Findings included: A review of an undated facility policy titled, Resident Council revealed, 1. The Activity Department will organize a Resident Council. 2. The Resident Council will meet monthly. 3. All residents will be invited. The policy also indicated, 7. Minutes will be kept of all meetings. The policy did not address how any concerns or grievance from the council would be handled. Review of an undated facility policy titled, Grievance Procedure, revealed, Purpose: 1. To resolve residents and families concerns or grievances. 2. To ensure the highest quality of services is offered to the facilities residents and families. The policy also indicated the following: - Procedure: 1. The person the grievance is identified to will initiate the form. - 4. The Social Services/Administrator is responsible for resolving the grievance along with the appropriate Department Head. - 6. The Social Services/Administrator will follow-up with the resident/family as to resolution within 48-72 hours of receiving the grievance. - 7. The findings, resolution and resident/family response will be documented on the grievance form. Completed grievance forms will be kept in the Social Services and/or Administrator's office. A review of a Resident Council Meeting form dated 06/13/2022 revealed 20 residents attended the meeting and had concerns and requests that the dietary department have an alternate vegetarian menu and that the revolving trays on the tables in the main dining room be cleaned and stocked. The section at the end of the form titled, Team Leader Review and Initial was not initialed as reviewed by the dietary department. A review of a Resident Council Meeting form dated 07/18/2022 revealed 15 residents attended the meeting, during which a concern was recorded that the food needs to be a little hotter. The section titled Follow-up on issues/concerns was blank. The section titled, Team Leader Review and Initial was not initialed as reviewed by the dietary department. A review of a Resident Council Meeting form dated 08/15/2022 revealed 19 residents attended the meeting. Concerns for dietary included that it took too long to get food to the residents and that the residents would like for food to be served on alternating sides each week. Additionally, the residents felt housekeeping/laundry staff were not attentive to problems. A concern for the nursing department indicated the certified nurse aides (CNAs) were talking to each other too much, resulting in the residents being unable to tell them what they needed. The section titled Team Leader Review and Initial was not initialed as reviewed by the dietary or housekeeping/laundry departments. A review of a Resident Council Meeting form dated 09/12/2022 revealed 22 residents attended the meeting, and a concern was recorded under dietary that indicated the need to do better with special dietary considerations (examples included unable to eat bread, cheese, vegetarian). The section titled, Team Leader Review and Initial was initialed as reviewed by the dietary department. The section titled Follow-up on issues/concerns was blank. A review of a Resident Council Meeting form dated 10/03/2022 revealed 16 residents attended the meeting, and a concern was recorded under dietary that indicated foods like oatmeal were cold, even when served in the dining room. Additionally, the concern indicated, All food is cold! Seems that the current staff level makes it difficult to serve at the correct time. A concern for the nursing department indicated the CNAs were talking to each other when providing care and could not hear the residents. The section titled Follow-up on issues/concerns was blank. The form was initialed as reviewed by the dietary department and the Director of Nursing (DON). A review of a Resident Council Meeting form dated 11/14/2022 revealed 22 residents attended the meeting. A new form had been initiated. The section titled, Follow-up Concerns revealed, Still having issues with food being cold, and CNAs still talking among themselves when providing cares and ignoring resident. The section of the form titled, Dietary revealed the residents suggested that every other week, the side of the dining room where they start serving should change. Additionally, the form indicated one resident suggested serving the residents who required assistance last so that their food would still be hot when staff sat down to assist them. The section of the form titled, Nurses/CNAs/Medication Aids [sic] revealed a resident reported receiving wrong pills last night. The resident asked for a record of the medications and was told, I don't know. A review of Resident Council Meeting form dated 12/05/2022 revealed 21 residents attended the meeting. The section titled, Follow-up Concerns revealed one side of the dining room was still being served first and the residents who required assistance were being served first even though they have to eat last. The section titled, Dietary indicated the food served in the dining room is still cold, especially vegetables. Additionally, napkins, straws, pepper, and salt were consistently empty. The section for nursing indicated the CNAs were still talking while giving care. Additionally, the residents indicated staff would say just a second then not come back. On 12/13/2022 a meeting was held with four Resident Council members, including Resident #4, Resident #21, Resident #47, and Resident #59. The meeting minutes for the last six months were discussed, and the residents all stated they had not heard back or had any resolution for the following issues: - CNAs talking to each other during care and ignoring the resident. - Cold food: The residents indicated this was still frequently an issue and that most of the time, the vegetables were cold. - Order of meal service: The residents indicated residents who needed assistance with eating still received their meals first but ate last due to waiting for staff to finish passing meals and assist them. Additionally, there had been no follow-up on alternating which side of the dining room was served first. An interview was conducted on 12/13/2022 at 11:22 AM with the Director of Nursing (DON). She stated that when the Activity Director, who oversaw the Resident Council meeting each month, brought the meeting minutes to her, she made notes on the issues and tried to investigate them for resolution, education, or teaching. She indicated she would then attach that information to the minutes form. The DON acknowledged that she had not followed up/communicated with the Resident Council regarding any efforts to resolve the issues they had brought up at the meetings. The DON stated she saw there was a need to close the loop and follow up on the residents' concerns. An interview was conducted on 12/13/2022 at 2:51 PM with the Activity Director (AD). He stated that after he conducted a Resident Council meeting each month, he would give the meeting minutes with the issues and concerns to the DON at the morning meeting. He stated he believed that after he gave them to the DON, she would read them and investigate the issues that were mentioned by the residents. The AD stated that the following month, he would just repeat the process and follow the template on the Resident Council Meeting form. He indicated that in November 2022, a new form was initiated, and one of the first areas addressed on the form was Follow up on Concerns. He stated that when he read that section to the residents, he felt stressed because he saw that the same issues were still happening. He stated he was upset that there had not been any follow up with residents on their concerns. A follow-up interview was conducted on 12/15/2022 at 8:29 AM with the DON. She stated the concerns that were brought up in Resident Council were looked at and addressed on the Resident Council form but not transferred to a concern or grievance form. She stated she was aware that a system of addressing concerns from the Resident Council meeting had not been completed. The DON stated there should be follow-through and a report back to Resident Council members on resolution of their concerns. An interview was conducted on 12/15/2022 at 5:30 PM with the Administrator. He stated his expectation for the concerns brought forward at Resident Council meetings would be that the Activities Director would bring the meeting minutes to the morning meeting. From there, whichever department had a concern from the Resident Council meeting would be assigned to take care of it to investigate and fix the problem. The Administrator stated he would expect that an answer or resolution should be given back to the members of the Resident Council about their concerns.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure assessments were completed and documented and informed consents were obtained prior to utilizing side rails on residents' beds for 3 (Residents #28, #49, and #46) of 3 sampled residents reviewed for the use of side rails. Findings included: On 12/14/2022 at 10:02 AM, a copy of the facility's side rail policy was requested from the Director of Nursing (DON) and was not provided by the end of the survey. 1. A review of an Admission Record revealed Resident #28 had diagnoses that included cerebral infarction (stroke) with left sided weakness, osteoarthritis, and rheumatoid arthritis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more people with bed mobility and transfer. According to the MDS, the resident had functional limitation in range of motion to both upper extremities and had no restraints in use. Review of a care plan, dated as initiated 05/22/2020, revealed the resident required assistance with activities of daily living (ADLs). An intervention dated as revised 12/13/2022 indicated the resident required extensive assistance of two people for bed mobility and had quarter side rails at the head of the bed to assist the resident. The care plan indicated the side rails do not restrict or limit my ability to move about freely in the bed. An observation on 12/12/2022 at 2:06 PM revealed Resident #28 had quarter side rails raised on both sides of the head of the bed. A review of Resident #28's medical record revealed no assessment or consent for the use of side rails. A review of Resident #28's physician orders revealed no orders for the use of side rails. During an interview on 12/13/2022 at 4:16 PM, the Director of Nursing (DON) stated all beds in the facility had quarter side rails at the head of the bed. She stated the facility had not viewed the side rails as a restraint and had not obtained consents or done assessments for any of them. She stated she had been the DON for four months and, when asked for the assessments during the survey, she realized they had not been done. She stated she immediately implemented an action plan for this. She stated a nurse went to Resident #28's room and got a consent form signed by the resident for the side rails and completed an assessment. She stated the facility did not have a specific bedrail assessment that could be completed in the electronic record, so she implemented this. During an interview on 12/14/2022 at 10:02 AM, the DON stated she spoke with the maintenance director that morning and confirmed that all beds in the facility had side rails and no side rail assessments had been completed for any of the residents. The DON stated some of the residents had consents for the side rails but not all of them. She stated her plan was to go down the list of residents and assess each resident to determine if the side rails were needed or not. She stated if they were needed, the facility would get a consent signed and obtain a physician's order. The DON stated if the side rail was not needed, then maintenance was going to zip tie the rails down to the frame to prevent them from being raised. The DON stated she was not sure why the assessments had not been completed. The DON stated she checked the list of risk management (incident reports) for the last three months and there had been no adverse outcomes related to the use of side rails. During an interview on 12/14/2022 at 12:35 PM, Licensed Practical Nurse (LPN) #12 stated the facility did not consider the side rails to be restraints. They were used for mobility, so she thought they did not have to have an assessment. During an interview on 12/14/2022 at 12:40 PM, LPN #11 stated she had not done any side rail assessments. She stated the side rails were used for mobility and not considered a restraint, so she did not think an assessment was required. During an interview on 12/15/2022 at 2:16 PM, Certified Nursing Assistant (CNA) #13 stated the residents used the side rails to hold themselves over in bed while care was being provided. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated if a resident requested or needed a side rail, then he expected an assessment to be completed to determine if the use of the side rail would be detrimental or beneficial to the resident. He stated if side rails were needed, a physician order should be obtained. He stated if the side rail was not going to be used, then it would be zip tied down. 2. A review of an Admission Record revealed the facility admitted Resident #49 with diagnoses that included right-sided weakness and low back pain. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The MDS indicated the resident was independent and required only set-up support for bed mobility and transfer. According to the MDS, the resident had functional limitation in range of motion to the upper and lower extremities on one side and had no restraints in use. Review of a care plan, dated as initiated 09/02/2022, revealed Resident #49 required some assistance with activities of daily living (ADLs) and had right-sided weakness due to a stroke. An intervention dated as revised 09/21/2022 indicated the resident had quarter side rails at the head of the bed to assist with bed mobility and repositioning. The care plan indicated the side rails do not limit or restrict my ability to move about freely in bed. An observation on 12/12/2022 at 12:17 PM revealed Resident #49 had quarter side rails raised on both sides of the head of their bed. A review of Resident #49's medical record revealed no assessment or consent for the use of side rails. A review of Resident #49's physician orders revealed no orders for the use of side rails. During an interview on 12/13/2022 at 4:16 PM, the Director of Nursing (DON) stated the facility had not viewed the side rails as restraints and had not obtained consents or done assessments for any of them. She stated she had been the DON for four months and when asked for the assessments during survey she realized that they had not been done. She stated she immediately implemented an action plan for this. During an interview on 12/14/2022 at 10:02 AM, the DON stated a side rail assessment was not even an option in the facility's electronic charting system until she implemented one the previous day. The DON stated some of the residents did have consents for the side rails but not all. During an interview on 12/15/2022 at 2:16 PM, Certified Nurse Aide (CNA) #13 stated some residents used the side rails to hold themselves over in bed while care was being provided. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated if a resident requested or needed a side rail, then he expected an assessment to be completed to determine if the use of the side rail would be detrimental or beneficial to the resident. He stated if it was needed, then a physician order should be obtained. He stated if the side rail was not going to be used, then it would be zip tied down. 3. A review of an Admission Record revealed Resident #46 had diagnoses that included fracture of the lumbar vertebra (a bone in the lower spine) with back pain and osteoporosis (a condition that weakens bone strength). The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfer. Review of a care plan, dated as initiated 09/02/2022, revealed Resident #46 required assistance of one person for bed mobility and had quarter side rails at the head of the bed. The care plan indicated the side rails did not restrict or limit the resident's ability to move about freely in bed. An observation on 12/12/2022 at 11:27 AM revealed Resident #46 had quarter side rails raised on both sides of the head of their bed. A review of Resident #46's medical record revealed no assessment or consent for the use of side rails. A review of Resident #46's physician orders revealed no orders for the use of side rails. During an interview on 12/13/2022 at 4:16 PM, the Director of Nursing (DON) stated all beds in the facility had quarter side rails at the top of the bed. She stated the facility had not viewed the side rails as restraints and had not obtained consents or done assessments for any of them. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated if a resident requested or needed a side rail, then he expected an assessment to be completed to determine if the use of the side rail would be detrimental or beneficial to the resident. He stated if it was needed, then a physician order should be obtained. He stated if the side rail was not going to be used, then it would be zip tied down.

Based on interview, record review, document review, and policy review, the facility failed to report sexual abuse to the state agency within two hours for 2 of 2 incidents of sexual abuse between Resident #17 and Resident #44. Findings included: The undated facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revealed, F. Reporting: 1. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknow origin and misappropriation should be reported immediately to the charge nurse. 2. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. 3. All allegations of Resident abuse shall be reported to the [State Agency] not late then two (2) hours after the allegations is made. A review of Resident #17's medical diagnoses sheet revealed a diagnosis of dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS revealed the resident had continuous disorganized thinking and inattention and fluctuating levels of altered mental status. The resident had delusions and hallucinations. The resident had behaviors including verbal behavioral symptoms directed toward others for one to three days during the seven day look back period, rejecting care for four to six days during the seven day look back period, and daily wandering. A review of Resident #17's care plan, revised 11/18/2022, revealed the resident was at the facility for long term placement. One intervention included the resident's breast was touched by a peer and staff intervened and separated them on 11/02/2022. Another intervention included another resident was rubbing Resident #17's breasts over the resident's shirt. Resident #17 had both hands on Resident #44's hips. The residents were separated immediately and neither resident was agitated or hurt. A review of Resident #44's medical diagnoses sheet revealed diagnoses of dementia with behavioral disturbance and Alzheimer's disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. The MDS revealed the resident had continuous disorganized thinking and inattention, hallucinations, and delusions. The resident had behaviors including daily rejection of care, daily wandering, and daily behaviors not directed toward others. A review of Resident #44's care plan, revised 11/22/2022, revealed the resident was at the facility for long term placement. One intervention included the resident touched Resident #17's breasts and staff separated them on 11/02/2022. Another intervention included the resident was rubbing Resident #17's breasts, and Resident #17 was holding Resident #44 by the hips and staff separated them on 11/17/2022 A review of the Self Report form, dated 11/03/2022, revealed a certified nursing assistant (CNA) reported to the charge nurse that Resident #44 walked up to Resident #17 while Resident #17 was standing next to Resident #44's bed. Resident #44 then took both of their hands and touched both of Resident #17's breasts. The CNA reported to the charge nurse that Resident #17 was standing there with their eyes closed after Resident #44 touched Resident #17's breast. Resident #17 was fully clothed at that time. The Self Report indicated the approximate date/time the incident occurred was 11/02/2022 at 3:00 PM. The report's submission date to the state agency was on 11/03/2022 at 1:03 PM. A review of the Self Report form, dated 11/18/2022, revealed facility staff saw that Resident #44 wandered into room [ROOM NUMBER] with Resident #17 and was rubbing Resident #17's breasts over their shirt as Resident #17 was holding Resident #44 by the waist. Resident #17 and Resident #44 were not upset at time of discovery. They were immediately separated by facility staff. Both residents were redirected very easily with no adverse behaviors. Both families were notified at time of incident. The Self Report indicated the approximate date/time the incident occurred was 11/17/2022 at 12:49 PM. The report's submission date was 11/18/2022 at 5:47 PM . During an interview on 12/15/2022 at 7:13 PM, the Director of Nursing (DON) stated she thought the incidents between Resident #17 and Resident #44 would fall under the abuse category because both residents were demented. The DON stated the Administrator was responsible for reporting to the state, and she thought it should be done within the appropriate time frame. During an interview on 12/15/2022 at 7:37 PM, the Administrator stated he reported to the state the incidents between Resident #17 and Resident #44 as potential sexual abuse because the residents could not consent to sexual touching. He stated he thought the period for reporting to the state was 24 hours, and he did report within the 24 hours, but now realized the federal regulations required a report within two hours, and the state regulations had the 24-hour period. He stated he would report sooner if the staff told him about the incidents sooner; they may wait until the next workday to report it to him. The Administrator stated, I understand the reporting was late.

Based on interview, record review, document review, and policy review, the facility failed to prevent two sexual abuse interactions on the secured dementia unit between 2 (Resident #17 and Resident #44) of 2 residents sampled for abuse. Findings included: The undated facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revealed, A. 2. Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy also indicated resident abuse was defined as D. Sexual abuse is non-consensual sexual contact of any type with a resident. A review of Resident #17's medical diagnoses sheet revealed a diagnosis of dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS revealed the resident had continuous disorganized thinking and inattention and fluctuating levels of altered mental status. The resident had delusions and hallucinations. The resident had behaviors including verbal behavioral symptoms directed toward others for one to three days during the seven day look back period, rejecting care for four to six days during the seven day look back period, and daily wandering. A review of Resident #17's care plan, revised 11/18/2022, revealed the resident was at the facility for long term placement. One intervention included the resident's breast was touched by a peer and staff intervened and separated them on 11/02/2022. Another intervention included another resident was rubbing Resident #17's breasts over the resident's shirt. Resident #17 had both hands on Resident #44's hips. The residents were separated immediately and neither resident was agitated or hurt. A review of Resident #44's medical diagnoses sheet revealed diagnoses of dementia with behavioral disturbance and Alzheimer's disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. The MDS revealed the resident had continuous disorganized thinking and inattention, hallucinations, and delusions. The resident had behaviors including daily rejection of care, daily wandering, and daily behaviors not directed toward others. A review of Resident #44's care plan, revised 11/22/2022, revealed the resident was at the facility for long term placement. One intervention included the resident touched Resident #17's breasts and staff separated them on 11/02/2022. Another intervention included the resident was rubbing Resident #17's breasts, and Resident #17 was holding Resident #44 by the hips and staff separated them on 11/17/2022 A review of the abuse investigation, dated 11/03/2022, revealed the file contained a state Self Report, and copies of three nursing notes dated 11/02/2022 which documented the physician being notified. No other portions of an investigation were available. A review of the Self Report form, dated 11/03/2022, revealed a certified nursing assistant (CNA) reported to the charge nurse that Resident #44 walked up to Resident #17 while Resident #17 was standing next to Resident #44's bed. Resident #44 then took both of their hands and touched both of Resident #17's breasts. The CNA reported to the charge nurse that Resident #17 was standing there with their eyes closed after Resident #44 touched Resident #17's breast. Resident #17 was fully clothed at that time. The Corrective Action Description on the Self Report form revealed staff were instructed to watch both residents closely to ensure that both residents did not engage in any further instances of this nature. A review of the abuse investigation, dated 11/18/2022, revealed the file contained a state Self Report, one progress note dated 11/17/2022 which described the incident, and a Risk Management note dated 11/17/2022 which listed who was notified. No other portions of an investigation were available. A review of the Self Report form, dated 11/18/2022, revealed facility staff saw that Resident #44 wandered into room [ROOM NUMBER] with Resident #17 and was rubbing Resident #17's breasts over their shirt as Resident #17 was holding Resident #44 by the waist. Resident #17 and Resident #44 were not upset at time of discovery. They were immediately separated by facility staff. Both residents were redirected very easily with no adverse behaviors. Both families were notified at time of incident. The Corrective Action Description on the Self Report form revealed staff were re-educated on the importance of ensuring future situations of this nature were prevented through situational awareness. A quick meeting was provided to staff to sign off on as well in regard to this incident and preventing any further occurrence. During an interview on 12/14/2022 at 2:33 PM, CNA #7 stated Resident #17 was somewhat restless and got up to walk often. CNA #7 stated the resident's family came in to visit the resident. The resident did not know them but appeared to trust them, and they walked in the hall together on the unit during visits. CNA #7 stated the resident spoke, but the words did not make sense, and staff had to anticipate the resident's needs. The CNA stated the resident rejected care at times. During an interview on 12/15/2022 at 1:55 PM, CNA #11 stated Resident #17 had behaviors of yelling, mainly when the resident needed to use the restroom. She stated the resident would raise their fist at times toward the staff and wandered the unit daily. She stated the resident did touch other residents' hands when they walked, and if it bothered them, staff would redirect the resident away from that resident. CNA #11 stated Resident #44's behaviors were toward staff; the resident asked the staff to lie in bed with them. CNA #11 stated she was educated on abuse last month, and sexual abuse education was part of that training. She stated if the residents wanted to touch on this unit, she thought it would be abuse because the residents could not consent to it. If she saw something she thought was abuse, she would separate the residents and report it to the nurse or to the Director of Nursing (DON). During an interview on 12/15/2022 at 2:07 PM, CNA #6 stated Resident #17 was not oriented to self, and during showers and toileting would swing at and hit the staff. She stated staff had identified the resident would become agitated when they needed to use the bathroom, and staff anticipated the resident's care. She stated staff walked down the hall with the resident and held their hand when the resident wanted to walk. CNA #6 stated Resident #44's behaviors included touching the staff or attempting to touch them in a sexual way and making sexual comments. She stated she was aware of the two incidents of sexual touching between Resident #17 and Resident #44 and had not received any additional education after those events, except staff was instructed to keep the residents apart and watch them. She stated that on this unit, the residents were Not with it enough to consent to sexual touch, and Resident #17 and Resident #44 could not consent. CNA #6 stated she completed abuse for dementia training, including sexual abuse. She stated if she saw something she thought was abuse, she would separate the residents and report it to the nurse. During an interview on 12/15/2022 at 2:23 PM, CNA #17 stated she was aware of the sexual interactions between Resident #17 and Resident #44. She stated she did not notice any behavior changes for either resident after the incidents. CNA #17 stated Resident #44 made sexual comments and attempted to touch staff when they provided care, but the resident had not acted inappropriately to any other residents. She stated if Resident #17 and Resident #44 sat by one another on the couch, staff moved one of the residents to another chair. CNA #17 stated she was trained on abuse, including sexual abuse, and thought both residents were not able to give consent to sexual touching, because they Were not in the right mind to give consent; they would not understand. CNA #17 stated she had not received any additional education after the touching incidents. She stated if she saw something she thought was abuse, she would separate the residents and report it to the nurse. During an interview on 12/15/2022 at 2:34 PM, CNA #18 stated she was educated on abuse, including sexual abuse, within the past three days. She stated sexual abuse included anything of a sexual nature which was unwanted or if the resident was not able to give consent to it. She stated if she saw something she thought was abuse, she would make sure the residents were safe and report it to a supervisor. During an interview on 12/15/2022 at 3:33 PM, the Unit Manager/QAPI Coordinator (UM/QC) stated she did not investigate abuse allegations. She stated her role during an abuse investigation was the DON or the Administrator would ask her if she identified a trend in that behavior, or if it happened to other residents. She stated that when there was a report of abuse, it was reported to a supervisor, then the information went to the DON or Administrator, and the UM/QC would be called to conduct a head-to-toe assessment on the residents involved. During a follow-up interview on 12/15/2022 at 7:12 PM, the UM/QC stated she was aware of the two incidents between Resident #17 and Resident #44, and no specific interventions were put in place after the first incident to prevent the second incident. She stated the Administrator educated that day on monitoring and activities to keep Resident #44 engaged, but the education was not done before 12/15/2022. She stated the staff and residents on the secured unit were monitored by the nurses doing rounds, assessments, and they evaluated the environment, checked on the residents, and asked the staff how things were going during the shift. The UM/QC stated her role after an incident was to ensure the charting was done and to conduct a head-to-toe assessment on the residents. She stated she was not called to conduct head-to-toe assessments on Resident #17 or Resident #44, and she thought the nurse at the time charted the assessment, but agreed it was not a head-to-toe assessment. During an interview on 12/15/2022 at 7:13 PM, the DON stated she thought the incidents between Resident #17 and Resident #44 would fall under the abuse category because both residents were demented. She stated it would have made sense to get written statements from staff and conduct more thorough investigations to clarify the situations. The DON stated she did not believe abuse could be prevented, because We cannot be one on one with every patient, but the intention was to deter abuse. She stated more interventions to prevent the abuse depended on the interventions and if the staff would comply with the interventions. The DON stated the UM/QC was the nurse who had oversight on the unit. She stated the immediate intervention was separating the residents but, We could have had something more aggressive in place to prevent another occurrence of abuse. During an interview on 12/15/2022 at 7:37 PM, the Administrator stated he reported to the state the incidents between the residents as potential sexual abuse because the residents could not consent to sexual touching. The Administrator stated, Of course abuse can be prevented; certain situations are harder than others. He stated interventions could be put in place to separate the residents. He stated the staff was trained on abuse and immediate reporting.

Based on interview, record review, document review, and policy review, the facility failed to conduct a thorough investigation of two incidents of sexual abuse on the secured dementia unit for 2 (Resident #17 and Resident #44) of 2 residents sampled for abuse. Findings included: The undated facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revealed, G. Investigation. 1. Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. 2. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident: A. Review documentation in resident record (including review of assessment if resident injury). B. Assess the resident for injury if the allegation involves physical or sexual abuse; D. Attempt to obtain witness statements (oral and/or written) from all known witnesses. A review of Resident #17's medical diagnoses sheet revealed a diagnosis of dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS revealed the resident had continuous disorganized thinking and inattention and fluctuating levels of altered mental status. The resident had delusions and hallucinations. The resident had behaviors including verbal behavioral symptoms directed toward others for one to three days during the seven day look back period, rejecting care for four to six days during the seven day look back period, and daily wandering. A review of Resident #17's care plan, revised 11/18/2022, revealed the resident was at the facility for long term placement. One intervention included the resident's breast was touched by a peer and staff intervened and separated them on 11/02/2022. Another intervention included another resident was rubbing Resident #17's breasts over the resident's shirt. Resident #17 had both hands on Resident #44's hips. The residents were separated immediately and neither resident was agitated or hurt. A review of Resident #44's medical diagnoses sheet revealed diagnoses of dementia with behavioral disturbance and Alzheimer's disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. The MDS revealed the resident had continuous disorganized thinking and inattention, hallucinations, and delusions. The resident had behaviors including daily rejection of care, daily wandering, and daily behaviors not directed toward others. A review of Resident #44's care plan, revised 11/22/2022, revealed the resident was at the facility for long term placement. One intervention included the resident touched Resident #17's breasts and staff separated them on 11/02/2022. Another intervention included the resident was rubbing Resident #17's breasts, and Resident #17 was holding Resident #44 by the hips and staff separated them on 11/17/2022 A review of the abuse investigation, dated 11/03/2022, revealed the file contained a state Self Report, and copies of three nursing notes dated 11/02/2022 which documented the physician being notified. No other portions of an investigation were available, such as witness statements, observations of the residents before the incident, a root cause analysis, steps taken to protect the residents during the investigation, identification of any other victims, a five-day conclusion of the investigation, et cetera (etc). A review of the abuse investigation, dated 11/18/2022, revealed the file contained a state Self Report, one progress note dated 11/17/2022 which described the incident, and a Risk Management note dated 11/17/2022 which listed who was notified. No other portions of an investigation were available, such as witness statements, observations of the residents before the incident, a root cause analysis, steps taken to protect the residents during the investigation, identification of any other victims, a five-day conclusion of the investigation, etc. During an interview on 12/15/2022 at 2:07 PM, CNA #6 stated she was aware of the two incidents of sexual touching between Resident #17 and Resident #44 and had not receive any additional education after those events, except staff was instructed to keep the residents apart and watch them. During an interview on 12/15/2022 at 2:23 PM, CNA #17 stated she was aware of the sexual interactions between Resident #17 and Resident #44. She stated she did not notice any behavior changes for either resident after the incidents. CNA #17 stated Resident #44 made sexual comments and attempted to touch staff when they provided care, but the resident had not acted inappropriately to any other residents. She stated if Resident #17 and Resident #44 sat by one another on the couch, staff moved one of the residents to another chair. CNA #17 stated she was trained on abuse, including sexual abuse. CNA #17 stated she had not received any additional education after the touching incidents. During an interview on 12/15/2022 at 3:33 PM, the Unit Manager/QAPI Coordinator (UM/QC) stated she did not investigate abuse allegations. She stated her role during an abuse investigation was the DON or the Administrator would ask her if she identified a trend in that behavior, or if it happened to other residents. She stated that when there was a report of abuse, it was reported to a supervisor, then the information went to the DON or Administrator, and the UM/QC would be called to conduct a head-to-toe assessment on the residents involved. During a follow-up interview on 12/15/2022 at 7:12 PM, the UM/QC stated she was aware of the two incidents between Resident #17 and Resident #44, and no specific interventions were put in place after the first incident to prevent the second incident She stated she was not called to conduct head-to-toe assessments on Resident #17 or Resident #44, and she thought the nurse at the time charted the assessment, but agreed it was not a head-to-toe assessment. During an interview on 12/15/2022 at 7:13 PM, the Director of Nursing (DON) stated she thought the incidents between Resident #17 and Resident #44 would fall under the abuse category because both residents were demented. She stated it would have made sense to get written statements from staff and conduct more thorough investigations to clarify the situations. During an interview on 12/15/2022 at 7:37 PM, the Administrator stated he reported to the state the incidents between the residents as potential sexual abuse because the residents could not consent to sexual touching. The Administrator stated, I understand the reporting was late, and a thorough investigation should have been done.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to provide a complete diet which lacked the appropriate nutritive value for 2 (Residents #29 and #54) of 3 residents who required pureed diets. This had the potential to affect 14 residents who received pureed or partially pureed diets. Findings included: A review of the facility policy, Therapeutic Diets, undated, revealed, 1. Therapeutic diets must be prescribed by the attending physician. 3. A current therapeutic diet manual shall be readily available to attending physicians, nurses, and dietetic service personnel. This manual shall be used a s a guide for writing menus for therapeutic diets. 4. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and reviewing procedures for preparation and service of therapeutic menus. 5. Personnel responsible for planning, preparing, and serving therapeutic diets shall receive instructions on those diets. A review of Resident #29's medical diagnoses sheet revealed the resident had diagnoses which included dementia and dysphagia. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS further revealed the resident was on a mechanically altered therapeutic diet and completed speech therapy on 08/04/2022. A review of Resident #29's nutrition care plan, revised 11/12/2022, revealed an intervention, dated 08/03/2022, for pureed foods. A review of the Order Recap Report revealed a physician's order, dated 12/02/2022, for a general diet, pureed texture. A review of Resident #54's medical diagnoses sheet revealed the resident had a diagnosis which included dementia. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS further revealed the resident was on a mechanically altered diet and completed speech therapy on 08/23/2022. A review of Resident #54's nutrition care plan, revised 10/20/2022, revealed an intervention, dated 08/23/2022, for pureed foods. A review of the physician's orders, revised 10/11/2022, revealed a general diet, pureed texture. A review of the facility Diet Type Report, dated 12/12/2022, revealed Resident #29 and Resident #54 were listed for a pureed diet. A review of the Menu Planning Guide, updated August 2019, revealed, [Company name] base menus are designed to include foods in amounts that will meet or exceed the Dietary Reference Intakes (DRIs) for older adults. The following components are included daily: Protein: 5-6 oz [ounce] equivalents. A review of the facility's menu plan for 12/13/2022 revealed residents receiving a regular diet were to receive one cheese stick and residents receiving a pureed diet were to receive one serving of pureed cottage cheese (in place of the cheese stick) for the noon meal. A review of the label on the cheese sticks planned for the noon meal on 12/13/2022 revealed the cheese stick contained 6 grams (g) of protein. An observation of the kitchen serving line on 12/13/2022 at 11:49 AM revealed Dietary Staff (DS) #4 did not add a cheese stick to Resident #29's tray and did not add any alternate protein source to the pureed meal tray. An observation on 12/13/2022 at 12:24 PM revealed Resident #54 did not have pureed cottage cheese or any alternate protein on their tray. During an interview on 12/13/2022 at 12:24 PM, DS #3 stated he forgot to prepare the pureed cottage cheese, which was the pureed diet alternate for the cheese stick; therefore Resident #54 did not receive the cottage cheese. During an interview on 12/13/2022 at 12:39 PM, DS #4 stated the pureed diets should have had pureed cottage cheese according to the spreadsheet menu, but none was available. DS #4 verified none was given to Resident #29 and Resident #54 . During an interview on 12/13/2022 at 12:40 PM, the Dietary Manager stated the staff used the spreadsheet menu to identify the replacements for the pureed diet textures. She stated the cottage cheese should have been served for the pureed diets, and the residents who did not receive it were short of 6 g of protein. During an interview on 12/14/2022 at 11:26 AM, the Registered Dietician stated for the missing cottage cheese, those residents were short 6 g protein for that meal. During an interview on 12/15/2022 at 6:49 PM, the Director of Nursing stated dietary should follow what the assigned dietary menu said and if there was a substitute for something else on the menu, it should have been put in place. During an interview on 12/15/2022 at 7:36 PM, the Administrator stated his expectation was for the dietary staff to follow the menus and prepare all the foods.

Based on interviews and record review, it was determined that the facility failed to have consistent communication with the dialysis center for 1 (Resident #41) of 1 sampled resident reviewed for dialysis services. Findings included: A review of an Admission Record revealed Resident #41 had diagnoses that included end stage renal disease and dependence on renal dialysis. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of a care plan, dated as initiated 05/11/2022, revealed Resident #41 required dialysis related to end stage renal disease and had a fistula (a surgically created connection between an artery and a vein to facilitate dialysis) in the left forearm. Interventions included to administer medications as ordered (initiated 05/11/2022); check for thrill (a rumbling sensation that should be present and can be felt over a dialysis fistula) to the dialysis site in the left arm every shift and notify the physician and dialysis center if not present (initiated 05/11/2022); encourage the resident to go to the scheduled dialysis appointments on Tuesdays, Thursdays, and Saturdays (initiated 05/11/2022); and monitor for any complications from dialysis such as hemorrhage, access site infections, or hypotension and notify the physician and dialysis center of any concerns (initiated 11/09/2022). Review of an Order Summary Report, which listed Resident #41's active orders as of 12/15/2022, revealed the resident had a physician's order dated 09/19/2022 for dialysis every Tuesday, Thursday, and Saturday. A review of Resident #41's medical record revealed, Doctor Visit Forms that were used for communication between the facility and the dialysis center. No communication forms were found in the resident's record for dialysis treatments on Thursday 11/17/2022, Tuesday 11/22/2022, Saturday 11/26/2022, Saturday 12/03/2022, Tuesday 12/06/2022, Thursday 12/08/2022, Saturday 12/10/2022 or Tuesday 12/13/2022. During an interview on 12/14/2022 at 4:15 PM, the Director of Nursing (DON) stated she realized the communication with the dialysis center was not consistent. She stated she expected communication to occur with the dialysis center every time the resident went to the center. The DON stated if the dialysis center did not send back the communication form, then the nurse should be contacting the center to have them send it over. She stated this was important for continuity of care. During an interview on 12/13/2022 at 12:35 PM, Licensed Practical Nurse (LPN) #12 stated a form was sent with the resident to the dialysis center, and sometimes the center would complete and send it back with the resident and other times they did not. LPN #12 stated when the form was returned, it would be placed in the file to be uploaded to the resident's record. She stated there was no certain person who was the liaison with the dialysis center. LPN #12 indicated if there were any changes with the resident, the dialysis center would call or the family would inform the facility. During an interview on 12/13/2022 at 12:40 PM, LPN #11 indicated the communication with the dialysis center was not consistent. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated he expected communication with the dialysis center to improve. He stated communication with the dialysis center had been an ongoing issue. He stated the facility would send the communication form to the dialysis center but would not get it back. The Administrator stated he expected the staff to follow up with the dialysis center if the resident returned without the communication form.

Based on observation, resident, staff and physician interviews and record review, the facility failed to provide timely assessments and interventions for 5 out of 5 residents reviewed (Residents #7, #8, #11, #12 and #13). The facility did not assess and/or did not provide interventions when they did not respond appropriately to low blood pressures (BP), low oxygen saturations (O2 sats), decline in a resident's condition, a resident who went days without a bowel movement, and skilled care assessments on a resident which were not being completed and the resident passed away. The lack of assessments and interventions resulted in hospitalization for 3 residents (low BP-[CONDITION(S)] (infection of the blood), and [CONDITION(S)] (urinary tract infection); low O2 sats, COVID 19 and hypoxemia; and change of condition ([CONDITION(S)], AKI (acute kidney injury). Resident #13 had a low BP without any interventions one day before she was admitted to ICU (Intensive Care Unit) with urosepsis (an infection of the blood that is caused by an infection in the urinary tract). This resident was hospitalized for several days. Resident #11 had low oxygen saturation that went days without an assessment or intervention and was admitted to the hospital for hypoxemia, COVID-19 and low O2 saturations. Resident #7 complained of not feeling well, decreased appetite, lethargy, and had a decline in her status over a 4 day period without intervention before the facility notified the physician and was hospitalized with [CONDITION(S)] (an infection in the blood) and acute kidney injury. Resident #8 required a [MEDICATION(S)] after 6 days of no bowel movements and no abdominal assessment. Resident #12 passed away without skilled assessment shortly after she was admitted . This resident was admitted to skilled level of care and was to have 3 assessments a day in 2 days for a total of 6 assessments. She was only assessed on the morning of her admission and lacked 5 of the 6 assessments. The facility was unable to show whether or not there was a change in condition related to the lack of assessments. These situations constituted Immediate Jeopardy to residents' health and safety. The facility reported a census of 72. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented Resident #13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resident was independent with transfers, ambulation in her room and personal hygiene. The Census page in this resident's electronic health record documented Resident #13 went into skilled care Medicare A on 4/18/22. The resident's Care Plan with a goal dated as initiated on 11/10/21 and a target date of 5/29/22, documented Resident #13 would continue to be independent with all ADL's except showers and donning/doffing of compression socks through the review period. An intervention revised on 4/18/22 directed staff that per therapy alert from Physical Therapy (PT) on 4/18/22: recommend assist of 1-2 with FWW (forward wheeled walker) and gait belt for stand pivot transfers only. Use wheelchair(w/c) to and from the bathroom. Resident #13's documentation of BP's (blood pressures) from 4/6/22 to 4/10/22 with warnings were as follows : 4/06/2022 at 2:00 AM 116/70 mmHg (Lying r/arm) 4/06/2022 at 9:26 AM 104/79 mmHg (Sitting l/arm) 4/06/2022 at 10:59 PM 104/79 mmHg (Sitting l/arm) 4/07/2022 at 12:37 PM 120/84 mmHg (Sitting l/arm) 4/07/2022 at 3:36 PM 105/69 mmHg (Sitting r/arm) 4/08/2022 at 1:10 AM 108/70 mmHg (Lying r/arm) 4/08/2022 at 9:26 AM 107/80 mmHg (Sitting l/arm) 4/09/2022 at 5:05 AM 102/56 mmHg (Lying l/arm) Diastolic Low of 60 exceeded 4/09/2022 at 8:28 AM 125/80 mmHg (Sitting r/arm) 4/09/2022 at 4:15 PM 78/56 mmHg (Sitting r/arm) Diastolic Low of 60 exceeded Systolic Low of 90 exceeded 4/10/2022 at 12:04 AM 100/54 mmHg (Lying r/arm) Diastolic Low of 60 exceeded 4/10/2022 at 9:15 AM 103/84 mmHg (Sitting l/arm) 4/10/2022 at 10:38 AM 103/84 mmHg (Sitting l/arm) 4/10/2022 at 5:45 PM 84/59 mmHg (Sitting l/arm) Diastolic Low of 60 exceeded Systolic Low of 90 exceeded Resident #13 had the following Progress Notes documented: On 4/9/22 at 4:15 PM, this resident had blurred vision for approximately one hour. Her blood pressure (BP) was 78/56. Resident was encouraged to ask for help when rising via call light. Signed by the Director of Nursing (DON). On 4/10/22 at 4:22 AM, this resident's BP was 100/52. Resident reported no episodes of dizziness or lightheadedness. Signed by Staff G, RN On 4/10/22 at 4:32 PM, this resident assessed due to lethargy and low BP. Vital signs were Temperature (T) 97.5, Respirations (R) 18, Pulse (P) 111, and BP 84/59. Resident's skin was pale. Resident reported she had been drinking but not eating well and she had also not urinated since early that morning. Resident was lethargic and falling asleep during assessment. The on call doctor was paged at that time and received a telephone order to send this resident to the emergency room (ER) for evaluation. This resident was in understanding of ER visit and agreed with the plan. A bed hold was received from resident. Signed by Staff Q, RN. On 4/10/22 at 8:35 PM, documented the ER called and this resident was to be admitted to the 5th floor for [CONDITION(S)], [CONDITION(S)], and COVID positive. Signed by Staff Q. On 4/10/22 at 9:54 PM, the resident was still in the ER. The nurse informed the ER this resident tested positive for COVID on 3/2/22. The ER stated understanding and that Resident #13 would be admitted to ICU due to low BP. Signed by Staff Q. A Discharge Summary from the hospital dated 4/24/22 documented Resident #13 was admitted to the hospital on 4/10/22 and was discharged from the hospital on 4/18/22. The Discharge Plan and Final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary documented the resident was admitted to ICU for septic shock from a [CONDITION(S)] on 4/10/22. It documented the resident was being discharged back to the facility with recommendation for Physical Therapy and to continue [MEDICATION(S)] (antibiotic) for a complicated urinary tract infection. A History and Physical performed at the hospital and dated 4/12/22, documented Resident #13 was admitted to ICU for [CONDITION(S)] (low blood pressure) unresponsive to fluid challenge requiring vasopressors (medications to raise low blood pressures). The resident came to the ER due to generalized weakness. She had felt generally fatigued the last month or so likely related to a COVID infection in the beginning of March. Over the last day it had progressed to the point where she needed assistance to walk and stand where normally she was ambulatory. It documented that associated symptoms noted by this resident were pain on urination. On arrival to the ER this resident's blood pressure was 102/43 and she had multiple subsequent readings while in the ER with systolic (top number in blood pressure readings) in the 70's. She did not have significant improvement in blood pressure despite fluid bolus of 3 L(liters)(fluids given intravenously). The labs were remarkable for urinalysis suggestive of [CONDITION(S)] and AKI. An Emergency/Urgent Care report from the hospital dated 4/10/22, documented the following: Resident #13 arrived at the hospital per ambulance. The resident presented with weakness. The onset of the weakness was 1 day ago (4/9/22). The resident reported she began to feel ill the night before and it had progressively worsened. This resident had said normally she was able to walk independently and the EMS (Emergency Medical Services) reported the resident needed 2 people to help her walk today. The differential diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Emergency/Urgent Care report documented that while patient was awaiting to go to her hospital room, her blood pressures began trending down, [MEDICATION(S)] (medication similar to adrenaline, used to treat life-threatening low blood pressure) was ordered as patient had already received fluid bolus intravenously. This resident was discussed with the critical care (team) and patient was accepted. Further care for this resident was by the critical care team. A Physician's Note dated 4/20/22, documented the note was for a readmission assessment (back to the facility from the hospital). It documented Resident #13 had a urinary tract infection ([CONDITION(S)]) and ended up with urosepsis. It documented the resident was in the ICU for several days. It documented Resident #13 had come out of it pretty well, the resident was still somewhat weak and did not walk very much. On 4/20/22 at 4:10 PM, Resident #13 was in her room with legs up in the recliner and blanket on. She stated she felt the facility did do everything they needed to do prior to her going out to the hospital. She stated it was her fault she didn't tell them sooner that she was feeling so crappy. Resident #13 stated she was so weak she could not stand to get on the stretcher and they all just picked her up from her recliner and put her on the stretcher. When asked how long she had been feeling crappy she said it was a slow progression over time. When asked if she remembered having a low blood pressure, this resident responded that she did remember. She said the DON (Director of Nursing) came into her room and took her blood pressure and that the DON could not believe her blood pressure was so low.When asked if she had been feeling dizzy she said she was feeling dizzy. She said she was really sick and they had to admit her to the Intensive Care Unit for 5 days. She said they (staff at the hospital) were really worried about her. She then went down to a regular unit (in the hospital) after that (ICU stay). She stated she was surprised when the hospital told her she was going to come back to the nursing home because she could no longer transfer or walk independently. She said the hospital told her that the nursing home could help her with transfers and ambulation. She said they are helping her and she cannot do either independently. She stated she started doing things in Physical Therapy the day before and had returned to the facility on Monday, 4/18/22. She hoped to get her strength back. On 4/21/22 at 12:20 PM, Staff G, RN (Registered Nurse) stated she knew there was a night that second shift had told her Resident #13 was not feeling well. Staff G stated she had asked this resident if she wanted help to the restroom and she said no, but Staff G stayed in the room and watched this resident walk. Staff G stated she had told the aides to watch her because the resident was feeling dizzy. When asked about the BP reading of 78/56 from 4:15 PM earlier that day, Staff G stated if she would have gotten that low of a reading she would have taken it over again and if it would have been that low again, she would have called the on call physician. Staff G said she would have called the doctor at that time because that was unusual for this resident. On 4/21/22 at 11:45 AM, Staff L, CNA (Certified Nurse Aide), stated she did not work on 4/9/22 evening shift but did help Resident #13 on 4/8/22 with removing her compression stockings. Staff L stated Resident #13 was independent at that time. Staff L stated she had brought this resident in her tray and removed the stockings but that was it. Staff L did not notice anything different with this resident and this resident did not complain about feeling weak or dizzy or anything. On 4/21/22 at 12:59 PM, Staff Q, QA nurse, RN, stated every day the facility checked this resident's blood pressure every shift. Staff Q stated she had taken Resident #13's BP by the wrist and it was 60s over 30s so Staff Q rechecked the BP. When she rechecked the BP it was 70s over 40s so then Staff Q got the manual cuff and it was 80s over 40s. Staff Q stated the resident told Staff Q that she hadn't ate much that day, and hadn't peed since that morning. Staff Q stated Resident #13 was pale and shaking during the assessment. Staff Q let Resident #13 know that Resident #13 was probably going out (to the hospital). Staff Q called the doctor and he gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff Q called the ambulance and sent Resident #13 to the hospital. When Staff Q was asked what she would do if a blood pressure was in the 70s over 50s, Staff Q stated she would have that resident lie down and put their feet up into the Trendelenburg position (head down with legs higher). Staff Q stated she would then call the doctor right away. She would do a full assessment and get the resident going (out to the hospital). Staff Q stated a BP in the 70s over 50s would constitute an emergency and the doctor would definitely need to be notified. Staff Q was not aware that Resident #13's blood pressure was in the 70s over 50s the day before. On 4/21/22 at 1:40 PM, the Director of Nursing (DON), stated she had taken Resident #13's BP and it was 70s over 50s. She said she then retook the BP, gave resident food, and had the CNAs watch Resident #13 closely. When asked what the 2nd BP was, she stated that she had Staff S, Licensed Practical Nurse (LPN), take it. When asked where that could be found, the DON looked for it in the electronic health record and was unable to find it. When asked if she felt enough was done with the BP reading, the DON stated in hind sight she should have done more. She repeated that in hind sight there should have been more done. The DON stated she was told that 70s over 50s was normal for this resident. When asked who told her that, she did not respond. The DON stated she had come in on 4/9/22 to cover for a RN who had went home sick at 8:30 AM and worked until 10:30 PM that night. On 4/21/22 at 1:55 PM, Staff J, LPN, stated she worked with Resident #13 the morning the resident was sent out. Staff J stated the resident had said she wasn't very hungry. Staff J said the night before this resident had a spell and was dizzy. Staff J stated the resident was feeling better and her vital signs were good at that time but then that afternoon, this resident had another spell and Staff Q had sent this resident to the hospital. Staff J stated this resident was up in a recliner when Staff J brought her, her tray. When asked what she would do with a BP of 70s over 50s. Staff J stated she would recheck and if it were still that low she would immediately call the doctor. On 4/21/22 at 3:11 PM, Staff S, LPN, stated she remembered the DON coming to ask Staff S to go down to check Resident #13's BP real quick. Staff S said she was working on the other side of the building. Staff S went over to the east side of the building and took this resident's BP but she didn't get a BP reading higher than the DON. Staff S did not remember what the BP reading was. Staff S stated she would say it was 70s over 40s. Staff S said she would be concerned with a BP that low and would call a doctor right away to report it. She stated she even told the DON that she (Staff S) didn't get a higher BP reading than the DON did. Staff S stated she then asked who was the on call physician. Staff S stated the DON replied with the physician's name and shrugged her shoulders. Staff S stated that she expected the DON was going to call the doctor, so she didn't think anything more about it until this day when she received a call about it. Staff S stated she had been a nurse for [AGE] years. Staff S stated every time she sees something that is not okay, she then reports to the physician, then she feels like she'd done the right thing. Staff S stated the facility wanted the nurses to limit sending residents out to the hospital. Staff S said her name came up at a nurse meeting regarding sending a resident out with abdominal pain. She said the resident ended up needing magnesium [MEDICATION(S)] (bowel evacuation medication). Staff S stated the resident complained of severe abdominal pain and she notified the physician who wanted the resident sent out. She said at the meeting it was said she should have tried other interventions first before sending him out to the hospital. Staff S stated she received a text from the DON asking her to make a note of the BP that the DON had asked Staff S to take for Resident #13. Staff S repeated she did not remember the exact BP reading. A copy of the text sent to Staff S from the DON on 4/21/22 at 1:40 PM, revealed Staff S was asked to give the DON a call. Staff S texted back 30 minutes later. The DON then text it was okay and Staff S did not need to call and she (the DON) just needed Staff S to write on a piece of paper that she had to recheck a BP for Resident #13. The DON then text that she did not remember the exact number; but it was higher than her (the BP reading the DON had gotten) BP of 76/54. On 4/25/22 at 9:52 AM, Resident #13's Primary Physician, after the Progress Note from 4/9/22 regarding blurred vision for approximately 1 hour and a BP of 78/56 was read to this doctor, the doctor stated somebody should have been notified of this. He stated that's a pretty low blood pressure. The on call physician should have been notified and Resident #13 should have been sent out. He stated in hind sight of knowing she had a [CONDITION(S)] that went septic and had to go into ICU for care on 4/10/22, the blurred vision and low blood pressure on 4/9/22 could have been the 1st sign of [CONDITION(S)]. This doctor repeated that the on call doctor should have been notified of this BP at the time it was taken. On 5/2/22 at 1:10 PM, Staff AA, PTA (Physical Therapy Aide), when asked how Resident #13 was progressing in her therapy, stated Resident #13 had a fall last week and went down to her knees. Staff AA stated the resident was having pain rated 7 out of 10 from the fall to both knees. Staff AA stated Resident #13 was currently a steady stand transfer with assist of 2. Staff AA stated she thought this resident would get back to being independent. It was just taking her longer related to pain. The Physical Therapist walked in on the above conversation. The Physical Therapist stated she hoped Resident #13 would make it back to her previous level of functioning. The Physical Therapist stated last week the resident had ambulated about 20 feet with assist and now she's back to ambulating 5 feet. A Physical Therapy Plan of Care dated 4/18/22, documented: The resident's prior level for gait distance was 150 feet, the current level was 5 feet and the anticipated level was to be 150 feet. The resident's prior level of functioning for mobility: roll left to right, sit to lying, lying to sitting on bedside, sit to stand, chair/bed to chair transfer and toilet transfer was independent; the current level was substantial/maximal assist and the anticipated level was independent. The resident's prior level of functioning for walking 10 feet, 50 feet with 2 turns and 150 feet was independent, the current level was not attempted due to medical condition or safety concerns and the anticipated level was independent. On 4/26/22 at 1:20 PM, the DON stated she had followed up on this resident's BP, as a 2nd BP was obtained which was higher than the one she had gotten. She stated she kept a close eye on the resident and had the CNAs keep a close eye on the resident as well. The DON stated she felt the BP did not require the doctor to be notified. Information was shared with the DON regarding nurses that were interviewed would have notified the physician with a BP of 78/56 and interviews did not support a 2nd blood pressure that was higher than 78/56, nor was there documentation to support further interventions, nor was there further assessment documentation until the 3rd shift. The DON stated understanding of the concern and agreed the documentation was not there to support further interventions or assessments by her. 2. A MDS dated [DATE], documented Resident #12 was admitted on [DATE]. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS score had not yet been assessed. The resident required extensive assist of 2 for bed mobility, assist of 2 for transfer and locomotion on and off unit, and required total dependence of 1 for eating. A Baseline Careplan dated 4/7/22, documented Resident #12 could communicate and easily understand staff. Resident's preference for care discussions was to have family involved. The Care Plan documented her admission goals were SNF (skilled care) level of care with PT/OT(Occupational Therapy)/ST (Speech Therapy) and her initial discharge goal was to return home. It documented discharge plans were initiated. It documented her cognition level was alert and intact. It documented her level of pain was at a 10 out of 10 (the worst pain). The resident was to discharge home. The Census page for Resident #12 documented: - 4/7/2022 Medicare A Active SNF/ICF - 4/9/2022 STOP BILLING A Medication Administration Record (MAR) dated April 2022, documented pain medications that resident received included the following: a. [MEDICATION(S)] Tablet 15 milligrams (MG), give 1 tablet every 12 hours for pain. This medication was administered at 7 PM on 4/7/22 for pain level of 10 and on 4/8/22 at 7 am with a pain level of 3 and 7 PM with a pain level not documented. The start date was 4/7/22 at 7:00 PM and the discontinue date was 4/8/22 at 8:10 PM. b. OxycontinTablet ER (extended release) 15 MG, give 1 tablet by mouth two times a day for pain. This medication was administered 1 time on 4/7/22 for pain level of 10. The start date was 4/7/22 at 6:00 PM and the discontinue date was 4/7/22 at 7:48 PM. c. [MEDICATION(S)] (Concentrate) Solution ([MEDICATION(S)]), 20 MG/ML(milliliters), give 10 mg by mouth three times a day for pain 10 MG=0.5 ML. This medication was administered at 10:00 PM on 4/8/22 for a pain level of 4. The start date was 4/8/22 at 10:00 PM and the discontinue date was 4/19/22 at 7:02 PM. This MAR showed that no PRN (as needed) pain medications were given to this resident. The Progress Notes (without displaying the eMAR progress notes (notes automated from the MAR regarding medication administration)) for this resident were documented as follows: -On 4/7/2022 at 10:15 AM Admission Summary Note Text: Resident was admitted from home. Recent hospitalization from [DATE]-[DATE] due to pancytopenia. admitted to SNF level of care. Waiting on PT/OT/ST orders. Daughter here and assisted with paperwork. Resident had been staying with her daughter for the last week due to increased weakness. Resident has a lot of pain and family has been pivot transferring with assist of 2. This nurse and another nurse attempted pivot transfer and resident had a lot of difficulty with standing and turning to sit. Family also reported that resident does better with softer food. This nurse asked for a mechanical soft with chopped meat and extra sauces/gravies until speech is able to evaluate. Rapid COVID test negative on admission. All departments and pharmacy notified of arrival. -On 4/7/2022 at 10:15 AM, COMS - Clinical Admission Evaluation: Admission mode: wheelchair. Living situation prior to admission: Lived alone. Vitals: Temperature: T 97.7 Route: Forehead (non-contact), Blood Pressure: BP 115/75 Position: Sitting r/arm, Pulse: P 100 - Pulse Type: Regular, Pulse is normal in character, Respiration: R 16 O2 sats: O2 95 % Method: Room Air. Height: H 63 inches Method: Standing (height, pox and vital signs all documented as taken on 4/7/22 at 10:15). Indicators of pain: Vocal complaints of pain. Pain Description: Generalized Pain Score: 10 Reports that pain occurs less than daily. Relaxation techniques encouraged. Resident position changed. Non-medication interventions did not provide relief. Neurologic: Resident obeys commands. Denies weakness, tremors, numbness or tingling. Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. Level of cognitive impairment: Alert. Ability to hear (with hearing aid or hearing appliance if normally used): Adequate. Hearing aid or other hearing appliance used when evaluating hearing: Yes. Ability to see in adequate light (with glasses or other visual appliances): Adequate. Mood / Behavior: Mood is pleasant, no unwanted behaviors witnessed. Resident does not wander. Resident sleeps through the night. Psycho-spiritual needs met: Yes. Cardiovascular: Circulation check: Extremities are warm and pink. Capillary Refill: Brisk < 3 seconds. Resident positive for [CONDITION(S)]. Generalized: Non-pitting [CONDITION(S)]. Lower extremity(s): +2 pitting [CONDITION(S)]. Other [CONDITION(S)]: No. Antiembolic treatment: No. Denies calf tenderness. Left pedal pulse: +2 normal. Right pedal pulse: +2 normal. Cardiovascular Note: Non pitting [CONDITION(S)] to bilateral hands +2 pitting [CONDITION(S)] to bilateral lower extremities and feet Respiratory: No signs of difficulty breathing. Left lung sounds location: Throughout. Left lung: Diminished on auscultation. Right lung sounds location: Throughout. Right lung: Diminished on auscultation. Utilizing oxygen: No. No cough. Currently on respiratory antibiotics: No. Gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4. Denies indigestion, nausea, vomiting, diarrhea or constipation. Continent of bowel: Yes. Date of last BM: 04/06/2022 Bowel movement appearance: WNL. Currently on gastrointestinalantibiotics: No. Nutrition: Nutritional intake < 75%. Difficulty chewing noted. Difficulty swallowing at times. Change in appetite noted. Decrease in fluid intake noted. Diet: Modified. See chart for full diet order. Complaints of thirst: No. No signs of symptoms or possible swallowing disorder. Upper dentures noted. Obvious or likely cavity or broken natural teeth. [CONDITION(S)]: Resident continent of bladder. Urine clear yellow. Denies urinary complaints. Perineal care provided: Yes. Currently on [CONDITION(S)] antibiotics: No. Skin: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Skin Note: Refer to skin and wound tab for pictures and skin sheets for measurements Safety: Call light is within reach. Resident is not on [CONDITION(S)] precautions. Use of assistive device: Yes. Assistive device: Grab bar. Use of physical restraint: No. Use of sensors / alarms: No. Functional: Resident is able to move all extremities. Upper extremity ROM: Impairment on one side. Lower extremity ROM: Impairment on both side. Gait is unsteady. Balance is poor. Resident is able to self-position. Resident continues to participate in physical therapy as ordered. Resident continues to participate in speech therapy as ordered. Resident continues to participate in occupational therapy as ordered. Resident uses a manual /wheelchair. Special Care: Labs / Education: Currently on antibiotics: No. Safety concerns: No. Comfort concerns: No. Resident / responsible party concerns: No. Education provided in preparation for discharge: Yes. Infection control. Clinical Interventions: Narrative Note: (same as admission summary note). This clinical evaluation is powered by COMS Interactive. -On 4/7/2022 at 11:00 AM, Health Status Note Text: This RN was present with admission nurse for admission skin assessment. The resident reports having pain all over and states the pain medication does not provide much relief. Daughter and granddaughter present. Daughter reports that her mother had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . She is followed by oncology and she sees dermatology every 6 months due to her history. Daughter reports that she had pre-[CONDITION(S)] [CONDITION(S)] to right shoulder for which she had surgery about 4 weeks ago. Daughter reports after surgery, it was discovered her platelet count was 0 and she spent a few days in the hospital. Daughter reports she (her mom) was discharged from the hospital on 3/25/22 and she spent a week at home and a week with another family member and she is now here for therapy. Goal is to return home. This resident has not had any falls in the last 6 months. The resident and her daughter denied a history of having [CONDITION(S)]'s. Daughter reported her mom receives an oral [CONDITION(S)] agent and also received [MEDICATION(S)] 8 weeks ago and experienced an [CONDITION(S)] response. The resident has swelling in her hands and ankles/feet that her daughter reports the oncologist had said was from the [CONDITION(S)] response. Daughter reported her mother has dry mouth and dry eyes. Appetite is poor for the last 3 weeks. Family reported she does better with softer foods. Toenails are clean and well trimmed. Feet have purple discoloration at the toes. Entire upper aspect RUE (right upper extremity) is dark purple in color from surgery 4 weeks ago. Skin tear observed to RLE (right lower extremity) that family reported happened yesterday they believe from removing her pants. Area assessed and covered with [MEDICATION(S)], Kling and gauze. The resident has an upper denture that fits with adhesive. She has her own bottom teeth. She has bilateral hearing aids and has a charger station that is in her room. Hearing adequate. She has glasses and can see regular print. Family reported they were SPT and assist of 2 with their mom at home as it hurts her arms to push onto a walker. They also report placing gait belt above her chest. This RN and admission nurse assisted her to the bathroom and she is very difficult to stand. She was unable to pull her pants up or down and staff wiped her after toileting. Upon standing, she had to sit back down onto toilet as she could not stand long enough to have skin assessed and pants pulled back up. She also reported a lot of lower back pain. Daughter reported this is from arthritis. Admission nurse assessed bottom, while this nurse held resident up as it was difficult for her to stand. -On 4/7/2022 at 1:01 PM, New Order Note Text: The system has identified this order as being outside of the recommended dose for this drug: Sodium Chloride Tablet 1 GM Give 2 tablet by mouth two times a day for Supplement COMMUNICATION-with Physician Note Text: Skilled certification. -On 4/7/2022 at 1:08 PM Social Service Note Text: Resident was admitted today from home for SNF level of care, she said she goes by (Resident #12). Family spoke of her recently being in the hospital and returning home, but is now needing more ADL (activities of daily living) care and is in quite a bit of pain. She and family said the goal is that she return home, discussed the possibility of homecare upon dc (discharge). Family said she is mentally sharp. Trauma screen done with a score of 6. Social Services. -On 4/7/2022 at 1:56 PM, COMMUNICATION-with Physician Note Text: Medical Director called facility with questions about script request for pain medications. The Medical Director will write script for 2 weeks but states these medications need to be addressed by Oncology for use beyond the 2 weeks. Admission nurse notified and reports Resident #12 has an appointment with Oncology tomorrow. -On 4/7/2022 at 5:54 PM, COMMUNICATION-with Physician Note Text: Received return fax from Medical Director with orders for a [CONDITION(S)] US for nodule on PET scan. Scripts sent for [MEDICATION(S)] and gave new order for [MEDICATION(S)] 15 mg 1 tab at 0800 and 2000. MAR and pharmacy updated. -On 4/9/2022 at 2:45 PM, COMMUNICATION-with Physician Note Text: on-call physician for PCP (primary care provider) contacted, via phone, giving an order to release body to Funeral Home, per family's request. Resident admitted to facility, on Thursday, on 4/07/22, presumably under the care of the Medical Director, MD; the Medical Director not having an opportunity to meet resident, t

Based on staff interviews, record review, facility policy and procedure, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing, failed to provide the necessary treatment and services to promote the healing of pressure ulcers for which a resident was transferred to the hospital with an infection for one of two residents reviewed (Resident #2). This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 74. Findings include: 1. The Quarterly Minimum Data Set (MDS) completed for Resident #2 with an Assessment Reference Date (ARD) of 2/11/22, documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had a Brief Interview for Mental Status score of 14 which indicated no impaired cognitive decisions and no impairments for hearing or the ability to be understood and understand others. The resident required extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene and was frequently incontinent of bladder and bowel. The MDS also documented the resident admitted with an unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar, and a new unstagable deep tissue injury, and pressure reducing device for chair, bed and pressure ulcer/injury care. The MDS documented the resident's admitted as 1/24/22. The Braden Scale for predicting pressure sores, dated 1/24/22 at 12:45 p.m., documented a score of 20, which indicated not at risk. The Braden Scale for predicting pressure sores, dated 1/31/22 at 12:31 p.m., documented a score of 19, which indicated not at risk. The Braden Scale for predicting pressure sores, dated 2/7/22 at 12:30 p.m., documented a score of 15, which indicated is at risk for pressure sores developing. The Braden Scale for predicting pressure sores, dated 2/11/22 at 2:22 p.m., documented a score of 14, which indicated at moderate risk for pressure sores developing. The Braden Scale for predicting pressure sores, dated 2/14/22 at 3:38 p.m., documented a score of 13, which indicated at moderate risk for pressure sores developing. The Care Plan with a focus areas initiated 1/31/22, documented Resident #2 was admitted with an unstagable pressure ulcer to my left heel. Goal is my pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions include: *(1/31/22) Administer treatments as ordered and monitor for effectiveness. *(1/31/22) I am to wear podus boots to my bilateral lower extremities at all times. *(2/3/22) General diet. High Nutrition portions. 1.5 portions of meat/entree at all meals. Likes whole milk. *(2/7/22) Dietician to review routinely for nutritional approaches to improve wound healing. *(2/7/22) Wound clinic appointments as recommended. *(2/16/22) Wants scrambled egg every breakfast. Premier protein once daily, cheese and crackers for a.m. snack. *(2/18/22) Order received for air mattress to bed. *(2/24/22) Sent to emergency room from wound clinic appointment and admitted for [CONDITION(S)]. *(2/24/22) Per therapy alert, Patient will need to be repositioned every 2 hours to promote healing of pressure wounds and increase skin integrity. The Care Plan with a focus area initiated on 2/7/22, showed Resident #2 had a potential to be at risk for skin breakdown/impaired wound healing related to incontinence, malnutrition diagnosis, decreased mobility. Goal: I will not develop any new areas of skin breakdown through the review period. Interventions include: *(2/7/22) Encourage good nutrition and hydration in order to promote healthier skin. *(2/7/22) Monitor my skin with cares and on shower days. Notify nurse and primary care provider of areas of concern. *(2/7/22) Pressure reduction cushion to wheelchair. *(2/7/22) Pressure reduction mattress on bed. *(2/7/22) Treatments as ordered by the primary care physician. *(2/8/22) Suspected Deep tissue injury to right upper buttock. Purple intact area. Red. Warm skin surrounding and non-blanching. Call to wound clinic with order for sacral dressing and to encourage me to position off area. *(2/10/22) Per therapy alert from Occupational Therapy, please encourage me to transfer to wheelchair and eat all meals in dining room. I will need to be repositioning every 2 hours to promote healing off pressure wounds and increase skin integrity. Recommend that I am seated at encouragement table in dining room to increase intake due to recent weight loss. I require maximum assist to minimum assist will vary depending on mental status. *(2/18/22) Two purple fluid filled blisters to right lateral foot. Areas cleansed and covered with [MEDICATION(S)] foam bordered dressing. *(2/18/22) Order received for air mattress to bed. The Weekly Skin Sheet dated 1/28/22, documented left heel measured 1.0 centimeter (cm) by 1.5 cm, open area with red granulated tissue, scant serous drainage, peri-wound blush colored/intact. The Wound Clinic Office Visit dated 2/3/22, documented wound #1- left heel, measured 0.9 cm by 1.6 cm by 0.1 cm. with no undermining, serous sangous drainage, callus, dry, intact, peri-wound, no odor, 70% slough, no eschar, and 20% pink granulation tissue. Procedure: Pressure Ulcer of left heel, Stage 3, post debridement measurements were 0.9 cm by 1.6 cm by 0.2 cm. Has a boot that they put on his left foot and lower leg when in bed to off load the heel area. Patient is currently not ambulating. Apply [MEDICATION(S)] AG to the ulcer bed. That was covered with [MEDICATION(S)] foam and tape. Dressing changes on Monday, Wednesday and Friday schedule. Clean ulcer with saline dressing changes. Avoid any pressure to the left heel area. Follow up in the wound clinic in 3 weeks. The Weekly Skin Sheet dated 2/4/22, documented left heel, open area, resident in hospital, not able to measure. The Progress Notes dated 2/8/22 at 8:46 a.m., documented call to wound clinic with report of purple, intact red area, warm surrounding, tender, non-blanching skin to right upper buttock, as reported to this nurse by 10:00 p.m.,- 6:00 a.m. nurse and observed by this nurse and 10:00 p.m.,nurse on shift change this a.m. Spoke with clinic nurse, who suspects the area is a deep tissue injury and advises to apply a sacral border to pad the area and change on bath days and as needed, and encourage him to stay off the area. Update to Point Click Care. The Progress Notes dated 2/8/22 at 9:30 a.m., documented sacral border foam to right buttocks, change on bath days and as needed, for loose/soiled. Applied per order. The Weekly Skin Sheet dated 2/11/22, documented: Left heel, 4.0 cm by 4.0 cm, open area, purple with red edges, open area, no drainage. Coccyx- 6.0 cm by 2.0 cm by 1.0 cm, open area, red wound bed with scant serous drainage, minimal slough. The Weekly Skin Sheet dated 2/18/22, documented: Left heel- 4.0 cm by 4.0 cm, open area, black, hard with red edges, no drainage. Gluteal Cleft- 6.0 cm by 2.0 cm by 1.0 cm deep, deep tissue injury, entire area yellow slough. Coccyx- Left gluteal- 6.0 cm by 1.5 cm, deep tissue injury, both sides denuded/red serous drainage. Right gluteal- 6.0 cm by 5.0 cm, deep tissue injury, both sides denuded/red serous drainage. He is followed by the wound clinic and has an appointment on 2/24/22 of this month. The Wound Clinic Office Visit dated 2/24/22, documented: Patient presents today lethargic, frequently falling asleep, slumping forward in wheelchair. Odorous left heel could be detected bringing patient back to exam room. Note from facility, to look at buttocks as there are new wounds, and concerns for left heel for 'extreme odor'. Wound #1- left heel, measured 3.2 cm by 3.5 cm by 0.3 cm, no undermining, moderate exudate with serous sanguineous drainage, peri-wound with dry drainage, macerated, odorous, 100% necrotic tissue. Wound #2- right buttock, measured 1.7 cm by 0.8 cm by 0.1 cm, no undermining, large purulent exudate, peri-wound with macerated induration and [CONDITION(S)], mild odor, 75% slough. Wound #3- right gluteal fold, measured 8.2 cm by 2.0 cm by 1.2 cm, no undermining, sinus tract-towards noon of 5 cm, large purulent exudate, with peri-wound macerated with induration and [CONDITION(S)], mild odor, 80% slough and 20% pink granulation tissue. This male presents to the wound clinic for follow-up examination. Patient was initially seen in the Wound Clinic on 2/3/22 for a pressure ulcer at the left heel. Patient resides at an extended care facility. Was brought in today and noted to be much more lethargic than previous visit. Ulceration at the left heel is significantly larger and covered with necrotic tissue. Patient also has a new pressure ulcer over the coccyx which extends onto the right buttock. There is tunneling proximally. Considerable necrotic tissue and wound odor. Large are of [CONDITION(S)] and increased warmth onto the right buttock. Patients temperature currently is 99.7 degrees Fahrenheit. Due to patient having significant changes in his mental status since his last visit coupled with the large new pressure ulcer over his coccyx with associated signs of [CONDITION(S)]. Patient will be taken to the emergency room for further evaluation. Dressings were placed over the coccyx and heel ulcer. The Final Report dated 2/24/22, from the emergency room , Chief Complaint-Wound Issue. Patient was sent from care center for evaluation of patients left heel wound and sacral wound. Patient was sent from the Wound Care Clinic to the hospital for further management. Patient complains of low back pain and left heel pain. Patient reports that his pain has been gradually getting worse. Patient denies fever or chills. Patient etiology is most likely secondary to a decubitus ulcer versus left heel ulcer (foul-smelling) Patient also has surrounding [CONDITION(S)] around the buttock area. Patient is hypotensive with systolic blood pressure in the 80's. Principle problems- [CONDITION(S)] most likely secondary to [CONDITION(S)] versus decubitus versus left heel ulcer. The Final Report dated 2/27/22, documented, Procedures performed- Extensive debridement of sacral decubitus ulcer, sharp and pulse lavage debridement of muscle and fascia including gluteal tissues incision and drainage of 2 large gluteal abscesses's (20 cm by 10 cm by 5 cm) and left heel decubitus ulcer debridement (3 cm by 3 cm by 1 cm). Indication for procedure- This is a [AGE] year old male who presented from outside facility after going to wound care appointment noting that he appeared altered and septic and had large wounds on the sacrum and his left heel both unstageable. He had an elevated white count and was started on broad-spectrum antibiotics there was a concern for osteomylitis, he ended up getting an MRI which showed no osteo but did show large abscess underneath the sacral decub and 2 large gluteal abscesses. He was then taken to the operating room after risks and benefits were discussed with the patient and caretaker. Description of procedure- Subsequently I began by unroofing the sacral decub and noting that there was a quite a large space both cranially and caudally that I extended. There was a large amount of devitalized tissue which was both muscle and fascia layer probably right above the sacrum. I noted there were 2 large pockets in the left buttock, that were unroofed, large amount of skin had to bed debrided as it would be devitalized due to the size of the space. I then proceeded to perform sharp debridement of all necrotic tissues and anything that appeared to be nonviable subsequently. I used cautery and [MEDICATION(S)] sutures to stop any oozing. The size of the wound was 20 cm longitudinal 10 cm and the width and 5 cm peek at the height of the wound. After performing sharp debridement and with cautery and using pulse lavage greater than 2 liters of irrigation, I then packed the wound with slightly soaked [MEDICATION(S)] gauze times 2 placing abdominal pads over this, the total size of the wound is 200 cm. I then focused my attention on the left heel decubitus ulcer I used a scalpel to convert this into unstageable ulcer it was quite deep and likely right over the fascia over the bone. The size was about 3 cm by 3 cm by 1 cm. I used cautery to stop any oozing. The patient will need daily wound care changes by the wound care team and then subsequently a VAC would likely have to be place onto the large sacral wound. There may be concern for osteo and if that is the case he will need to have long term at least 6 weeks of IV antibiotics. Subsequently he will likely need to have plastics consultation for possible reconstruction likely to be performed at a large tertiary academic center. The Final Report dated 2/28/22, documented, Patient resting in bed, reports that his decubital ulcer pain is better. *Assessment/plan- admitted for [CONDITION(S)] with [CONDITION(S)]. Patients etiology of [CONDITION(S)] is most likely secondary to the decubitus ulcer versus left heel ulcer (foul-smelling). Patient also has surrounding [CONDITION(S)] around the buttocks. area. Patient is hypotensive, improved with fluids. Patients decubitus ulcer over the coccyx probes to the bone also has purulent drainage patient most likely has osetomylitis. The Skin Assessment Policy dated 3/18/21, documented: Purpose- Timely focused assessments are critical to care. Procedure-Assess integrity each shift for patients at risk for skin breakdown and patients with incisions, pressure ulcers, or wounds. Assessment of skin integrity includes: 1. Skin Condition a. Note is skin is dry, moist, abraded, or fragile. Note any [CONDITION(S)], blisters, discoloration, or other abnormalities. 4. Pressure points a. Assess pressure points, Do not massage reddened areas. b. Use positioning to alleviate pressure. 5. Pressure ulcers a. Perform thorough wound assessment including wound stage. b. Assess healing and describe signs of healing. Notify provider if wound is deteriorating. The Treatment Medication Record (TAR) dated 2/1/22-2/28/22, instructed staff to apply sacral border foam to right buttocks, change on bath days and as needed, one time a day every Monday and Thursday for deep tissue injury with start date of 2/10/22. Review of the TAR revealed that on 2/17/22 and 2/21/22, the boxes were left blank with no initials. During an interview on 3/7/22 at 4:22 p.m., Staff G (Certified Nursing Assistant) confirmed and verified that 2-3 days prior to Resident #2 leaving the facility for a wound clinic appointment there was an odor that would come from their room. Staff G stated they would go into the resident room to check the resident bottom to see if the resident was soiled and the resident was not. Staff G explained that the smell was like a rotten flesh smell. Staff G stated that they remember telling the charge nurse but was not able to remember or recall which nurse that was. During an interview on 3/7/22 at 4:45 p.m., with Staff A (Certified Nursing Assistant) explained that Resident #2 was very compliant with being turned from side to side, he didn't like to lie on his back due to his bottom would hurt and he would be in so much pain. He would keep his podus boots on at all times, said that they helped his heels from not hurting by relieving the pressure. He didn't like to get out of bed due to having so much pain all over, it took all he got just to get up for meals and sit and then he wanted to go to bed right away. When we did cares on him a couple of days prior to him leaving he had an odor that was coming from his bottom, I would walk by his room and smell this odor than I would go in an check him and there was nothing in his brief. The odor was very strong I would let the nurse know that there was an odor coming from his bottom. The smell that came from his bottom was very foul and strong. During an interview on 3/7/22 at 5:00 p.m., Staff B (Licensed Practical Nurse) stated Resident #2 was admitted to the facility on [DATE] to room D which was on the skilled side, he was up independently and would walk, do therapy and was alert and oriented times 4, as the days went by he was almost like a person with an emotional breakdown for which he didn't seem to want to focus on anything, he could not remember how to use his phone, started to decline working with therapies and so therapies decided to discharge him from their skilled services due to him not wanting to participate. He then got moved to room [ROOM NUMBER]-b. He was on a pressure reducing mattress and that he was in a lot of pain and would not like to lie on his back or bottom and wanted to be on his sides the majority of the day, it was difficult even to get him up out of bed for meals, he would sit up and eat a few bites and then would go back to bed and lie on his sides. Staff B said that they were not able to smell anything from his heel wound due to having covid three times and not able to taste or smell, there might have been an odor but Staff B didn't smell anything. The treatment to his bottom was scheduled on the 2:00 p.m.-10:00 p.m. Staff B was not able to remember what the heel looked like, if it had gotten worse or better and that the facility wound nurse would measure and describe accordingly. During a further interview on 3/8/22 at 2:30 p.m., with Staff B, confirmed and verified if the Treatment Record had no initials in the box or no documentation in the Progress Notes than the dressing to Resident #2's bottom failed to get done. Staff B informed this surveyor if staff said the dressing on Resident #2's bottom needed to be changed, Staff B would think that they would of changed it, but since it was not charted means it was not completed. During an interview on 3/8/22 at 1:55 p.m., Staff C (CNA) explained Resident #2 was really good about being repositioned from side to side and that he didn't like to be on his bottom due to it hurting so much, he would get out of bed and sit in the chair for meals but would be there for a short time only. Staff C, did say that there was an order to his bottom when they would go into his room and reposition him and even change him, the odor smelled (like rotten flesh), some days and you would check him and there was nothing. Staff C went onto say that the odor was 2-3 days prior to him leaving on the 24th, there were times when Staff C would go in and change him and the dressing to his bottom was soiled and you could see the drainage on the dressing so we would tell the charge nurse. The day that he went to the Wound Clinic there was drainage coming out from underneath the dressing and was like it was oozing, and would not stop. During an interview on 3/8/22 at 2:45 p.m., Staff D (CMA/CNA) explained Resident #2 was very good at being repositioned on his side and didn't like to lie on his back due to it would hurt his bottom. He was a really nice guy and that he hurt all over and just didn't feel like moving and wanted to be either on his left or right side. Staff D went on to say they could not remember if there were any odors coming from Resident #2's bottom or heel. During an interview on 3/8/22 at 3:30 p.m., the facility Director of Nursing, explained during the investigation into the area on Resident #2's bottom it came to her attention that the area was seen first 2/7/22. The Director of Nursing stated it was an expectation of the nurses to document on areas when they are noticed and to follow the facility skin assessment and that it was not until 2/28/22 that she even knew Resident #2 was in the hospital due to [CONDITION(S)] and that she also reviewed his chart and noticed his dressing change to his bottom was not documented as completed on 2/17/22 and 2/21/22 and if it is not documented it is not done. It would be an expectation of staff to notify the physician of any changes in the area to Resident #2's bottom or heel and if there was an odor than the staff needed to notify the Wound Clinic Dr. right away to make sure the necessary treatment will get ordered and completed. During an interview on 3/8/22 at 4:30 p.m., Staff F (Licensed Practical Nurse) stated that they worked on 2/17/22 and also on 2/21/22. Staff F verified and confirmed that if there are no intials in the box on the treatment record for the dressing changes to be completed than the treatment failed to get completed as ordered. Staff F did verifty Resident #2's bottom was red and swollen and was not able to remember or recall when the resident's bottom was red or swollen and if there is no documentation in the Progress Notes than it was missed. Staff F also confirmed and verified the Physicians orders are to be followed. During an interview on 3/9/22 at 10:15 a.m., Staff E (Registered Nurse) stated she had seen the area on Resident #2's bottom on 2/11/22 and also on 2/18/22. On 2/11/22 she said that she was understanding staff already had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . And per the documentation if that is what she documented than that is what she saw. On 2/18/22, she explained she saw the area and that it had gotten worse and that to her memory there was no odor, only that it was on both sides now. At that time she went and called to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not able to explain how come on 2/11/22 she didn't order an air mattress. During an interview on 3/10/22 at 11:30 a.m., the Wound Clinic Physician, explained with the resident coming to the facility with a pressure ulcer on his left heel, the resident was already compromised and felt that the facility needed to put in place the necessary interventions to keep other pressure areas from developing, and if they had done those interventions and notified the Wound Clinic with the new area, and let the Wound Clinic know the wound on the heel was deteriorating, we could of gotten Resident #2 in sooner than 2/24/22. By the time he had come to the Wound Clinic, the wound on sacral/bottom was so infected that you could smell the odor in the hallway prior to going into the examine room that the resident was in. The Physician has never admitted a resident with a pressure ulcer that could not be managed as an out patient at the clinic and that if the facility would of let us know sooner it might of kept him out of the hospital. With the resident being at risk for ulcer, it would have been expected that the facility put into place the necessary interventions to keep the resident from developing any more areas. The State Agency informed the facility of the Immediate Jeopardy (IJ) and gave them the IJ Template on March 10, 2022 at 3:24 p.m. Facility staff removed the Immediate Jeopardy on March 10, 2022 through the following actions: a. Staff Education on Skin Assessment Policy and Wounds from the How to Books. b. Assessment for concerns with stop and watch and/or alerts, immediatley notifying the charge nurse or Director of Nursing. c. Staff Education on reporting and identifying potential wounds, open areas, immediatley upon discovering areas. d. Staff education on every new admission will have two (2) nurses examing all areas, with proper documentation, from both. The scope was lowered from J to D at the time of the survey exit after ensuring the facility implemented education and their policy and procedure.

Based on observations, interviews, and record reviews, the facility failed to address symptoms of a urinary tract infection [MEDICAL CONDITION] for one resident reviewed (Resident #1). The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) completed with an Assessment Reference Date of 6/25/20 showed a Brief Interview for Mental Status score of 5, indicating severe cognitive impairment. The resident was admitted to the facility on [DATE] from an acute hospital. The resident had a readmission date of [DATE] from an acute hospital. The resident was always incontinent of bowel and bladder during the seven day lookback period. The resident required extensive assistance of one staff with toileting and personal hygiene during the seven day lookback period. The resident had [DIAGNOSES REDACTED]. Observations On 8/19/20 at 2:38 PM, watched Staff G, CNA, and Staff H, CNA, assist the resident in the bathroom. Staff G and Staff F wash their hands. Staff G applied the gait belt around the resident's waist while Staff H applied gloves. The CNAs explained what they were going to do and then helped the resident sit on the toilet. Staff G removed their gloves and sanitized their hands. Staff H removed gloves and applied new gloves without completing hand hygiene. Staff H got the resident removed the resident's pants, held them while putting on the resident's fresh pullup, and then put pants back onto the resident. Staff H then removed old gloves and applied new gloves without hand hygiene. Staff G got out the wipes, then stood behind the resident and with wipe reached up to the vagina and wiped to the buttock. Then with a different hand, Staff G wiped the front of the resident and then removed gloves. The CNAs helped the resident sit into the wheelchair. Record review The Urine Culture dated 3/31/20 showed the resident was treated with [MEDICATION NAME] VK 500 milligrams (mg) orally three times a day for five days due to catheterized urine showing greater than (>) 100,000 colony-forming streptococci, beta-[DIAGNOSES REDACTED] group B (Urinary Tract Infection UTI) and dysuria (pain with urination). The Dietitian Assessment for 4/13/20 showed the resident had a UTI on 3/31/20. The Clinical Nursing Home Note dated 6/2/20 showed the resident visited with the Physician via telemedicine. The resident denied pain at the time of the visit, but the staff said the resident seemed bloated with a decreased appetite. Due to the assessment, the Physician ordered [MEDICATION NAME]. The Physician noted the resident was not real distended at that time. The Physician Visit note dated 6/2/20 at 12:19 PM showed the resident had a 60-day recertification visit with the Doctor (Dr.) via telehealth. The nurse, per Dr.'s request, performed the physical assessment. The resident's vital signs (VS), medications, and blood sugars were reviewed. New order received for [MEDICATION NAME] 80 mg chew to give after each meal and at bedtime, [MEDICATION NAME] PM one hour before bedtime, and talk to the resident's family regarding the donepezil to determine if it was ok to discontinue? The New Order Follow Up Note dated 6/2/20 at 7:31 PM showed the resident had an initial dose of [MEDICATION NAME] and [MEDICATION NAME] with no adverse effects noted. The New Order Follow Up Note dated 6/3/20 at 1:47 PM showed the resident was up as usual. No signs or symptoms of adverse reactions were noted related to the start of [MEDICATION NAME]. Bowel sounds active in all four quadrants. The abdomen was noted to be soft, round, and slightly tender with palpation. The resident denied any abdominal discomfort. The resident slept through breakfast but ate 100 percent (%) of lunch without difficulty-no complaints of gas. The Health Status Note dated 6/7/20 at 12:38 PM showed the resident with VS of temperature of 97.7, a pulse of 75, respirations 18, blood pressure (BP) of 163/72, and oxygen saturation (SpO2) 98% on room air. The resident had three loose stools since the previous shift. Bowel sounds active in all four quadrants. The abdomen was noted to be soft, non-distended, slightly tender with palpation. The resident was up per usual. The resident's appetite was per usual, but the resident had an occasional loose stool. The Health Status Note dated 6/7/20 at 8:51 PM documented the staff reported the resident had two loose stools that shift. The resident was in good spirits, up to supper, and consumed the meal without difficulty. The resident showed no facial grimacing, complaints of pain or discomfort, the resident's abdomen non-tender, and non-distended with bowel sounds active in all four quadrants. The resident noted to be afebrile (no fever) and passing gas with a noted foul odor from the resident throughout the shift. The Physician Communication dated 6/7/20 showed a request for Immodium due to the resident having loose stools with bowel sounds active in all four quadrants, soft non-distended abdomen, with slight tenderness on palpation. The Physician responded with an order of Immodium AD one capsule by mouth after a loose stool up to four doses in twenty-four hours for two weeks, then discontinue. The COMMUNICATION-with Physician note dated 6/8/20 at 8:58 AM explained the facility received a fax back about the resident's loose stools. Received a new order for [MEDICATION NAME] AD one capsule with loose stools up to four doses in twenty-four hours for two weeks and then discontinue. The Health Status Note dated 6/8/20 at 1:35 PM explained the staff reported the resident with two loose stools that shift. The resident's [MEDICATION NAME] was ordered from the pharmacy. The resident's VS were temperature of 97.4, a pulse of 80, respirations of 16, and SpO2 of 95. The resident up per usual. The staff reported the resident with a decreased appetite. The Health Status Note dated 6/9/20 at 5:23 AM showed the resident had one small loose stool that shift. The resident slept good with no complaints, signs, or symptoms of discomfort. The Health Status Note dated 6/10/20 at 1:32 AM showed the resident had extreme abdominal distention with complaints of pain when checking for bowel sounds. The bowel sounds showed active upper quadrants, with no audible sounds on the lower right quadrant and hypoactive (slow) sounds on the lower left side. The SpO2 was 94% on room air and temperature of 97.8. The resident's heart rate was 78. The resident was lying on the left side. The CNA's were concerned for several days of the resident's change in condition. The Health Status Note dated 6/10/20 at 2:37 AM explained that after evaluation by the east side, Registered Nurse (RN) confirmation received that bowel sounds were very hypoactive on the left lower quadrant with none on the right lower quadrant. Pain medication given at 6:00 PM kept her comfortable at the time. At 6:00 AM, planned to confirm with the DON and recommend the resident be sent to the emergency room (ER). The Health Status Note dated 6/10/20 at 7:46 AM documented the night shift nurse reported a change with the resident during the morning report. The night shift nurse said the resident with a distended abdomen, hypoactive bowel sounds, and the loose stools. The resident had loose stools over the last few days, in which an [MEDICATION NAME] order was received. The resident continued to have loose stools on and off. It was reported the resident with a decreased appetite. The nurse worked with the resident on and off. The resident was having all of the above on and off in the time the nurse worked with the resident. The resident now complained of pain with palpation of the abdomen. The resident left the facility with staff. A copy of the Medication Administration Record [REDACTED]. The COMMUNICATION - with Resident note dated 6/10/20 at 2:15 PM showed the facility received a report from the RN at the hospital. The resident was admitted for UTI and [MEDICAL CONDITION] with plans to get intervenous (IV) [MEDICATION NAME] for two days then the resident would return by the weekend. The History and Physical dated 6/10/20 showed the resident admitted due to abdominal pain and dysuria at the skilled nursing facility (SNF). The impression and plan showed [MEDICATION NAME] [DIAGNOSES REDACTED]. The resident had the additional [DIAGNOSES REDACTED]. The Hospital Progress Note dated 6/10/20 showed the resident's chief complaint was abdominal pain, [MEDICATION NAME], Diabetes Mellitus type 2, bacteremia, hypomag (low magnesium), and dementia. The resident appeared to be tired and weak. The Admission Summary dated 6/12/20 at 3:10 PM documented the resident arrived from the hospital via the facility van due to [MEDICATION NAME], diverticulitis, and UTI symptoms. The Clinical Summary dated 6/12/20 showed the resident with [DIAGNOSES REDACTED]. The Health Status Note dated 6/14/20 at 1:27 PM explained a follow-up to the antibiotic therapy. The resident had loose stools that shift with a good appetite at meals-a PRN Immodium given for relief. The Hospital Discharge Notification signed by the Physician on 6/30/20 showed the resident's hospital [DIAGNOSES REDACTED]. The Physician Notification on 6/30/20 showed a request for Immodium due to the resident having loose stools. The provider responded on 6/30/20 with an order for [REDACTED]. The Health Status Note dated 8/10/20 at 10:01 PM explained the CNA's came out and reported the resident complained of burning with urination and had gone frequently. After supper, the resident asked to go to the restroom and had difficulty with going. The urine observed in the toilet was cloudy; the nurse couldn't tell if there was an odor to it at the time. The resident was afebrile. A fax was sent to the Physician, awaiting a response. The Health Status Note dated 8/10/20 at 10:34 PM added an addendum to the previous note: The CNA reported the burning with urination was going on for two weeks. The burning was previously reported, and the nurses were pushing fluids. This week resident was in tears while urinating. The COMMUNICATION-with Physician dated 8/11/20 at 3:18 PM indicated the facility received a fax back from the doctor informing the resident of burning with urination for two weeks. The Dr. ordered a urine specimen by catheter for urinalysis (UA) with culture and sensitivity (C&S), Push oral fluids, [MEDICATION NAME] 500 mg one tablet by mouth twice daily for five days after the urine collection. Then get a urine specimen via catheterization for UA with C&S 48 to 72 hours after the antibiotic was completed. The Clinical Laboratory reported collected on 8/11/20 showed the urinalysis routine, noting the amber color's catheterized urine with turbid clarity. The urine was negative for [MEDICATION NAME] and showed one plus (+) glucose level with an expected level of negative. The urine had >100 white blood cells and 2+ of protein stix with an anticipated negative level. The Health Status Note dated 8/13/20 at 1:20 AM documented return fax received from the UA with lab results, awaiting final results with culture. The COMMUNICATION-with Physician note dated 8/13/20 at 4:48 PM explained the facility received a fax back on the UA with C&S. The fax sent back to the Dr. with the final specimen results, awaiting a response for treatment. The Clinical Laboratory report with a collection date of 8/11/20 showed a catheterized urine specimen with >100,000 colony-forming [DIAGNOSES REDACTED] pneumoniae and >100,000 colony-forming streptococci beta-[DIAGNOSES REDACTED] group B. The provider responded on 8/14/20 to change [MEDICATION NAME] to Bactrim DS one tablet twice daily for five days. The COMMUNICATION-with Physician note dated 8/14/20 at 9:05 AM documented new orders received from the provider to discontinue the [MEDICATION NAME] and start Bactrim DS twice daily for five days. The COMMUNICATION-with Physician note dated 8/14/20 at 5:20 PM explained the facility received a fax back from the provider for the Dr. with new order for Bactrim DS 1 tablet twice daily for five days due to a rash from the [MEDICATION NAME]. The Health Status Note dated 8/19/20 at 1:46 PM showed the last dose of antibiotics given that morning with scheduled medications. The resident was afebrile and stated the burning with urination was better. The urine odor and color with some improvement. A follow-up UA was scheduled four 48 to 72 hours. The Health Status Note dated 8/19/20 at 5:40 PM, labeled as a late entry, showed the resident had the last dose of antibiotics that morning. The resident had no complaints of pain or discomfort. The Orders - Administration Note related to the follow-up catheterization UA dated 8/21/20 at 8:00 PM explained the resident was up on the shift and not in bed from 2:00 PM until 7:00 PM. The Orders - Administration Note related to the follow-up catheterization UA dated 8/23/20 at 2:24 PM showed the UA was unable to obtain that shift. The Orders - Administration Note related to the follow-up catheterization UA dated 8/23/2020 at 9:00 PM showed a straight catheter collected the UA with one attempt. The COMMUNICATION-with Physician note dated 8/25/20 at 1:16 PM explained the facility received a fax back from the Dr. regarding the UA and C&S collected on 8/23/20, ordered to await the C&S results. The Urinalysis Routine collected on 8/23/20, noted by the facility on 8/25/20, showed the urine with a yellow, cloudy appearance with > 100 white blood cells. The Physician responded on 8/25/20 to await the culture and sensitivity report. The Urine Culture Lab collected on 8/23/20 returned from the Physician on 8/26/20, showed the Physician indicated no treatment need, and to discontinue the Bactrim if not finished. The culture showed no growth. The Care Plan problem dated 4/01/20 showed the resident at high risk for falls related to confusion, dementia, history of falls, incontinence, and psychoactive drug use. The intervention dated 4/1/20 said to offer routine toileting as the resident was incontinent of urine and has a history of UTI's. The resident did not always voice toileting needs. The resident was an assist of one with a gait belt for toileting. The Care Plan problem dated 3/31/20 said the resident had a UTI and was taking an antibiotic. The interventions dated 4/1/20 1. To encourage adequate fluid intake. 2. Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. 3. Monitor, document, and report to the Dr. PRN for signs and symptoms of a UTI such as frequency, urgency, malaise (weakness), foul-smelling urine, dysuria, fever, nausea, vomiting, flank pain, supra-pubic pain, hematuria (blood in urine), cloudy urine, altered mental status, loss of appetite, and behavioral changes. 4. Obtain and monitor lab or diagnostic work as ordered. Report results to the Dr. and follow up as indicated. The Care Plan problem dated 4/1/20 said the resident had [MEDICAL CONDITION] stage two. The resident had urinary incontinence with a history of UTI's. The interventions dated 4/1/20 1. Ensure thorough pericare and incontinence cares as the resident couldn't do themselves. 2. Monitor, document, and report for signs and symptoms of acute failure: Oliguria (urine output less than < 400 milliliters ml per 24 hours). Increased kidney labs (BUN and Creatinine). In the Diuretic phase (output >500 ml in 24 hours), the BUN and Creatinine level out. 3. Monitor, document, and report to the Dr. PRN for signs and symptoms of a UTI such as frequency, urgency, malaise, foul-smelling urine, dysuria, fever, nausea, vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes. 4. Offer routine toileting as the resident does not always alert staff of the need to urinate. The resident's record lacked bowel and bladder assessments. Interviews On 8/20/20 at 11:05 AM, Staff B, Certified Nurses' Aide (CNA), reported taking the resident to the bathroom, and the resident had a burning sensation. Staff B said they told Staff A, Licensed Practical Nurse (LPN), about the burning sensation and saw Staff A write something up. Staff B reported this was the first time they saw someone write something up about it. Staff B said they had reported this before. Staff B was unsure how long the resident had the burning with urination, maybe a shift or day or so before that. Staff B said they have trouble reporting things and having some of the nurses follow-up on it. Staff B said they have never reported it to the Director of Nursing (DON) but knew another aide had many times to the DON. On 8/21/20 at 7:05 AM, Staff F, CNA, said they did not report the burning with urination as the other aides were reporting it for weeks. The nurses said to push fluids, but the resident was in tears when she went to the bathroom. Staff F said they weren't sure who reported it. Staff F said they don't feel like the nurses pay attention to the residents. Staff F said they don't think the nurses like when they report things. On 8/20/20 at 11:27 AM, Staff A, Licensed Practical Nurse (LPN), said that staff reported the resident was having problems with urination, so Staff A sent a fax to the Physician right away. Staff A said there is a possible barrier due to some nurses having issues with some of the aides. On 8/24/20 at 3:15 PM, Staff C, LPN, reported the resident had burning off and on. The burning was reported to the Physician. Staff C said they didn't learn of the burning until after the Physician gave orders. On 8/24/20 at 1:07 PM, Staff E, CNA, said the resident had trouble going to the bathroom. The resident had difficulty with their bowel movements as for a while; they were all watery, not formed, or normal. The nurses were aware of the burning with urination since the resident was admitted to the facility. The nurses were going to the cath the resident but didn't but not sure why. On 8/25/20 at 8:48 AM, Staff K, CNA, explained the resident had burning off and on a lot. Staff K said they always reported this to the nurse since the resident first came. The resident even went to the hospital once for something in their belly. Staff K stated they never had a problem with the nurses not listening. Often, the nurses say to push fluids for the resident as it was a reoccurring problem. On 8/25/20 at 9:41 AM, Staff H stated they told Staff C the resident had burning while peeing. Staff H was told to push fluids or cranberry juice. The resident started to cry and the nurse appeared not even to care. Staff C is the one nurse that if something is reported to, Staff C does nothing about it. Staff H doesn't know why Staff C isn't charting things when they are reported. On 8/25/20 at 2:36 PM Staff R, LPN, said the resident had problems with UTIs off and on multiple times. Staff R was unsure if the CNAs reported the concern with burning to anyone. If Staff R got a complaint, they would document it and then report it to the next shift coming on. Staff R said that sometimes things change from one shift to another. Follow-up interviews On 8/26/20 at 1:20 PM, the DON said if a resident was having burning with urination, the expectation was to do an assessment and push fluids using nursing judgment. If this did not help the resident, the nurse could collect urine as a physician's orders [REDACTED]. If the interventions did not help, the nurse should notify the Physician either by calling or faxing them. If the resident had a history of [REDACTED].

Based on interviews and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers, failed to provide the necessary treatment and services to promote the healing of pressure ulcers and to avoid infection for three of four residents reviewed (Resident #2, #3, and #5). The facility reported a census of 74. Findings include: 1. The Minimum Data Set (MDS) completed for Resident #3 with an Assessment Reference Date (ARD) of 8/6/20 showed the resident had short-term and long-term memory problems, indicating severely cognitively impaired. The resident required extensive assistance of one staff with eating. The resident had no weight gain or weight loss. The resident ate a mechanically altered diet. The resident had [DIAGNOSES REDACTED]. Observation On 8/20/20 at 10:11 AM, observed Staff D, Licensed Practical Nurse (LPN), walk to the resident, and explain what they were doing. Staff D removed the resident's dressing labeled 8/19/20 as the resident laid calmly on the bed. Staff D took the wound cleaner and gauze then sprayed the resident's wound to wash the wound. The wound was seen to be superficial in-depth on the coccyx. Staff D placed a white dressing to the wound then covered with a transparent dressing. Staff D then removed the gloves and labeled the dressing on the resident with a sharpie. Also noted a large dark pink area with peeling dry skin to the left heel. Interviews On 8/20/20 at 9:03 AM, Staff D said one nurse thought the area was a blister while another thought it was a Kennedy Terminal Ulcer (KTU). If the nurse was unsure, they should get the doctor involved in Staff D's opinion, mostly if there was a Kennedy ulcer's concern. If there was a concern with skin issues, the wound nurse could consult with the opinion difference. On 8/20/20 at 11:05 AM, Staff B, Certified Nurses' Aide (CNA), said they reported the area to the nurse approximately two weeks before. Staff B said they noticed blisters that looked pretty bad. Staff B said the area was reported to another nurse by someone else before they reported it sometime before 8/13/20. Staff B said they believed nurses were putting some iodine on the blister. Staff B said the blister was intact when they first saw it. One of the blisters was full, and one on the bottom of the foot had popped. The area looked like there was a blister there before. Staff B said they noticed the wound to the resident's buttocks and reported it to the nurse, who said it was already reported. On 8/20/20 at 11:27 AM, Staff A, LPN, explained they didn't usually work in that area but said they knew the resident had a stage III (3) pressure ulcer on their backside. Staff A said that things might have already been addressed, but if it were reported to them, they would report it because they felt it was important to notify the doctor. On 8/20/20 at 12:24 PM, Staff N, CNA, said the area to the resident's heel was there maybe a week to two weeks. Staff N said they found the area to the resident's coccyx when they showered the resident. The resident was mainly in the recliner because of their anxiety, but now the resident didn't move much. Staff N said the resident would sometimes allow a cushion in the recliner but would sometimes push the cushion out. The resident could be sleeping then could wake up and be on the floor. Due to the resident's decline and decreased anxiety, the staff put the resident in the bed. On 8/24/20 at 1:07 PM, Staff E, CNA, said they saw the resident's pressure area. Staff E reported telling the nurse around a month ago. Staff E said they reported the wound to Staff C, LPN. Staff E reported being in the bathroom with the resident when it was found. Staff E said they had the resident stand up to show Staff C the area to the coccyx. Staff E said Staff C said okay and did not tell them what to do, so they put a cream on the wound. Staff E said that the nurses usually chart on the wounds, and CNAs don't have anywhere to chart on it. Staff E said they could only tell the nurse. On 8/24/20 at 3:15 PM, Staff C said the wound started about three to four weeks ago. Staff C said the doctor was faxed to get the wound dressed using a barrier cream. Staff C said they didn't know who it was reported to and couldn't remember if it was reported to them. Staff C said they get things reported to them all of the time. On 8/25/20 at 8:48 PM, Staff K, CNA, reported finding out about the wounds when everyone else knew about it. Staff K said they did not find it. Staff K stated the wound wasn't there very long, maybe a couple of weeks. Staff K reported not being good at knowing the time but said the heel was there longer than the buttock. The area to the heel came and went. The resident was to wear pressure boots while keeping their heels up but said the resident wouldn't always keep the pillow under their legs. Somedays, the resident would be up all day, all night, or both. The resident usually told them when they needed to go to the bathroom. The resident would sleep in the recliner. Most of the time, the resident had a cushion, but the resident would take it out so they didn't have a cushion in the recliner because they didn't like it. The pressure sore on the resident's buttock was recent and not very long. On 8/25/20 at 9:41 AM, Staff H, CNA, stated that they saw the resident's area to the buttocks around 8/4/20 or 8/5/20. Staff H reported telling Staff C to look at the resident's buttocks as it was just starting to have a sore. Staff C looked at the area but did not say anything. Staff H said they did not see the resident's blister on the heel. Staff H said they came back to work around 8/7/20 or 8/8/20, and the nurse said they just found it as it was only reported that day. Staff H said they did not chart on the area on 8/4/20 as they told the nurse that the area was just starting to open, and it was very red. On 8/25/20 at 2:36 PM, Staff V, LPN, said if they get a complaint, they document it and then report it to the next shift coming on. Staff V said that sometimes things change from one shift to another. Staff V reported the nurses were dressing the resident's wound to the buttock and were overseeing things. Staff V said the resident had two different orders for dressings, and the current dressing was working. On 8/26/20 at 1:50 PM, Staff N said the resident slept in the recliner because the family requested him to sleep there. The resident slept in the recliner because the resident kept trying to get up, and they were afraid the resident would fall. The resident had a cushion, but they kept pushing it out. Staff N did not remember anything else tried. Staff N said the staff would walk the resident as they were able. Record review The Fax Transmittal Log Sheet dated 8/7/20 documented the staff reported the resident had a heel blister measuring 5.4 by (x) 5.5 centimeters (cm). The area was clean, dry, and intact. The left foot was elevated, and [MEDICATION NAME] was applied. They requested an order for [REDACTED]. The Health Status Note dated 8/7/20 at 9:13 PM explained the staff reported that while providing bedtime cares after supper, they noted a fluid-filled blister to the left heel that wrapped around the inside and outside of the heel measuring 5.5 cm x 5.4 cm. The blister was intact with no redness, warmth, or drainage. No apparent rubbing was seen where this could develop-the resident wearing socks and slippers at times. The resident sat in the wheelchair at supper, and the majority of the day up in the recliner. The resident's heels float up on a pillow, the resident was up in the recliner with their legs up, and iodine applied. The nurse faxed the doctor and called the wife. The resident showed no signs of pain or discomfort. The Health Status Note dated 8/8/20 at 2:39 AM indicated the resident's fluid-filled blister was flat. The resident had no drainage or redness noted. The resident's heel was offloaded on the pillow. A skin sheet was initiated, and the nurses would continue to monitor. The Skin/Wound Note dated 8/8/20 at 9:45 AM indicated no blister noted to the left heel. The left heel had a small dark, a discolored area measuring approximately 0.4 x 0.4 cm with no open area. There did not appear to be raised. The resident had no signs or symptoms of pain or discomfort. The staff attempted to float the resident's heel, with no avail. The resident would move the foot back on top of the footrest. The staff would try boots. The Skin/Wound Note dated 8/8/20 at 6:55 PM stated the resident did not have a fluid-filled blister to left heel. The left heel had a small dark, a discolored area with no open area noted. The resident showed no signs or symptoms of pain or discomfort. The 24 Hour Follow-up Incident note dated 8/9/20 at 2:56 AM documented a follow-up on the left heel's burst blister. Upon assessment, the staff noted the fluid-filled blister to the same area on the left heel. The heel showed no redness, signs, or symptoms of infection. The heels were offloaded as much as the resident would tolerate. The nurses would continue to monitor. The Skin/Wound Note dated 8/9/20 at 7:41 AM indicated that after the resident's whirlpool, the staff observed an area to the coccyx. The area measured 1.9 x 1.0 x 0.15 cm. The wound bed was pink with frayed skin to the left side. The resident complained of pain during the examination. The wound had no drainage noted at the time of the examination. The area had no increased redness noted to the peri-wound. The wound appeared to be a stage 3 pressure injury. A fax was sent to the doctor, and a skin sheet was initiated. The Skin/Wound Note 8/9/20 at 11:06 AM stated the nurse could visualize and observe a deflated blister. The resident flinched when examined. The area covered a large part of the left heel with no increased redness or warmth noted. The resident was up per usual with some agitation noted with care and repositioning. The Fax Transmittal Log Sheet faxed on 8/9/20 explained the staff observed an area to the coccyx after the resident's whirlpool. The area measure 1.9 x 1.0 x 0.15 cm. The wound bed was pink with frayed skin to the left side. The resident complained of pain with the examination. No drainage was noted at the time. No increased redness was noted to the peri-wound. They requested to use a pressure skin sheet and mark the wound as a stage III. The staff asked if the wound was a KTU with the recent decline. The staff asked if the resident could have an order for [REDACTED]. The Health Status Note dated 8/9/20 at 5:26 PM showed a fluid-filled area remained to the left heel. Prevalon Boots were intact to both of the resident's feet. The blistered area remained closed. The coccyx pressure area was noted to be red and open with a scant amount of blood at the site. The wound/skin nurse to evaluate tomorrow per the nurse report. The Skin/Wound Note dated 8/10/20 at 2:39 AM indicated a fluid-filled area remained to the left heel. Prevalon Boots were intact to both of the resident's feet. The blistered area remains closed at this time. An open area to the resident's coccyx reddened with a scant amount of bloody drainage. The area was cleansed, and a protective dressing was applied. The wound nurse was notified and was aware. The resident was up two times for toileting and repositioning into the wheelchair with scheduled Tylenol given. The Skin/Wound Note dated 8/10/20 at 7:51 AM stated there was no order for the wound nurse. Fax out to the doctor with the request. The COMMUNICATION-with Physician note dated 8/10/20 at 1:31 PM documented the facility received a fax back about the resident's blister and area to the coccyx. The fax showed an order of [MEDICATION NAME] twice daily to the left heel. The facility received a new order for a wound consult and okay to mark the area as a pressure ulcer stage 3 to the coccyx. The Infection Preventionist informed the new order as they completed a zoom visit with a wound consultant. The facility also asked to stage it as a KTU due to the resident's recent decline. The Wound Care Skin Integrity Evaluation dated 8/10/20 showed the resident had a wound on the coccyx that started on 8/9/20. The assessment was completed on 8/10/20 with variable minimum to moderate exudate with a full-thickness stage three pressure ulcer. The wound measured 1.90 x 1.00 cm with a depth of less than (<) 0.2 with a Pressure Ulcer Scale for Healing (PUSH) score of 7.00 with no tunneling or undermining. The wound had serosanguineous drainage. The wound was facility acquired. The wound bed was 100 percent (%) red, friable (fragile/bleeds), and or dusky. The periwound / wound edges showed the periwound tissues were intact and uninvolved tissues flush with the wound base. The wound edges / Margins were irregular wound edges. The additional periwound / wound edge showed a mild [DIAGNOSES REDACTED]/purple hue. The wound showed no pain. The clinical ration/wound comments stated that Collage AG stimulates the growth of granulation and provides sustained antimicrobial action to the wound. A bordered hydrogel dressing was to be used to sustain a moist wound environment that promotes autolysis (the breakdown of all or part of a cell or tissue by self-produced enzymes) and moist wound healing. Daily dressing changes were needed because the dressing became dislodged within 24 hours due to moisture or incontinence. The treatment intervention said to clean the coccyx wound per the facility protocol. Apply Collagen AG, cover with hydrogel bordered dressing, then change dressing daily and as needed (PRN). The Skin/Wound Note dated 8/10/20 at 1:18 PM explained the resident had a Zoom meeting with the wound consultant. Examined and assessed the area to the coccyx, discussed the right heel and overall decline. The wound note stated it might be KTU but would wait to see if the treatment would respond. The recommendation was received and forwarded to the doctor for review. The Fax Transmittal Log Sheet dated 8/10/20 indicated the facility could initiate the treatment to cleanse the coccyx wound per the facility protocol. Then apply Collagen AG and cover with hydrogel bordered dressing. Then change the dressing every day and PRN. The doctor responded yes on 8/13/20. The Skin/Wound Note dated 8/11/20 at 10:52 AM showed the resident had a fluid-filled area to the left heel. Bilateral Prevalon boots were intact to the resident's feet. The blistered area remained closed at the time to the heel, and an open area to the coccyx remained reddened with no drainage. The area was cleansed, and a dressing was applied. The Skin/Wound Note dated 8/11/20 at 6:50 PM explained the resident had a fluid-filled area to the left heel. Bilateral Prevalon boots were intact to the resident's feet. The blistered area remained closed to the heel, and an open area to the coccyx remained reddened with no drainage. The area was cleansed, and a dressing was applied. The Braden Scale for Predicting Pressure Sore Risk dated 8/11/20 showed a score of 18, indicating a mild risk for developing a pressure ulcer. The Skin/Wound Note dated 8/12/20 at 12:10 AM showed the resident had a fluid-filled area to the left heel. Bilateral Prevalon boots were intact to the resident's feet. The resident was sleeping in the recliner in the lounge. The Skin/Wound Note dated 8/12/20 at 3:01 PM indicated the resident continued to have an area to the back of the left heel and the coccyx. The dressing to coccyx remained intact and unsoiled. [MEDICATION NAME] applied to the left heel. The blister remained intact and fluid-filled. The resident showed no signs or symptoms of pain or discomfort with the treatment. The resident was resting in the recliner with boots on. The Fax Transmittal Log Sheet faxed on 8/12/20 showed the resident's blister on the left heel kept draining and filling back up with fluid. They asked if an antibiotic was necessary. The doctor responded on 8/13/20 said not if the liquid was not puss. The patient would be seen in their room on Zoom. The Nutrition/Dietary Note dated 8/13/20 at 9:45 AM showed a quarterly nutrition review. The resident had two new pressure injuries to the heel and coccyx. The Dietitian recommended adding a multivitamin with minerals and [MEDICATION NAME] Extra. Try the [MEDICATION NAME] Extra one at any time the resident was awake and ready to drink. If that goes well, increase to the recommended therapeutic amount twice daily: a continued goal for weight greater than 110 pounds (#) with a new goal for skin integrity. The COMMUNICATION-with Physician note dated 8/13/20 at 12:12 PM stated the facility received a fax back about the blister on the heel with no new orders - also received a fax about a multivitamin and supplement. The fax showed a new order for a multivitamin with minerals daily and [MEDICATION NAME] Extra one carton by mouth daily. The Physician Visit note dated 8/13/20 at 12:37 PM showed an acute telehealth visit with the doctor per their request. The left heel and the left lateral ankle were examined and assessed. A new order was received to increase [MEDICATION NAME] treatment three times a day to the left heel and ankle. The doctor requested extra cushioning in the boot. The floor nurse notified, and the electronic Medication Administration Record [REDACTED]. The Resident's Representative voiced understanding about the extra padding to the boots and the resident's decline. The Nutritional assessment dated [DATE] showed the resident had a skin condition of a blister to the heel as of 8/10/20 and a stage III to the coccyx as of 8/9/20. The resident had a loss of 3.7 % in one month and 6.3% in six months. The resident was seen by speech therapy (ST) between 7/20 and 8/20. The resident's mobility level indicated was the recliner. The resident slept a lot and was alert to only one sphere. The New Order Follow-up Note dated 8/13/20 at 1:03 PM indicated the resident continued to have an area to the heel, ankle, and the buttock. The night shift nurse stated before starting the shift, they assessed the area to buttock with clean, intact dressing. Per the doctor's orders, they did not apply [MEDICATION NAME] as the doctor wanted to look at the resident's heel at the visit at noon that day. The doctor did observe the area to the heel with another nurse. The area to the heel continued with a large intact fluid-filled blister. The resident did not appear to have any pain or discomfort. The Orders - Administration Note dated 8/13/20 at 3:57 PM indicated increased cushioning in the Prevalon boots with a thick foam or sheepskin to prevent further skin issues was not done due to the facility not having it yet as they were waiting on the foam. The COMMUNICATION-with Physician dated 8/13/20 at 5:05 PM documented the facility received signed fax regarding the treatment and the wound nurse's suggestion. The doctor responded Okay. The treatment administration record (TAR) was updated. An order was received to clean the coccyx wound per the facility protocol. Then apply collagen AG and cover with a hydrogel border dressing. Change the dressing daily and PRN. The Physician's Telephone Orders Audit, dated 8/13/20, showed a change in the [MEDICATION NAME] treatment three times a day to the left heel and left lateral ankle blister. With an order to increase the cushioning in the boots with thick foam or sheepskin. The Fax Transmittal Log Sheet dated 8/13/20 said the resident had new pressure injuries to their heel and coccyx. They requested to have an order for [REDACTED]. The Skin/Wound Note dated 8/13/20 at 9:27 PM explained the resident coccyx was intact with no change, no drainage, or warmth. The resident was assisted with pericares and up to the bathroom every two to three hours. The resident left heel intact, noted raised, mushy, and soft to touch. The fluid inside the blister was red with a spot of green. The blister had a foul odor, but the resident showed no facial grimacing or signs of pain. The Orders - Administration Note dated 8/13/20 11:31 PM indicated increased cushioning in the Prevalon boots with a thick foam or sheepskin to prevent further skin issues was not done due to it not being available. The Health Status Note dated 8/14/20 at 1:00 AM explained [MEDICATION NAME] was applied to the left heel blister. No changes were noted from using the [MEDICATION NAME] treatment. The blistered area was soft and filled with bloody greenish fluid. The resident showed no signs or symptoms of pain. The resident was wearing Prevalon boots. The Weekly Skin Sheet dated 8/14/20 showed the resident had a blister to the left heel that measured 5.5 x 5.4 cm. The fluid-filled blister had no redness that popped with scant drainage. The Skin/Wound Note dated 8/14/20 at 1:19 PM documented the initial treatment to the coccyx applied without difficulty. The resident tolerated the treatment well. The New Order Follow-up Note dated 8/14/20 at 1:36 PM showed no initial dose of the multivitamin or [MEDICATION NAME] was given as the resident slept. The [MEDICATION NAME] applied to the heel and ankle per order without difficulty. The blister to the ankle was still inflated and intact. The Health Status Note dated 8/14/20 at 7:31 PM indicated [MEDICATION NAME] was applied to the left heel blister. No changes were noted from using the [MEDICATION NAME] treatment. The resident showed no signs or symptoms of pain-the resident wearing Prevalon boots. The Health Status Note dated 8/15/20 at 12:11 PM showed the resident remained in bed for the shift. The staff repositioned the resident every two hours. The dressing was changed to the coccyx area as ordered. Dark brownish-yellow drainage was noted with odor to the old dressing. The [MEDICATION NAME] treatment was applied to the left heel areas. The skin remained intact with Prevalon boots in place with sheepskin to the left lower extremity. The Health Status Note dated 8/16/20 at 5:15 AM explained that as [MEDICATION NAME] was applied to the left heel, a slight amount of fluid drained from the blister. The Health Status Note dated 8/17/20 at 4:33 AM indicated the resident's blister to the left heel drained. The heel had a skin flap. The resident was to have a hospice consult today, and Hospice would be made aware of skin issues. A report was given to the 6:00 AM to 2:00 PM nurse to follow-up on mottling noted to the resident's right leg. The resident was resting in bed. The Health Status Note dated 8/17/20 at 9:00 PM explained the resident was observed in bed for the 7:00 PM to 10:00 PM shift. The resident was moving arms and laying with eyes open. The nurse assisted the CNA with repositioning. The nurse observed the blister to the left heel to be open with a skin flap rolled up and hard, pressing against the heel. A [MEDICATION NAME] pad was placed under the heel for protection. A partial skin flap remained snug against the heel. A note was left for the doctor and day nurse to look at the area. The Health Status Note dated 8/17/20 at 11:41 PM documented the resident rested quietly in bed. The scheduled Tylenol was given and tolerated well. No drainage was noted from the blister to the left heel, and a [MEDICATION NAME] dressing was placed under the heel. Prevalan boots were on bilateral feet as the resident was repositioned. The Staff was to continue to monitor the resident. The Orders - Administration Note dated 8/18/20 at 1:07 AM explained that [MEDICATION NAME] to the blister on the left heel and the left lateral ankle was not done as the blister was open and draining. The Health Status Note dated 8/18/20 at 4:47 AM stated the nurse called and spoke with the hospice nurse. Discussed the need for them to come today and admit the resident to hospice services and the need for pain medication. The hospice nurse stated they would look into the resident's orders for hospice services and call back later in the morning with an update. The Orders - Administration Note dated 8/18/20 at 7:35 AM explained [MEDICATION NAME] to the blister on the left heel and the left lateral ankle was not done as the blister was open. The Orders - Administration Note dated 8/18/20 at 5:14 PM explained that [MEDICATION NAME] to the blister on the left heel and the left lateral ankle was not done as the blister was open. The Orders - Administration Note dated 8/19/20 at 4:13 AM, explained that [MEDICATION NAME] to the blister on the left heel and the left lateral ankle was not applied per nursing judgment. The Health Status Note dated 8/19/20 at 4:52 AM documented the resident kept the boots on for about three hours, and no [MEDICATION NAME] was applied to the wound per nursing judgment. The COMMUNICATION-with Physician note dated 8/19/20 at 7:20 AM showed fax was sent to the doctor regarding the resident's [MEDICATION NAME] treatment. The Orders - Administration Note dated 8/19/20 at 7:21 AM explained [MEDICATION NAME] to the blister on the left heel and the left lateral ankle was not done as fax was sent to the doctor to clarify the treatment. The Hospice Note dated 8/19/20 at 1:43 PM documented the resident's skin was warm and dry with normal tones. No mottling was noted so far this shift. The treatment of [REDACTED]. The area was noted with some improvement. No signs or symptoms of pain were noted with the dressing change. The resident remained in bed and appeared comfortable. The resident was repositioned every two hours with oral care performed at that time. The Health Status Note dated 8/19/20 at 1:50 PM indicated the left heel continued to be open with no drainage-fax sent to the doctor regarding the treatment. The Physician's Fax form dated 8/19/20 showed the resident had an order for [REDACTED]. The facility requested to change the order to apply [MEDICATION NAME] to intact skin or blister. The Physician responded yes on 8/19/20. The Weekly Skin Sheet dated 8/19/20 showed the resident had a blister to the left heel's backside measuring 5.6 x 6.4 cm with a date of onset of 8/7/20. The comments indicated the blister was flat with drainage apparent. The resident also had a stage III pressure ulcer to the coccyx that started on 8/9/20. The skin was frayed on the left side. The Skin/Wound Note dated 8/20/20 at 8:09 AM, the wound consultant, was notified of the resident's admission to Hospice Services. The Hospice Certification and Plan of Care dated 8/20/20 showed the resident had a sacral region stage III pressure ulcer. The nurse attempted to measure the wound at approximately 3.2 x 1.5 x 0.2 cm as the resident became uncooperative, and the resident had an old blister that healed. The Plan of Care had a goal to have an improved pressure ulcer, as evidenced by a decrease in size, drainage of the wound, absence of the infection, and decreased pain due to skilled intervention. The resident had a hospital bed with rails and a cushion for the wheelchair. The Physician certified the resident prognosis was six months of life or less if it ran its normal course. The Hospice Plan of Care (POC) report dated 8/20/20 showed the problem of impaired skin integrity and the need for pressure ulcer care. The interventions dated 8/18/20 said to provide pressure ulcer care with a goal for the resident to verbalize tolerance to the pressure ulcer care. The Physician certified the resident prognosis was six months of life or less if it ran its normal course. The New Order Follow-up Note dated 8/20/20 at 6:39 PM, showed the resident rested comfortably in bed. The resident was repositioned throughout the shift by the CNA's. The resident rested on the right side with pillows supporting their back. Bilateral Prevalon boots remain on while in bed with sheepskin protector in place. The dressing was intact on the resident's buttock, and the left heel appeared to be healing with no drainage. Follow-up interviews On 8/26/20 at 2:15 PM, the Infection Preventionist said the area was reported to them after the resident's shower, said it was a few days after it opened. The Infection Preventionist told if it wasn't documented, it wasn't addressed. On 8/26/20 at 1:20 PM, the Director of Nursing (DON) said the expectation was always to look and document. If something was not documented, it wasn't done. Even if it was just a scratch, it was best to document it. The DON said they couldn't back the staff if it wasn't documented or done. 2. The MDS completed for Resident #2 with an ARD of 8/13/20 showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was admitted on [DATE] with a stage IV pressure ulcer. The resident required pressure ulcer care. The resident had a pressure-relieving device in the bed and chair. The resident required extensive assistance of one staff with bed mobility, dressing, transfers, and toileting during the seven day lookback period. The resident exhibited no instances of rejection of care during the seven day lookback period. The resident showed verbal and other behaviors for one to three days in the last seven days in the lookback period. The resident used opioids for seven of seven days of the lookback period. The resident was always incontinent of bowel and bladder in the seven day lookback period. The resident had [DIAGNOSES REDACTED]. Resident interview On 8/19/20 at 1:03 PM, the resident said they didn't like it at the facility and planned to go home on 9/1/20. The staff did treatments to their bottom without issues. The resident said they never tell the staff that they didn't want it done. The resident said that they took that back; the resident said that two times they would wait until after they smoked. The resident reported the staff knew they didn't like to get dressed and get into the chair. Then the resident would have to get back into the bed. Then the staff would have to remove their clothes. The resident said that was not right. The staff would come in to do the resident's treatment around 8:00 AM. The resident reported the staff were friendly to them and took good care of their pain. Observation On 8/24/20 at 4:41 PM, Staff A prepared the resident to transfer with a mechanical lift. Staff E wore a face mask with a face shield while Staff A only wore a face mask. Staff A and Staff E transferred the resident with the mechanical lift to the bed. Staff A removed their name badge and placed it on the empty bed in the resident's room. The resident was incontinent with urine. Staff A removed wipes from the package, and Staff A wiped the resident's front. With used gloves, Staff A removed more wipes from the package leaving leftover wipes on top of the package. Staff E rolled the resident, and Staff A removed the resident's brief, then removed gloves and applied new gloves without hand hygiene. Staff A touched the resident's backside and then opened the new bulk gauze package without hand hygiene. No dressing to the wound. Staff A reported not knowing how to complete the new dressing change. Staff E rolled the resident and Staff A sprayed wound cleaner into the wound, then wiped the area with gauze. Staff sprayed the wound again and wiped with more gauze. The resident began to urinate; Staff A held the resident in place as they finish urinating. Staff A then used wipes off the top of the package to wipe the resident, then removed gloves. Observed a superficial pink dime-sized area with a red center to under the gluteal fold on the left leg and the pressure ulcer on the resident's coccyx. Staff A inserted a dressing into the wound while saying this piece is supposed to go first. Then bunches up sheets of collagen; Staff A said I hope this was right, I don't know how to do this. Then(TRUNCATED)

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision to Resident #4 to ensure against hazards from self or elements in the environment when wandered outside the secured memory care unit into the adjoining courtyard, unnoticed by staff. This placed an immediate jeopardy to the health and security of the resident. On 12/4/17 the facility had adjusted the door to ensure closure, added an additional door alarm to alert staff and provided an inservice to staff about the emergency door use. The facility reported a census of 78 residents and the sample consisted of 7 residents. Findings including: 1. According to the Care Plan, Resident #4 entered the facility on 11/13/13 and had [DIAGNOSES REDACTED]. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/11/17. The MDS indicated Resident #4 was unable to complete the brief interview for mental status (BIMS) and had a problem with long term and short term memory problems and a severe impairment of cognition for decision making skills. The MDS assessment described Resident #4 as requiring extensive staff assistance with activities of daily living, including bed mobility, dressing, eating, toilet use and personal hygiene and bathing. Resident #4 was able to transfer and ambulate in the memory care unit with staff supervision. The Care Plan identified Resident #4 as able to transfer self and ambulate as desired in the memory care unit without an assistive device. The Care Plan identified the resident to be an elopement risk due to impaired safety awareness and a history of attempts to leave the facility unattended on 10/30/14. The interventions/tasks directed staff to implement the following: Disguise exits; exit doors with murals, Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and book(s), Do not argue or get in her face, give the resident space, Keep traffic to a minimum; in and out of the memory care unit, The resident moved to the secured (locked) unit on 3/27/14, Do not block interior doors, Speak in a calm voice, Use courtyard if other areas are not successful. According to documentation in the Nurse's Notes dated 12/2/17 at 5:45 p.m., a nurse entered the memory care unit and stated Resident # 4 was observed sitting on the ground inside the locked courtyard area. Resident #4 was seated on her buttocks with her back against the building. The nurse assisted Resident #4 back into the building. According to the facility incident report Resident #4 walked into the building without difficulty. The report indicated Resident #4's hands were cold to touch and an assessment identified an abrasion to Resident #4's right shoulder blade, measuring 6 centimeters (cm) by 2.5 cm and a skin tear to Resident #4's left side rear scalp measured 1.3 cm by 0.3 cm with a scant amount of blood. The notation indicated staff applied an ice pack to the area, checked vital signs (temperature 96.6 (normal 98.6), pulse 79 (normal 60-100), blood pressure 145/67 and respirations 20 (normal 16-20). The nurse initiated neuro (neurological) checks as per facility protocol. On 12/12/17 at 2:09 p.m. Staff A (certified medical assistant) was interviewed and stated on the afternoon shift of 12/2/17, she heard Staff B state to Staff C that she (Staff B) was going on her thirty minute break. Staff A stated she observed Staff B go to the emergency door and exited the memory care unit. Staff A stated she had observed other staff using the emergency door to exit the memory care unit. Staff A stated she recalled during her orientation to the facility she was aware that certain doors were marked for emergency exit while other (secured) doors were for staff to routinely use utilizing their key fobs. On the afternoon of 12/2/17, Staff A described Resident #4 as in a good mood and constantly wandering into other resident rooms. Staff A stated Resident #4 would go towards and stand by an exit door, but did not push on the door, nor did Resident #4 activate the door alarm. Staff A stated she was unaware that Resident #4 had exited the memory care unit until staff accompanied Resident #4 back into the unit. Staff A stated no alarms had sounded indicating a door had been opened. Staff A stated when Resident #4 returned inside the unit she assisted the nurse to complete a physical assessment. Staff A stated Resident #4's fingers and hands were cold, and her gait per usual. Staff A stated blankets were put around Resident A, but she tossed them off. On 12/12/17 at 4:41 p.m. Staff C (certified nursing assistant) was interviewed and stated she worked in the memory care unit the evening of 12/02/17. Staff C described Resident #4 as a wanderer, going into other resident rooms, and at times tried to follow staff from one unit to the next. Staff C stated on the evening of 12/2/17 (at about 4:45 p.m.), Staff B exited the memory care unit through the emergency door. Staff B returned about 6:30 p.m. Staff C stated she was unaware that Resident #4 had exited the building as she was getting residents ready for the evening meal and figured Resident #4 was in another resident room. On 12/13/17 at 7:46 a.m. Staff B (certified nursing assistant) was interviewed and stated she exited the memory care unit at about 4:40 p.m. on 12/2/17. Staff B stated she was not aware that Resident #4 was near her when she left the building. Staff B stated she was unaware that the door did not latch. She stated she went through the door and thought the door would shut. On 12/12/17 at 4:28 p.m. Staff D (licensed practical nurse) was interviewed and stated she became aware that Resident #4 had exited the memory care unit when another staff member brought Resident #4 back into the unit. Staff D stated she was unaware that Staff B had left the unit for a break. Staff D stated she did not know how Resident #4 could exit the memory care unit, other than to follow someone out. She stated the only exit in the memory care unit is the emergency exit and it is not to be used (routinely). On 12/12/17 at 2:49 p.m. (licensed practical nurse), was interviewed and stated she left the faciity on the evening of 12-02-2017 through the east, back employee door. Staff E stated as she headed toward her car, she heard something but didn't see anything. Staff E stated she went to the enclosed courtyard and saw Resident #4 sitting on the ground. Staff E stated she covered Resident #4 with her own coat and ran back inside the facility to get help. On 12/12/17 at 9:00 a.m. the State Climatologist was contacted and stated the weather on 12/02/17, at the airport (nearest to the facility) at 5:18 p.m. was 37 degrees Fahrenheit. The winds were calm and the sky was clear. On 12/11/2017 at 3:51 p.m. the facility Administrator and Director of Nursing (DON) was interviewed and stated they had completed an investigation of this event. According to their interview as well as a written summary of the event, Staff B exited the memory care unit on 12/02/17 at approximately 4:40 p.m. Initially it was assumed Resident #4 followed Staff B out the door at that time. According to camera review, it was noted Resident #4 exited the memory care unit at 1710 (5:10 p.m.). Via the video camera staff could observe Resident #4 walked around the sidewalk within the courtyard. Resident #4 sat on the chairs and a bench in the courtyard. The resident's gait was steady and even. Resident #4 did not show any signs of distress, nor did she attempt to exit the gate on the opposite side of the courtyard. At 5:36 p.m. Staff E noticed Resident #4 sitting on the ground next to the building at which time Resident #4 started to get up, and Staff E assisted Resident #4 back into the building. The Administrator and Director of Nursing stated the resident wore gray pants, long sleeved sweater, socks and gripper socks. The resident did not have a coat, shoes or gloves. On 12/4/17, the facility had corrected the immediate jeopardy situation. The maintenance employee adjusted the door tension to ensure closure of the door and a back up alarm was added to the door. The staff received an inservice on 12/4/17 about the emergency door and staff are not to use the door unless in the event of an emergency.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision to protect 1 of 7 residents from hazards. Resident #1 wandered away unnoticed by staff from an offsite facility activity for approximately 30-45 minutes. Staff interviews revealed they were not aware of Resident #1's whereabouts during this time. Observation of area Resident #1 traveled revealed the highway speed limit between 45 to 65 miles per hour; and record review revealed Resident #1 lacked the cognitive skills to make safety decisions. The findings constitute an immediate jeopardy to resident's health and safety. The facility reported a census of 78 residents. Findings include: According to review of the clinical record, Resident #1 entered the facility on 12-08-2015 and had [DIAGNOSES REDACTED]. Documentation in Resident #1's medical record indicated he/she scored 9 (of 15) on the Brief Interview for Mental Status (BIMS) indicating moderate impairment of cognition for decision making skills. The assessment tool also described Resident #1 as requiring staff supervision with most activities of daily living, including bed mobility, transferring, ambulation, eating, toilet use and personal hygiene. Resident #1 required extensive staff assistance with bathing. Review of the facility plan of care identified Resident #1 as being cooperative but restless at times and able to express only very basic thoughts. Resident #1 resided in the memory care unit of the facility and for staff to monitor the resident if restless. Staff were alerted to be aware of the following: a.) Resident #1 sometimes sees/hears people that others don't. Don't argue with resident's reasoning; attempt to reassure resident of his/her safety. Resident likes to pack his/her items as he/she feels he/she is leaving. b.) Resident #1 used antidepressant medications and staff are to monitor/document/report PRN (as needed) changes in behavior/mood/cognition; hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, gait changes, balance problems, dizziness/vertigo and fatigue. An update to the individual plan of care identified a new intervention dated 05-12-2017 which directed staff to provide one to one (supervision) for any activity off campus. The plan of care indicated Resident #1 was independent with bed mobility and transferring, dressing, personal hygiene and toileting. Resident #1 ambulated independently with a walker. Resident #1 required one staff to assist with bathing. During an interview on 05-15-2017 at 1:46 p.m. the facility Director of Nursing (DON) stated on 05-11-2017 a small group of residents and staff had gone on an outing. About 3:00 p.m. that afternoon she received a phone call from another Long Term Care (LTC) facility in town wondering if they (IOOF) were missing a resident. The DON stated about the same time a facility charge nurse received a call from staff C stating the group was missing a resident (#1). The DON stated an employee at a cement company had noticed an individual walking, with a walker, toward their office building, which was rather unusual and went to meet the individual. The employee then called a LTC facility that was in close proximity to their company. Having all their residents accounted for, that LTC facility called IOOF. According to a written statement by the facility activity director (AC), (dated 05-11-2017 at 3:21 p.m.) at 1:00 p.m. on 05-11-2017, 7 residents and 3 staff went to the Lime Creek Nature Center for an outing. Staff were each given a list of those residents that were going. Instructions were given to go into the building, see the exhibits and maybe sit out on the patio and watch the birds and animals, then go to McDonalds and get ice cream cones for everyone, but stay in the van. The AC stated she stood on the van steps and asked if anyone had any questions/concerns but no one did. The AC stated about 3:00 p.m. a call was received at IOOF reporting that Resident #1 was lost at the Lime Creek Nature Center, and the caller was wondering what should be done. The AC added that at some point another LTC facility had called IOOF asking if IOOF had a resident missing as the cement company had called them. The AC explained the facility bus can accommodate two wheelchair dependent residents and 10 ambulatory residents. For the outing on 05-11-2017 one wheelchair bound resident, six ambulatory residents as well as three staff planned to attend. This allowed one staff to supervise two ambulatory residents as well as pushing one wheelchair dependent resident and then two residents to one staff for the other four residents. The AC stated she had taken all the attending residents on community outings at one time or another and felt very confident that this was a very appropriate ratio. She stated all three staff had successfully completed outings together without incident or concerns expressed. These staff were hired with their full knowledge that they would be taking IOOF residents into the community on outings. The AC stated the staff (and residents) were going to one building all together and then all back into the same bus to eat ice cream on the bus without getting out again. During an interview on 05-15-2017 at 4:03 p.m. Staff A stated he was one of the three employees who had accompanied seven residents on the outing to the nature center. Staff A stated upon arrival the individual in the nature center office was notified that they were there, but nothing formal had been set up, so everyone went their own way. Staff A stated they looked at the exhibits and then he and four of the residents sat in a row of purple chairs where they could observe the wildlife activity outside. He stated the bus driver had pushed the wheelchair bound resident outside and then Staff B stated she was going to take another resident outside. Staff A stated he last observed Resident #1 about 2:00/2:15 p.m. where he/she was just to the left of the group of purple chairs. Staff A stated he thought one of the other employees had Resident #1 and he stated he did not miss him/her until they did a head count shortly before 3:00 p.m. Staff A stated he walked down the main road looking for Resident #1 but did not see him/her. During an interview on 05-16-2017 at 3:32 p.m. Staff B confirmed that she had been on a facility outing with seven residents and two additional staff. Staff B stated it was her understanding that her job included being responsible for the residents and to account for them all as well as to assist them with ambulation/wheelchair locomotion while on an outing. Staff B stated during the outing on 05-11-2017 Staff C went outside with the wheelchair dependent resident and at that time the other six residents and two staff were accounted for. Staff B stated Staff A and four residents were sitting (in the purple chairs). At that time Staff B stated she also went outside with a resident. She stated Staff A remained in the building with five residents. Staff B stated she thought she could have taken care of five residents as they were just sitting there. Staff B stated she and Staff C (plus the two residents) were outside for 20 to 25 minutes. When they returned back to the building they noticed they were missing one resident. Staff B stated they began to search in the building and around the building and alerted the workers of the nature center to assist in the search. Staff B stated about 3:05 p.m. they were made aware that Resident #1 was found at the cement company. Staff C's written statement dated 5/11/17 revealed the following: around 2:00 p.m., he had gone to the patio with a resident. Around 2:15 we noticed a resident missing. The resident was inside and one minute gone the next. He reported picking up the resident (Resident #1) at 3:15 after returning back to the nursing home around 3:30 p.m. (Staff C was not available for an interview.) During an interview on 05-16-2017 at 12:32 p.m. Resident # 5 stated he/she recalled the outing to the nature center. Resident #5 commented that Resident #1 left while on the outing. Resident #5 stated Resident #1 did not sit on the purple chairs as she did, and Resident #5 stated he/she noticed Resident #1 wasn't with the group when they sat down. Resident #5 stated he/she did not see Resident #1 leave the group but he/she stated she told a staff/employee that he/she hadn't seen Resident #1 for a while and staff began to look for Resident #1. During an interview on 05-16-2017 at 12:55 p.m. Resident #6 also recalled the outing to the nature center and stated he/she enjoyed those outings. Resident #6 stated one resident left the group and everyone was aware that the resident had left the group and searched for about one half hour. Resident #1 stated they (staff) counted heads every now and then and at the last count they came up short. Resident #6 did not see Resident #1 leave the group nor did he/she know the name of the resident who left. Observation of the nature center on 05-15-2017 (7:00 p.m.) revealed a long black topped road exiting off the main state Highway 65. The posted speed of the state highway was 45 miles per hour. According to a nature center brochure the maximum speed limit on the black top road was 15 miles per hour. The distance and time to travel the distance by foot was reenacted from the nature center building to the cement company. The distance was 1.01 miles and time to walk the distance was 17:46 minutes. The road was bordered by wooded areas on both sides and on one side there was a small pond with a dock and at another point a gravel parking lot. There were no fences to obstruct or distract entrance to the wooded area. During an interview on 05-15-2017 at 2:44 p.m. Resident #1 stated he/she recalled taking a long walk a few days prior. Resident #1 could not state where he/she had taken the walk, but did indicate that it was so beautiful that he/she thought he/she would check it out. Resident #1 stated he/she did end the walk in a place where there were big trucks and someone came out and gave him/her a glass of water. On 5/11/17, the facility made the following corrections after the 5/11/17 incident: a.) updated the resident's care plan b.) educated staff all three staff responsible for resident safety c.) suspended the staff until further investigation. d.) placed a Wanderguard code alert bracket on Resident #1 on 5/11/17. The facility updated their Safety and Supervision policy on 5/12/17 to include the following: the Activity Coordinator will assign each resident to a specific staff member for the activity held off campus. The staff member will have the opportunity to review the resident's plan of are and ask question prior to the activity. The activity coordinator will confer with the DON regarding residents that are attending an activity held off campus. During the transportation and activities held off campus, a ratio of one staff member to a maximum of three residents depending on acuity will be obtained. Staff were trained on the revised policy on 5/12/17.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and protection to ensure against hazards from self for 1 of 13 residents reviewed in the CCDI (Chronic Confusion or a dementing illness) unit failed to ensure fall interventions for one of seven were followed to prevent accidents. The facility identified a census of 81 residents. ( Resident #3 & #6) Findings include: 1. A History and Physical report by a psychiatrist, dated 6/3/13 identified Resident #5 had been experiencing paranoid, delusional thinking with suggestion of hallucinations and possible psychotic and depressive features. A psychiatrist ' s final report identified Resident #5 had organic mental syndrome, dementia with possible psychotic and depressive features. The Admission Nursing Assessment documented Resident #5 had an admitted to the facility on [DATE]. The assessment reflected the resident transferred and walked independently and at risk for elopement due to Alzheimer ' s dementia, recent changes and he/she did not accept the situation. This resident's Admission Record documented Resident #5 had medical [DIAGNOSES REDACTED]. The Interdisciplinary Progress Notes (IPN) indicated the following: On 6/7/13 10:30 a.m. the resident was admitted to facility. The resident had occasional periods of confusion and agitation. The resident voiced " I ' m not staying in jail here." Resident walked with a steady gait, and did not use devices. The resident attempted to go out the door of the building, after going through the CCDI unit door when open. On 6/7/13 at 12:00 noon, the psychiatrist gave a new order for Ativan (antianxiety) 1 mg (milligram) every four hours as needed. On 6/7/13 at 12:30 p.m., the resident had increased anxiety, restlessness and agitation. The staff provided one on one, distraction and redirection without success. The resident received Ativan. The resident stated, "I will throw a chair through the window." On 6/7/13 at 6:30 p.m. resident is talking with another resident and thinks it is his/her spouse. Resident attempted to go out door. On 6/7/13 at 8:45 p.m. resident become agitated and would not take medications. The resident did have a gait belt and stated he/she was going to put it around C.N.A.s (Certified Nursing Assistant) neck and strangle her. On 6/7/13 at 9:15 p.m. resident became more agitated. Attempted to go out door. C.M.A. (certified medication aide) attempted to give resident his/her medications four times. The resident started to become combative. On 6/10/13 at 10:15 p.m. resident up sitting at dining room table. Resident expressed concern that his/her spouse (mother) did not know where he/she was and he/she wanted to take him/her to an appointment on 6/11/13. Staff gave resident a dish of ice cream. Resident stated there was something green at the bottom and he/she did not want to eat worms. Staff did not see anything. Staff informed resident that they would not want him/her to eat any worms. On 6/10/13 at 2:50 a.m. (Question if this was an error and writer meant 6/11/13) Resident resting comfortably in bed. Resident asked that staff would be honest with him/her. On 6/11/13 at 9:50 a.m., At 7:05 a.m. received a phone call from a nurse aide who stated a woman came to the facility and reported she saw a man/woman outside on railroad tracks struggling to get across. Immediate head count performed. Resident not in facility. Noted resident ' s room window open and screen taken out. Screen had been placed by window on the outside. C.N.A. had last seen this resident at 6:30 a.m. packing his/her clothes. Window alarm did not activate. Two staff found resident. Resident had crossed the railroad tracks. Resident returned to facility at 7:10 a.m. Resident's clothes wet and muddy. This resident's undated Plan of Care, (Resident Status Sheet) did not identify the resident at risk for elopement and approaches and interventions to attempt to manage risk factors. This resident's Minimum Data Set (MDS) assessment with a reference date of 6/17/13 assessed the resident as 7 out of 15 on cognitive scoring (severe impairment). This resident's behaviors included hallucinations, physical, verbal and other behaviors, which placed the resident and others at risk for physical injury, were disruptive and significantly intruded on the privacy or activity of others. The resident wandering placed the resident at a significant risk of getting to a potentially dangerous place. The assessment noted this resident was independent with transfers, walking, dressing, eating, toilet use and personal hygiene. The facility Elopement Form dated 6/11/13 noted this resident eloped from the facility on 6/11/13 at 7:05 a.m. The resident was last seen in his/her bedroom that day at 6:30 a.m. packing. The staff was alerted to the elopement by a woman. The resident exited from the window. The resident was found walking by the rail road tracks. The resident stated he/she was escaping. An Incident Report dated 6/11/13 at 7:05 a.m. noted a woman (non-employee) came to the facility and reported seeing a man/woman outside on the rail road tracks struggling to get across. The staff checked the residents (in the CCDI unit) and found this resident missing. Staff reported last seeing this resident at 6:30 a.m. The resident had been packing. The window alarm did not activate. An Activity Progress Note dated 6/7/13 at 2:00 p.m. noted resident admitted that day to the CCDI Unit. The resident expressed him/she did not plan on staying here when he/she arrived. Resident got agitated about staying at the facility. A Social Service Progress Note dated 6/17/13 noted this resident had shown agitation, threatening, restless, hallucinations, trials to leave facility, leaving the facility, and combative. A Physician's Progress Note dated 6/11/13 noted this resident had a history of [REDACTED]. The resident had recently been admitted to the psychiatric unit for the treatment of [REDACTED]. The staff retrieved the resident back to the facility without incident or obvious injury. This facility's CCDI Special Care Unit Philosophy and Objectives included: Our units will emphasize care within a sheltered, low stimuli environment, and homelike atmosphere. Objectives for special care units include: 1. Reduce resident stress and agitation by providing a low stimuli environment with reduced stress potential. 2. Provide protection for the resident who wanders. Observation of the facility and the grounds around the facility on 6/27/13 at 12:50 p.m. revealed this former resident's window led to a small rocky area, then a grassy lawn which led to a driveway. Large boulders line between the lawn and the driveway. After the driveway is a very large yard that slopes downward, leading to the train tracks. After this long front yard there is a patch of knee high grass. Then a patch of gravel and raised train tracks. There are multiple train tracks. Due to the traffic travels overhead on the viaduct, these train tracks lack any warning, such as cross bars or flashing lights to warn of oncoming trains. One set of train tracks run north and south and one set runs east and west. Then there are large concrete pillars supporting a viaduct. After the pillars are additional train tracks. This area is not a well-traveled area (by car or on foot), due to all visitors and staff enter the property from the east and this area is on the west. An unplowed field borders the south of the building. Observation on 7/17/13 at 4:45 a.m. revealed 2 train cars parked on the train tracks near the area where this resident was found. Observation on 7//17/13 at 4:47 a.m. revealed a train came along the train tracks from the north and moved slowly and then stopped on the track between where the resident was found and parallel to the bedroom window of Resident #5. A man exited the train and walked south along the tracks swinging a large light. He went to the track junction, looked at the tracks, approached a box on a post near the tracks and then returned to the train. He then climbed up into the train. The train then continued south along the tracks past Resident #5 ' s bedroom window. Observation on 7/17/13 at 6:45 a.m. revealed 3 stopped train cars along the junction on the east side, near the area Resident #5 had been found. Observation also revealed stopped train cars to the west of this area on the tracks. Observation also revealed a train stopped on the tracks south of this area. Observation at this time revealed a vehicle drove directly past the pillar where the resident was found on the road that ran between the train tracks just to the west of the pillars where staff found Resident #5. On 6/27/13, the Administrator was interviewed and stated the resident came to them from the local, locked psychiatric unit. The day of the resident ' s admission to their facility, the resident became so agitated they had to give him/her an injection. At their team meeting they discussed how the resident had eloped from the facility without activating alarms. The Administrator stated they then checked the windows and found the new windows, were double window that slid open from the right and from the left. They installed these new windows in the fall of 2012. Staff routinely checked their alarm system every shift. The Administrator stated the staff checked the alarms by visualizing the control panel to ensure the on/off switches were in the on position. They did not test the alarms by actually opening the window to test the function of the alarm system. The Administrator stated they never alarmed the left windows. Every window in the south/locked dementia unit had been replaced last fall. The south unit is licensed for 14 residents. The facility opened a new dementia unit, north unit in August of 2012. The facility units houses the confused residents who require physical assistance in the north unit and the demented residents at risk for elopement in the south unit. The Administrator stated they had another resident elope from this facility last summer, when a service person turned off the door alarms and the resident eloped from west exit door, unnoticed. The Administrator stated was unaware that both sides of the double windows opened and only the right side was alarmed. The housekeepers cleaned the windows from the outside. After this resident eloped they secured the windows, they updated their policy and they educated the staff on their elopement policy. When interviewed on 7/16/13 at 10:46 a.m. Staff K the Co-Director of Nursing assigned to the locked units stated when the new windows were being installed in the south unit, she asked they if they knew the windows were alarmed and they needed to make sure the alarm was reconnected to the windows. Staff K stated in their lounge some of the residents like to have the windows cracked a little to allow fresh air. On 7/9/2013 at 8:00 a.m., Staff H (Co-Director of Nursing) was interviewed and stated she was in the facility the morning of the resident ' s elopement. She stated the staff had failed to "call" a code purple, their code for an elopement. She stated they re-educated the staff member who failed to call the Code Purple. Staff H stated she always assumed the new windows were fully alarmed. Staff H stated that morning they first learned that one of their residents had eloped when a stranger stopped in the facility around 6:50 a.m. and reported seeing a person outside, struggling to walk through the grass. Staff H went out the front door to assist in looking for the resident. Staff H then saw staff members bringing the resident back to the facility. The resident's pants were wet and muddy from the wet swamp due to all the rain they had recently had. Staff H stated during their team meeting that morning, they discussed how this resident was able to elope without staff knowledge. The office manager asked if both sides of the windows were alarmed due to both sides of the windows opened. When interviewed on 7/8/13 at 1:00 p.m. a Licensed Practical Nurse, Staff N, the Dementia Unit Coordinator stated she was present when the resident was admitted to the facility. The resident was agitated on admission day. The psychiatrist was in the building that day to do their routine rounds. The resident became agitated with the psychiatrist. Staff N recalled the resident threatening to throw a chair through the window in order to get out of the facility. Staff N stated the resident had the presence of mind to know if the doors were locked the only way out was through the windows. When agitated and wanting out, they would assist the resident out into the secured courtyard; however that did not satisfy this resident, who then looked for a way out of the courtyard. Staff N was working and in the building at the time of this resident's elopement. A stranger stopped to inform the staff they had seen a person walking outside. She instructed the unit staff to do a head count of the residents. They found this resident's window open and the screen off. The staff then brought this resident back into the building. On 7/9/13 at 11:43 a.m., Staff Q (Licensed Practical Nurse) was interviewed and stated the morning the resident eloped, a woman from the community came to the facility early in the morning. The women reported she was driving her car over the bridge when she looked down and saw a person in the grass and wondered if he/she belonged to the nursing home. Staff Q stated she was not overly concerned due to she had not heard any alarm sound. Sometimes, older people from a nearby independent living walk around their building near the tall grass. At the time of this elopement she assumed it was someone from the independent living walking around their property. Staff Q stated she then heard a door alarm sound, and when she responded she observed staff returning the resident to the facility. On 7/9/13 at 12:30 p.m., Staff S (Licensed Practical Nurse) was interviewed and stated she was working the day the resident was admitted to the facility and on the morning the resident eloped from the facility. She reported the resident could change in a split second. The day the resident came to the facility he/she was trying to elope. The resident was agitated with the staff. The resident told the staff he/she wanted out of this jail. The resident stated he/she was going to throw a chair through the window. The resident could be very cooperative and then suddenly agitated. The resident followed someone out of the south unit, and entered the north unit. The resident varied on how well he/she could be redirected. The resident did not accept his/her placement at the facility and stated he/she wanted out of this prison. On the day the resident eloped, she first learned there was a concern when a woman from the community reported seeing a man/woman having difficulty walking across the railroad tracks. Staff S stated she was new and had not been trained in Code Purple. Staff S stated the staff brought this resident back into the facility/unit. The resident was covered in dirt. The resident stated he/she was going home. On 6/27/13 at 12:30 p.m. Staff A (Licensed Practical Nurse) was interviewed and stated she was working the morning the resident eloped from the facility. She first learned of a potential concern approximately 6:45 a.m. when a woman reported her concerns about a man/woman walking outside. They did a head count and determined a resident was missing from the secure, south unit. She went outside the front door. She saw this resident on the other side of the railroad tracks. The resident was laughing and stating they needed a clear get a way path. The resident's pants were wet. The tall grass was still wet from dew. Staff A stated she assumed the windows were alarmed. On 7/9/13 at 1:45 p.m. Staff R (Certified Nursing Assistant) was interviewed and stated the morning about 6:00 a.m. the front door alarm sounded when a woman from the community entered the building. The woman reported a gentleman/woman was walking down by the railroad tracks. She took the lady to the nurse; Staff Q. Staff R glanced briefly out the front door and did not see anyone. The woman stated she was driving by when she observed a man/woman having trouble walking by the train tracks. The woman reported the man/woman was struggling, not very balanced, he/she looked confused. Staff R saw staff bring this resident back to the facility. The resident was muddy. On 7/16/13 at 11:00 a.m. Staff G (CNA) was interviewed and stated she normally worked in the dementia unit. She reported Resident #5 had periods where he/she would sit and visit with the staff and then had periods he/she wanted out and to be with spouse. This was a very active resident who was not used to being confined. He/she just wanted to go home. The morning the resident eloped, they were instructed to do a head count, at which time they could not find the resident. She went outside to look for the resident. She saw the resident by the train tracks. He/she was on the other side of the tracks bracing him/her on the pillar. The resident was looking around like he/she was trying to figure out where he/she was going to go. The resident's pants were dirty so she had wondered if the resident had fallen. The tall grass was up to just under her knees. She had to cross the train tracks to reach the resident. It was muddy. The resident stated, "I am not going back to the IOOF home." "I am going home." The resident stated he/she was thirsty, so she convinced the resident to return to the facility by stating she was going to give him/her something to drink. The resident stated he/she went out the window and he/she hoped he/she did not break the window. On 7/9/13 at 1:22 p.m. Staff I (Certified Nursing Assistant) was interviewed and stated the morning the resident eloped, she had seen him/her in his/her bedroom, early in the morning, rummaging around. The resident had all his/her belongings, even the phone book, on the bed. She did not ask the resident what he/she were doing. That morning she had gotten report from the night shift that this resident had been up all night and worried about an appointment. After the staff brought the resident back into the facility and gave him/her a shower, she provided one on one supervision for the rest of the shift. The resident told her, "You guys ruined my great escape." The resident also stated, "I got out and I started jogging as fast as I could." The resident told her that he/she was going to hitch hike home. On 7/9/13 at 1:00 p.m., Staff C (Certified Nursing Assistant) was interviewed and stated the resident would go to the exit doors and push the keys next to the door in an attempt to open the locked doors. Prior to his/her elopement that morning, the resident had emptied the closet and the dresser drawers and wrapped everything in the bedspread. The resident had even removed everything from the walls and placed items in the bedspread. The resident stated he/she was leaving. The resident stated he/she was going home. She did not see the resident again that morning until she saw two staff members bring the resident back to the unit. The resident's pants and shoes were muddy. The resident spoke about how the resident and mother use to be hobo ' s and ride the train. On 7/8/13 at 11:10 a.m. Staff B (Certified Nursing Assistant) was interviewed and stated she went outside that morning to search for this resident. She saw the resident near the highway and by the railroad tracks. He/she was under the highway leaning on a pillar. She called out and asked the resident to stay and not move. The resident had gone through knee high grass. It was very wet due to a large amount of rain. The resident's shoes and pants were wet. It was about 7:00 a.m. She asked the resident what he/she was doing. The resident stated hitch hiking. He/she was trying to get a ride. The resident stated he/she was thirsty. On 7/8/13 at 11:35 a.m., Staff D (Certified Nursing Assistant) was interviewed and stated she was working in the unit the day the resident eloped. She stated this resident had told her, "You're locking me up." "That's against the law." When the resident wanted to exit the unit, he/she would go to the doors, and then the staff would redirect him/her. The resident just wanted to go home. Normally this resident wanted a shower every morning. The morning of this elopement, the resident did not want a shower. The resident stated she/he was leaving with spouse. The resident's clothing lay on the bed and was packing. The resident's roommate was a late sleeper. Later that morning someone instructed them to do a head count. At that time she noticed this resident's window was open. She also noticed the window screen was leaning against the window. She reported the resident was gone. The window alarms were turned on, and yet they were not sounding. Staff D saw this resident when the staff brought him/her back into the unit. On 6/27/13 at 1:00 p.m. the Maintenance Supervisor stated when the new windows were installed in the locked/south unit he went around and connected the windows to the alarm window system. The alarms were tested for each window; however, he only checked the right side. He did not check the left side of the window. The old windows looked similar to the new windows, but the old windows could only be opened from the right side, therefore, the windows were only alarmed on the right side. The new windows opened from both the right and the left. Prior to this event, he never went into resident rooms to check if the window alarms were working. The CNAs checked the window alarms by visualizing the alarm panel was turned on. After the resident eloped, he cut wooden dowels about 7 inches in length and placed them in the windows on the unit on the left side of the windows to ensure the windows could not be opened fully on the left side. Also now he physically checks each window on a weekly basis to ensure the alarms are on and functioning properly. Note: At the time of the complaint investigation, the complaint was coded at a " J " immediate and serious jeopardy. By 7/10/2013, the facility had implemented measures that adequately addressed the immediate jeopardy, and the grid placement was lowered to the " D " level. The facility Maintenance Supervisor placed wooden dowels above the window (approximately 6 feet in height). The dowels fit securely by being wedged into the window and adhesive applied to further secure the dowels. As of the 7/30/2013 exit conference, the facility continued to need to monitor the windows for alarm activation and continued placement of the dowels to ensure the windows could not be completely opened on the left side. 2. An Admission Record for Resident #6 recorded an admission date of [DATE]. This admission record noted a primary/admission [DIAGNOSES REDACTED]. An Admission [DIAGNOSES REDACTED]. A Clinical (hospital) Summary dated 5/24/13 included transfer orders/instructions. These orders included, "Precautions: Fall". A hospital CT Scan report dated 11/11/12 documented reason for exam due to a head trauma. Findings negative for intracranial hemorrhage. A hospital Diagnostic Radiology report dated 11/11/12 noted radiographs of the thoracic spine demonstrated a mild thoracolumbar curvature and degenerative change in the thoracic spine. The Admission Nursing assessment dated [DATE] assessed this resident required one person assistance with transfers and walking. This assessment also noted resident was forgetful. Admission nurse's progress notes, "IOOF Home Interdisciplinary Progress Notes" dated 11/13/12 at 2:10 p.m. noted resident arrived to the facility. Resident noted with confusion. A Level of Care Certification for Facility dated 1/29/13 noted the resident would not ask for help, and would try to get up on own, and required assistance for safety. A CAA (Care Area Assessment) Review Report dated 2/4/13 for cares for daily living (ADL) documented the resident was admitted to the facility, from the hospital on [DATE] after sustaining a fall at home. The cause of the fall was thought to be vasovagal, related to oxazepam (antianxiety), bradycardia (heart rate under 60 beats per minute) or other cardiac arrhythmia and/or deconditioning. He/she needs assistance of one person with walking, toileting and transfers. The resident seldom used the call light and staff had to anticipate care needs as the resident would try to do things independently. He/she is able to get in and out of bed by him/herself. Staff to provide supervision to minimal assistance with transfers and walking. A CAA Review Report dated 2/4/13 for falls assessed the resident with a shuffled gait, unsteady at times. Staff found the resident self-transferring. The resident did not always use the call light and staff anticipated his/her needs. resident sustained [REDACTED]. Resident unsteady at times. Staff tried and anticipated resident needs. A CAA Review Report dated 2/4/13 for pressure ulcer noted staff provide assistance for transfers. Resident walks with assistance of one, gait belt and walker. Staff reported they often find this resident up and out of bed when they enter this resident's bedroom in the morning. This resident's primary medical physician's progress note dated 5/21/13 assessed the resident with osteoporosis. The physician also assessed the resident with pedal edema and gave a new order for furosemide (diuretic-remove fluid) (Lasix). A hospital History and Physical dated 5/22/13 noted the resident transferred to the hospital for the treatment of [REDACTED]. Past Medical History included degenerative joint disease status [REDACTED]. A Physician's hospital progress note dated 5/23/13 assessed this resident with pneumonia, mild dementia, hyponatremia and mild anemia. A Restorative Nursing Daily Documentation report for May of 2013 noted increased confusion. Resident made statements like, "I don't know if I should be here" and "should I be doing something." An Occupational Therapist Cognition, Cognitive assessment dated [DATE] assessed this resident's cognitive ability as moderate, 51% (percent) to 71%. Cognition was functional only in a structure environment; supervision and/or cueing was necessary for activities of daily living needs and simple ideas. Deficits involved orientation, simple and complex problems solving, attention and/or short term memory. An Occupational Therapist Progress Note dated 5/22/13 noted this resident demonstrated reduced range in motion of feet and ankles due to edema. A Social Service Progress Note dated 6/3/13 assessed this resident's cognitive skill (BIMS) a four out of fifteen (severely impaired). The resident voiced frustrations with his/her limitations and occasional thought of feeling he/she would be better off dead. The staff reported noticing "more confusion" and "more orneriness". A psychiatrist progress note dated 6/7/13 noted this resident's insurance company will no longer pay for the anti-anxiety medication, Oxazepam without prior authorization. This is anxiety disorder, not otherwise specified. I think we may be seeing a mild dementing process, although it may just be the anxiety that is causing (him/her) not to concentrate." and extreme with declining health. The physician switched this resident from Oxazepam to Ativan (anti-anxiety) and added Zoloft (anti-anxiety, anti-depressant). A Restorative Nursing Daily Documentation report for June of 2013 noted an increase in refusals due leg pain. A Fall Risk assessment tool found in this resident's clinical record revealed the facility staff assessed this resident, and found this resident at a high risk for falls on 11/13/12, 2/4/13, 5/3/13 and again on 5/31/13. Risk factors identified included: intermittent confusion, history of falls, chair bound, balance problems, required use of assistive devices, systolic blood pressure and medications. This resident's plan of care dated 5/2/13 documented, "It is not safe for me to live at home by myself anymore." The goal read, "I will not have any falls with significant injury over the next quarter." Approaches included: 5/8/13 education given to me, to not lean forward too far in wheelchair, 6/12/13 more frequent visual checks, 6/13/13 increase visual checks, 6/15/13 had recent medication change, 6/8/13 Dr. Armstrong need medication review with changes (increased medications) on 6/7/13, 6/8/13 resident continues to be non-compliant summoning staff assistance with increased edema makes resident unstable, 2/4/13 encourage me to lock wheelchair brakes with standing to toilet and standing at sink, 1/7/13 I now have non-skid strips on my floor to help with my balance, No date: I may not always use my call light, anticipate my needs. I attempt to get up on my own at times. No date: I need assist of one with walking, transfers. Use gait belt and walker. I have a shuffled gait. Review of this resident's clinical record revealed this facility utilized Fax Transmittal Log Sheets to communicate information from the facility to the physician. These faxed included: 1) 12/15/12: resident laying over foot board of bed, feet on floor, left foot/ankle inverted. Resident trying to get to the telephone and tripped. Bruising noted to left hand, left wrist, and right foot. 2) 1/7/12 (signed by the nurse on 1/8/13) resident transferred self from wheelchair to bed and was found on the floor. The Incident Report dated 1/7/13 documented Steps Taken to Prevent Recurrence: to have maintenance apply non-skid strips to floor. An IOOF Home Interdisciplinary Progress Notes dated 3/4/13 at 4:00 p.m. noted staff spoke with this resident's family about possibly changing this resident to a different bedroom for increased supervision. The family agreed with this possible intervention, however family wished staff to ask the resident, who stated he/she wanted to stay where he/she was. 3) 4/25/13 resident slid out of wheelchair to floor while reaching for television remote. An Incident Report dated 4/25/13 documented Steps Taken to Prevent Recurrence: padding removed from wheelchair. An IOOF Home Interdisciplinary Progress Notes dated 4/26/13 (no time given), noted resident assisted with one staff, gait belt and walker. Resident non-compliant. Staff found resident numerous times transferring self from bed to wheelchair to bathroom. Resident found standing at end of hall and walking with walker. 4) 4/28/13 noted increased, 3 plus and 4 plus edema (swelling) to both lower extremities. Resident reported being very painful. Resident encouraged to keep feet elevated but noncompliant. The physician documented, "suspect chronic venous insufficiency." 5) 5/8/13 noted staff found this resident on the floor in front of wheelchair. A Skin Condition Report dated 5/9/13 assessed this resident with a skin tear to the right arm. The nurse's progress note in the IOOF Home Interdisciplinary Progress Notes dated 5/8/13 at 4:25 p.m. noted the nurse heard an unusual noise from the resident's room. The nurse found the resident on the floor in front of the wheelchair. The nurse turned away from the doorway to retrieve assessment equipment, upon nurse's return, found resident had gotten up, independently from the floor and was sitting in a chair. The Incident Report dated 5/8/13 documented Steps Taken to Prevent Recurrence: attempted to educate resident of fall risks. Resident's confusion prevented effective education. 6/8/13 resident found on floor next to bed, appeared to be reaching for bedside table. The Incident Report dated 6/8/13 documented Steps Taken to Prevent Recurr