Every finding on record at Iowa City Rehab & Health Care

Based on staff interview, facility document review, and the Centers for Medicare and Medicaid Services (CMS)- 2567 form Statement of Deficiencies review, the facility failed to implement appropriate plans of action as part of Quality Assurance and Performance Improvement (QAPI) program to correct quality deficiencies previously identified at the facility, resulting in repeated deficient practices on the facility's current survey. The facility reported a census of 52 residents. Findings include: The facility's CMS-2567 Statement of Deficiencies dated 6/3/26 revealed deficiencies identified with the environment (F584), Dialysis (F698), QAPI (F865), and the resident call system (F919). During the current facility survey that ended on 8/3/26, deficient practices were again identified with the following federal regulations: F584, F698, F865, and F919. On 8/3/26 at 3:54 PM, the Administrator reported the facility continued to work on the deficiencies previously cited through the performance improvement projects (PIP)s. The Administrator acknowledged a concern with the repeated concerns identified during the survey that ended on 8/3/26. The facility provided the QAPI (Quality Assurance and Performance Improvement) Manual, undated, which reflected the following agenda item: review the Plan of Correction in progress.

Based on observation, resident interview, staff interview, and facility document review, the facility failed to ensure 2 of 2 resident shower rooms routinely cleaned, and 2 of 12 resident (Resident #4 and Resident #10) clean and comfortable. The facility reported a census of 54 residents.Findings include1. During an interview on 7/29/26 at 9:02 AM, Staff A, Certified Nursing Assistant (CAN) stated the East shower room drain gets clogged and will flood the floor. She added that at times the drain has backed up and an unidentified substance came up with the water. Staff A stated she had not reported this to facility management. During an observation on 7/29/26 at 9:05 AM, the East shower room had one shower head and one floor drain. Staff A turned on the water to the shower, after approximately 15 seconds of water running, observed the floor drain filled and standing water remained around the drain. During an interview on 7/29/26 at 10:00 AM, Staff H, CNA, stated she noticed recently that the East shower room had been backing up. Staff H reported that the facility used to have a work order book to write down maintenance concerns, but said this was no longer in place. Staff H denied knowledge of an electronic system used to report work orders. During an interview on 7/29/26 at 3:45 PM the Director of Nursing (DON) stated she'd been told about a week ago that the East shower room overflows a little bit. The DON said she instructed staff to report concerns to maintenance using the electronic work order system and said staff can use the South shower room instead if the East shower room was not working. During an interview on 7/29/26 at 5:30 PM, the facility Administrator denied knowledge of clogged floor drain in the East shower room but stated that a plumber would be contacted to fix the drain. The Administrator stated that all staff should be trained to use the electronic work order system for reporting maintenance issues. Review of the facility provided document titled, Work History Report, dated 6/30/26 through 8/01/26, lacked work order history for maintenance work completed in the East shower room. 2. During an observation 7/29/26 at 9:20 AM, the South shower room wall, located between the resident shower area and whirlpool bathtub, a dried black/brown colored splatter was observed approximately 2 feet from the floor just above a trash can. During an interview on 7/29/26 at 9:20 AM, Staff A, CNA, present in the South shower room, stated the black/brown colored splatter on the wall was stool that had been on the wall for months. When queried about whose responsibility it was to clean the shower rooms, Staff A said housekeeping used to clean the shower rooms but no longer do this and the CNA staff were responsible for spraying the shower chair with cleaning spray between residents. During an interview on 7/29/26 at 5:00 PM, Staff H, CNA and DON, both present in the South shower room, observed the splatter on the wall. Staff H stated the splatter appeared to be right above where the trash can is placed. The DON stated she had not seen this splatter on the wall before and revealed the expectation of CNA staff to clean the shower room between residents and to notify housekeeping if additional cleaning is needed. Staff H stated she would clean the splatter on the wall. 3. Review of Resident #10's Minimum Data Set (MDS) assessment, dated 5/23/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS indicated Resident #10 dependent on staff for all hygiene tasks and mobility. During an interview on 7/27/26 at 3:20 PM, Resident #10 reported having issues with flies in his room and pointed to a fly trap container filled with a red colored solution on the floor near the right-side foot of bed, Resident #10 stated this fly trap has helped but said he has also ordered some fly strips to put up in his room. During an observation on 7/27/26 at 3:20 PM, Resident #10 laid in bed while 3 to 4 flying insects flew around the resident's room, landing occasionally on the overbed table placed over top the resident's bed. Resident #10 was covered with a blue microfiber blanket and on top of the blanket at least 4 dead insects were observed. During an observation on 7/28/26 at 1:15 PM, Staff G, CNA, and Staff I, CNA, performed cares on Resident #10 and changed his bed linens. When the soiled linens were removed, two areas of dry/crusted debris were observed on the mattress, one near Resident #10's right lower leg and the second near his left shoulder. Staff G and Staff I did not clean off debris on the mattress before remaking the bed. When queried about whose responsibility it was to clean the mattresses, Staff G stated that would be a question for housekeeping. During an interview on 7/29/26 at 8:10 AM, a housekeeping staff member reported that he only does the sweeping and mopping in resident rooms and the CNAs do the mattress cleaning. During an interview on 7/29/26 at 10:00 AM, Staff H, CNA, stated that she's seen flies in Resident #10's room and said his family kept wanting to bring in fly strips. Staff H stated mattresses are cleaned by housekeeping with a cleaning spray on the resident's first shower day of the week, when bed sheets are changed. During an observation on 7/29/26 at 2:50 PM, Resident #10 laid in bed, approximately 5 flying insects observed flying around bed and overbed table. A fly strip now hung in the corner of Resident #10's room with a few insects observed stuck to the strip. During an interview on 7/29/26 at 3:45 PM, the DON stated she had noticed flies in Resident #10's room and stated the facility has sprayed for flies, the DON denied knowledge of a fly trap solution container or fly strip set up in Resident #10's room but stated these items would be a concern for infection control. The DON revealed an expectation of CNA staff to clean debris off a resident's mattress when changing linens using sanitizing wipes. 4. Review of Resident #4 the MDS listed BIMS of 14 out of 15, indicating intact cognition. During an interview on 7/27/26 at 8:41 AM, Resident#4 stated that his room is dirty, with dead bugs on the floor. Resident#4 reported he just moved into the room last week. During an observation on 7/27/26 at 8:44 AM, two dead, black bugs noted on the floor near the resident's dresser, one fly present and brown debris scattered on the floor. On 8/3/26 the DON reported it's everyone's responsibility to keep things picked up and clean int he building. The facility an undated policy titled Cycle Cleaning which declared: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies for maintaining regularly scheduled environmental service tasks. The policy directed all specific areas have a form that has a designated legend and cycle related to specific areas include: Hallways/Dayrooms/Dining Rooms; Offices/Support Rooms/Exterior; Showers/Utility/Bathrooms; Resident Rooms The frequency of cleaning and disinfection of the facility environment may vary according to the: Type of surface to be cleaned; The number of individuals in the area; Amount of activity in the area; Risk to residents; Amount of soiling.

Based on clinical record review, staff and resident interview and facility policy review the facility failed to follow Physician's orders to obtain laboratory results for 2 of 4 residents reviewed (Resident#4 & Resident #7). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 7/14/26 listed diagnoses of below the knee amputation, end-stage renal disease (ESRD), multidrug-resistant organism (MDRO), and diabetes mellitus (DM). The Brief Interview for Mental Status (BIMS) for Resident #4 showed a score of 14 out of 15, which indicated intact cognition. The MDS showed Resident #4 required hemodialysis before admission, and was on dialysis during the resident's stay at the facility. The Care Plan for Resident #4 revised 7/16/26 revealed an intervention for labs as ordered. Resident#4's Medication admission Record (MAR) dated July 2026 directed the following on 7/14/26 through 7/16/26: Complete blood count (CBC), comprehensive metabolic panel (CMP,) magnesium (Mg) , phosphate (Phos), Lipid panel, Zinc, B12 one time only related to sepsis due to methicillin resistant staphylococcus aureus (a type of staph bacteria that is resistant to many common antibiotics like methicillin, penicillin, and amoxicillin).The resident's clinical record failed to hold results to the ordered labs. The Provider Note dated 7/20/26 at 11:59 PM described per facility coordination and Director of Nursing (DON) request, vancomycin trough levels were scheduled to be obtained weekly on Fridays. Due to limitations at the current facility, the patient will be transported to [Laboratory redacted] facility for lab draws to ensure appropriate monitoring. The patient has been informed of and is agreeable to this modified plan of care, including off-site lab coordination and adjusted dosing schedule. On 8/03/26 at 2:25 PM the Director of Nursing (DON) reported the facility and dialysis got confused on which one would complete the labs ordered.2. The MDS assessment for Resident #7 dated 7/5/26 listed diagnoses of cancer, diabetes mellitus (DM), anemia, and chronic lung disease. The MDS reflected a BIMS score of 14 out of 15, which indicated intact cognition. The Provider's Progress note dated 7/6/26 reflected weekly labs: CBC, basic metabolic panel (BMP), liver function tests (LFTs), creatine kinase (CK), and inflammatory markers. The Plan section of the note revealed CBC, CMP, hemoglobin a1c (A1C), Lipid panel, Mg, and Phos with next lab draw.The Progress Note for Resident #7 dated 7/13/26 at 5:25 PM reflected the Nurse Practitioner (NP) ordered the following: CBC, CMP, A1C, lipid panel, Mg, and Phos.The resident's MAR dated July 2026 revealed the following on 7/14 through 16/2026: CBC, CMP, A1C, Lipid Panel, Mg, and Phos one time only related to DM and chronic pancreatitis.A Physician's faxed Order dated 7/20/26 revealed multiple attempts to send orders for weekly labs, and a lack of labs completed after the resident's discharge from prior location on 7/1. Resident #7 took three high risk antibiotics. The order directed complete labs as soon as possible (ASAP) and send results to the provider. The Providers Progress Note dated 7/20/26 directed weekly labs CBC w/diff, (blood urea nitrogen (BUN)/Creatinine (Cr), LFTs, CK, C-reactive protein (CRP). The Rationale section of the note revealed, in part, Close lab monitoring is necessary to detect antimicrobial toxicity (e.g., CK elevation with daptomycin, renal/hepatic dysfunction). Consistent wound care supports healing and reduces bacterial burden, while coordinated Infectious Disease (ID) follow-up is essential to guide duration and prevent recurrence or complications such as sepsis or limb loss.On 7/28/26 at 1:13 PM, the Registered Nurse Practitioner reported the facility may have missed a few labs due to the transition with the lab provider. On 7/28/26 at 4:59 PM, the Director of Nursing (DON) reported the facility lacked the lab results for Resident #7. The DON reported the facility went through a lab service change and went without lab services for about a month. During an interview on 8/3/26 at 2:23 PM the DON reported she expected the laboratory tests completed in a timely fashion. She reported miscommunication with the dialysis center for Resident #4's labs and said they missed the labs for Resident #7. The facility provided a policy titled Consulting Physician/Practitioner Orders, undated, directed to document the verification order by entering the order and the time, date, and signature on the physician order sheet.Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

Based on observation, staff interview, and facility policy review, the facility failed to maintain safe storage of smoking materials when a cart containing smoking supplies was left unlocked and unsupervised with residents present in the area during 2 of 3 smoking times observed. The facility reported a census of 54 residents. Findings include:During an observation on 7/27/26 at 1:14 PM, Staff J, Maintenance staff obtained a key and unlocked the cart containing smoking materials, kept in the activity room/dining room near the smoking patio. Staff J handed out cigarettes to residents from the cart, then went outside with residents to the smoking area. The cart containing smoking materials remained unlocked and unattended with the key left on top of the cart. One resident remained in his wheelchair in the activity room and a second resident ambulated independently through the activity room. At 1:22 PM, the facility Administrator approached the area, locked the cart, and took the key from the top of the smoking material cart. During an observation on 7/27/26 at 1:22 PM, the facility Administrator opened the smoking material cart and explained that the drawers contained opened packs of cigarette boxes organized by resident, various packs of extra cigarette boxes, and an electronic nicotine vape. During an observation on 7/29/26 at 10:55 AM, the smoking material cart kept in the activity room/dining room was left unlocked and unattended. Four residents were present in the activity room and no staff were present. The top and middle drawers of smoking material cart opened, and observed packs of cigarettes inside the cart. The Director of Nursing (DON) approached the area and locked the cart. During an interview on 7/29/26 at 5:30 PM, the facility Administrator revealed the expectation of the smoking material cart to remain locked when unattended for resident safety and stated they would eventually like to keep the cart in a locked room as extra safety precaution. Review of the facility policy titled, Tobacco Policy, dated 9/21/23, revealed the policy Statement: The facility shall establish and maintain safe resident tobacco/smoking/electronic cigarette, vape use practices. The policy identified that all employees shared the responsibility for enforcing the policy. The Section titled Employees revealed under the third bullet point, No smoking paraphernalia shall be left unattended anywhere in the facility.

Based on clinical record review, staff and resident interviews and facility policy review the facility failed to consistently complete pre and post dialysis assessments for Resident #4, and also failed consistently coordinate transportation to and from dialysis for Resident #4. The facility reported a census of 52 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 7/14/26 listed diagnoses of below the knee amputation, end-stage renal disease (ESRD), multidrug-resistant organism (MDRO), and diabetes mellitus (DM). The Brief Interview for Mental Status (BIMS) for Resident #4 showed a score of 14 out of 15, which indicated intact cognition. The MDS showed Resident #4 required hemodialysis before admission, and was on dialysis during the resident's stay at the facility. The Care Plan for Resident #4 dated 7/16/26 reflected a goal that the resident would continue with dialysis treatments without complications through the next review date. The Interventions dated 7/16/26 revealed, Dialysis flow sheet to be completed daily to observe for shunt access site complications-report abnormalities to physician. Labs as ordered. The Treatment Administration Record (TAR) dated 7/2026 directed to inspect dialysis access site for infection daily: Left chest port. Access for localized pain, erythema, warmth, edema to site, bleeding or abnormal drainage, caps secure, shortness of breath (SOB)/generalized edema. Access for thrill/bruit. Click yes if monitored and none of the above complications are observed, caps are intact and thrill/bruit noted. The TAR also included a place to record the resident's vital signs daily. The TAR showed eleven out of twenty-one days had been left blank. The TAR read Post-Dialysis to assess access site left chest site for signs and symptoms (s/sx) bleeding, or for s/sx infection and notify dialysis for bleeding or s/sx infection. Assess cognition and document in the evening every Tue, Thu, Sat for dialysis. Six days failed to show documentation of assessments post scheduled dialysis treatments. On 7/27/26 at 8:41 AM Resident #4 reported the facility failed to line up weekend transportation to dialysis. He reported one time he had to coordinate his own transportation and it cost him out of his own pocket. He said the facility van worked only during the week and they didn't have a driver for Saturday on his dialysis days. He reported he missed dialysis on 7/11/26 and 7/18/26. Resident#4 reported the facility did not do assessments of him before and after dialysis and they didn't check vitals or check the site. On 7/30/26 at 10:56 AM, Staff E, Registered Nurse (RN) reported she did the pre and post dialysis assessments, blood pressure (BP), and then checked the site and documented in the MAR or the Progress Note. On 7/30/26 at 3:10 PM, the Administrator acknowledged the facility failed to provide transportation to and from dialysis on the weekends because their driver worked during the week only. On 8/3/26 at 2:15 PM, the Director of Nursing reported she expected pre and post dialysis assessment completed and documented in the resident record. She said she expected the residents to go to dialysis as the Physician ordered. The facility provided a policy titled Hemodialysis, undated, which directed: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The facility will assure that arrangements are made for safe transportation to and from the dialysis facility. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The nurse will ensure that the dialysis access site (e.g. arteriovenous (AV) shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist.

Based on observations, clinical record review, facility policy review, facility group meeting notes review, and staff and resident interview, the facility failed to answer call lights in a timely manner for 2 of 3 residents reviewed (Resident #3 and Resident #4). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #3 dated 6/23/26 listed diagnoses of stroke, and high blood pressure The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS revealed Resident#3 required partial/moderate assistance with toileting hygiene and toilet transfers, and required substantial/maximal assistance with lower body dressing. The Care Plan for Resident #3 dated 12/31/25 directed one person assist for toileting. It further directed, Provide peri-care with every incontinent episode and as necessary. An intervention dated 12/31/25 revealed to keep call light within reach to use to notify nursing if the resident needs to use the toilet/has had an incontinence episode. On 7/27/26 at 10:07 AM, Resident#3 said call lights times depended on the people here, at times it could take an hour for help. On 7/29/26 at 1:53 PM, Resident#3 in the hall in his wheel chair reported his call light on for 30 minutes waiting for help from the staff, and he needed changed. Resident#3 told the Social Worker (SW). The SW told him she would get the staff. At 2:01 PM, Resident #3's call light went off, and staff went into his room to help him. On 7/29/26 at 2:10 PM, Staff B, Certified Nurse Aide (CNA) showed on the call light log at the nurses station, Resident #3's call light went on at 1:36 PM. Staff B and Staff A, CNA pointed out Resident #3's call light was not on 30 minutes. Staff A and Staff B reported they were busy with other residents when his light was on. Staff A said they had enough help on day shift most of the time, but when call-ins happen.2. The MDS assessment for Resident #4 dated 7/14/26 listed diagnoses of below the knee amputation, end-stage renal disease (ESRD), multidrug-resistant organism (MDRO), and diabetes mellitus (DM). The BIMS for Resident #4 showed a score of 14 out of 15, which indicated intact cognition. The MDS reflected Resident #4 required Substantial/maximal assistance from staff with toileting hygiene and toilet transfers. The Care Plan for Resident #4 dated 7/16/26 revealed to keep call light within reach to use to notify nursing if the resident needs to use the toilet/has had an incontinence episode. On 7/27/26 at 8:41 AM, Resident #4 reported his call light is on for hours, and when he has a bowel movement (BM) they don't clean him up and it made him mad. Resident#4 said the staff told him they were busy with other residents. On 7/30/26 at 7:43 AM, the call light showed in the hall for Resident #4. On 7/30/26 at 7:45 AM, Resident #4 reported he turned the light on a while ago and no one came to help him. Staff E, Registered Nurse in the hall and Staff A left another resident room. At 7:50 AM, Staff E was in the room, turned off the call light, and set up his tray for breakfast. On 7/30/26 7:52 AM. the call light monitor at he nurses station reflected the call light for Resident #4's room started at 6:57 AM. On 7/30/26 at 10:02 AM, Resident #4 turned on the call light for staff to help him get ready to go out. On 7/30/26 at 10:18 AM, Staff E entered the Resident#4's room and turned off the call light. The Resident Council Minutes dated 6/18/26 reflected call lights took around 30 minutes. On 8/3/26 at 2:14 PM, the Director of Nursing (DON) reported she expected the staff to get to the call lights as soon as possible (asap) 15 minutes or sooner. The DON said call lights could be longer if they are busy. She said they were always working on staffing. The facility provided a policy titled Call Lights: Accessibility and Timely Response, undated, which directed all staff members who see or hear an activated call light were responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observations, clinical record review, staff interviews and facility policy review the facility failed to use Enhanced Barrier Precautions (EBP) for 2 out of 2 residents reviewed (Resident#1 and Resident #2). The facility reported a census of 52 residents. Findings include:1. The MDS for Resident#1 dated 7/16/26 listed diagnoses of cancer, diabetes mellitus (DM), dementia, pressure ulcer right heel and bipolar disorder. The MDS reflected a BIMS of 11 out of 15, indicating moderate cognitive impairment. The MDS identified Resident#1 dependent on staff for toileting hygiene, toilet transfers and dressing. The MDS reflected Residet#1 always incontinent of bladder and frequently incontinent of bowel. The Care Plan for Resident#1 dated 7/20/26 identified requires Enhanced Barrier Precautions related to the presence of a pressure wound to the heel. EBP will be instituted during completion of high contact activities. The Care Plan dated 4/17/26 directed 1 person assist, provide peri-care with every incontinent episode and as necessary. Review of Resident#1 July 2026 Medication admission Record (MAR) revealed:a. Cephalexin 500 milligrams (MG) give four times a day for right heel wound infection for 10 days. Start Date: 7/2/26. b. Cephalexin 500 MG give four times a day for suspected cellulitis pending culture for 7 Day. Start Date: 7/29/26.During an observation on 7/30/26 at 8:15 AM, Staff G, Certified Nurse Aide (CNA) and Staff B CNA entered Resident#1's room to complete morning care. No sign to direct the use of EBP (personnel protective equipment of gloves and gown) when caring for Resident #1 noted to be posted, or supply of gowns available. Both staff completed hand hygiene and gloved. Staff G gathered Resident#1's clothing. Resident#1's brief appeared yellow and wet with a blue line visible down the center of the brief. Staff G washed Resident#1 where the brief covered, front and the back. Staff B put clean sock on the right foot over the dry dressing to Resident#1's heel. Staff G placed a new brief on Resident#1. Both CNA's sat Resident#1 on the side of the bed and applied a gait belt. Both staff physically assisted Resident #1 to stand and pivot and with his walker transfer to a wheel chair. Both CNA's failed to put on a gown during the care. 2. The MDS assessment for Resident #4 dated 7/14/26 listed diagnoses of above the knee amputation, end-stage renal disease (ESRD), multidrug-resistant organism (MDRO), and diabetes mellitus (DM). The BIMS score of 14 out of 15 indicated Resident #4 cognition intact. The MDS indicated Resident#4 required substantial/maximal assistance with toileting hygiene, lower body dressing, chair to chair and toilet transfers. The MDS identified Resident#4 received hemodialysis before admission and during the stay at the facility. Resident#4's Care Plan dated 7/16/26 identified required Enhanced Barrier Precautions related to the presence of an indwelling medical device - central line, MDRO infection/colonization when contact precautions do not otherwise apply and diabetic foot ulcer. Enhanced Barrier Precautions will be instituted during completion of high contact activities. Resident#4 MAR dated 7/26 listed vancomycin (antibiotic) Intravenous (IV) 500 mg IV in the evening every Tuesday, Thursday, Saturday related to sepsis due to methicillin resistant staphylococcus aureus (MRSA) (a type of staph bacteria that is resistant to many common antibiotics like methicillin, penicillin, and amoxicillin).During an observation 7/29/26 at 10:55 AM, Staff B, CNA and Staff A, CNA entered Resident#4's room to assist with hygiene after use of the bed pan. No sign to direct the use of EBP (personnel protective equipment of gloves and gown) when caring for Resident #4 noted to be posted, or supply of gowns available. Staff B reported his deep bedpan causes him some pain so they lined the bedpan with a brief for padding. Staff A and Staff B completed hand hygiene, and gloved. Neither Staff A or B donned a gown. Staff A and Staff B used wipes and cleaned his bottom from a bowel movement (BM). The top of Resident#4's appeared to have been scraped and red. A dressing intact on Resident #4's left heel. Staff A and Staff B placed a clean brief on Resident#4, and adjusted him for comfort while he waited for the nurse. During an interview on 7/30/26 at 10:56 AM Staff E, Registered Nurse (RN) reported she put on EBP due to Resident#4's IV line and the dialysis port and the wound. Staff E stated she did not know what the CNA's needed to use during resident care. During an interview on on 7/30/26at 11:38 AM, the Director of Nursing (DON) and Infection Preventionist (IP) reported the staff needed the EBP when they cared for a resident with catheters wounds, IV, or ports, etc. She said staff needed to use the EBP when they are dealing with the area that qualified them for EBP. The DON reported the CNAs don't need to use the EBP if the are not doing wound care. During an interview on 7/30/26 at 2:39 PM Staff F, Certified Medication Aide (CMA) stated EBP needs to be used when providing care to a resident with a feeding tube, would, IV catheter. Review of an undated facility policy titled Enhanced Barrier Precautions (EBP) revealed it is the policy of this facility to implement EBP for the prevention of transmission of MDRO. EBP refers to an infection control intervention designed to reduce transmission of MDRO that employ targeted gowns and gloves to use during high contact resident care activities. The policy further directed: Initiation of EBP: an order for EBP will be obtained for residents with any of the following: wounds, (e.g., chronic pressure ulcers, diabetic foot wounds, unhealed surgical wounds, chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, tube feeding, tachometry /ventilator tube, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with MDROs. Make gown and gloves available immediately near or outside of the residents room. High contact activities identified: high contact activities as: dressing, bathing, transferring, provide hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tachometry /ventilator tube, hemodialysis catheters, PICC lines, midline catheters, wound care: any skin opening requiring a dressing.

Based on observation, resident interview, staff interview, clinical record review, and facility policy review, the facility failed to ensure call lights functioned or an alternative provided for 1 of 3 residents (Resident #10) reviewed for call lights. The facility reported a census of 54 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included cerebrovascular accident (CVA or stroke) with hemiplegia or hemiparesis (lack of muscle movement/sensation on one side), muscle contractures of left shoulder, left forearm and left hand, and peripheral vascular disease (PVD). The MDS identified Resident #10 dependent on staff for all hygiene tasks and mobility, occasionally incontinent of bladder and always incontinent of bowel. Review of the Care Plan, initiated on [DATE], revealed a Focus area for incontinence of bowels and risk for impaired skin, rashes, irritation in the perineal area. An intervention instructed staff to keep call light within reach to notify nursing if the resident needs to use the toilet/has had an incontinence episode. During an interview on [DATE] at 3:20 PM, Resident #10 stated his call light is not working properly and he told the staff about this. Resident #10 reported that a maintenance worker had informed him that new batteries were ordered to fix his call light box but had not seen him come back. Resident #10 pressed his call button and the light outside his room did not light up when pressed to indicate the call light was activated. Resident #10 pressed the call light again harder and held down for a few seconds, the light outside his room did not light up when pressed again. A small bell was observed out of reach, on top of a dresser across the room, when queried if Resident #10 was given the bell to use as an alternative to call light, he stated yes, but they kept taking it away from me. Resident #10 estimated that the bell had been on top of the dresser for about a month. During an interview on [DATE] at 10:23 AM, Staff J, Maintenance staff, denied knowledge of Resident #10's call light not working.During an observation on [DATE] at 10:25 AM, Staff J, entered Resident #10's room, removed the cover of call light receiver box located on the wall, replaced a battery, then returned the cover. Upon pressing the call button, the light outside Resident #10's room lit up indicating that the call light had been activated. During an interview on [DATE] at 10:53 AM, Staff D, Maintenance staff/driver stated that the call light receiver box having a low battery was a common problem with the facility's call light system. Staff D explained that the screen at nurses station that indicated which call lights had been activated and when, would show highlighted in yellow if the battery is low. When asked what would be shown if a resident's call light receiver battery was depleted, Staff D stated that should never happen, nursing staff should notify maintenance when they see a yellow highlighted call light. During an interview on [DATE] at 9:00 AM, Staff A, Certified Nursing Assistant (CNA), said she's heard about Resident #10's call light not working but thought the resident was not pushing the button hard enough. Staff A said Resident #10 may need a soft touch call light. Staff A reported that all residents had a bell in their room due to the whole call light system not functioning properly at times and explained that it was hard to know who was ringing the bell especially when a resident's door was closed. During an interview on [DATE] at 3:45 PM, the Director of Nursing (DON), said she was aware that Resident #10 felt like his call light wasn't working at times. The DON stated that Resident #10 would be unable to reach a bell across the room to use for help, due to his immobility. During an observation on [DATE] at 5:15 PM, the light outside of Resident #10's room was flashing on and off. Staff D, maintenance worker, present in the area, stated Resident #10's call light was not functioning again and explained that they flipped a breaker to reset it, now the light outside resident's room flashed continuously. Staff D said Resident #10 would be unable to use call light tonight but a technician from the call light company would be in on [DATE] to repair. During an interview on [DATE] at 5:30 PM, the Administrator confirmed that Resident #10's call light was not functioning properly and a technician would be in to fix it on [DATE]. The Administrator stated that Resident #10 had the bell in reach to use until call light is repaired. Review of the facility policy titled Call Lights: Accessibility and Timely Response, dated 2025, revealed the policy Statement: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.The Section: Policy explanation and compliance guidelines instructed under #8: Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.)

Based on clinical record reviews, staff interview, and facility policy review, the facility failed to ensure that 4 out of 5 residents reviewed for unnecessary medications were provided with education regarding the risks and benefits of psychotropic medications (Resident #4, Resident #6, Resident #7, Resident #43). Additionally, the facility failed to offer alternative treatment options prior to the administration of the medications. The facility reported a census of 47 residents. Findings include:1. The Minimum Data Set (MDS) Assessment for Resident #4 dated 2/12/26 documented diagnoses that included: Non Alzheimer's dementia, depression and schizophrenia. The MDS recorded an admission date to the facility of 2/22/22. The MDS recorded a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated severe cognitive impairment. The Medication Administration Record (MAR) for Resident #4 for August 2025 reflected the resident had an order for Sertraline, an antidepressant medication, start date 8/29/25 at 25 mg (milligram) for seven days, increasing to 50 mg daily following the initial seven days. A clinical record review of the Resident's Electronic Health Record (EHR) failed to reveal consent obtained for any of the medications prior to administration. Additionally, no progress notes or assessments revealed education was provided of the side effects, risk versus (vs) benefits of psychotropic medications or offering of any alternative treatments. The EHR revealed a Care Conference was held on the morning of 8/29/25, though no resident representative was recorded as being present. The social work summary documented increased symptoms of depression resulting in medication changes. No documentation of education, side effects or alternative treatments were found. 2. The MDS Assessment for Resident #6 dated 3/19/26 documented diagnoses that included: Non Alzheimer's dementia and anxiety disorder. The MDS recorded an admission date to the facility of 9/17/25. The MDS identified a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. The MAR for Resident #6 for September 2025 reflected that the resident had an order for fluvoxamine, an antidepressant medication, lorazepam, an antianxiety medication, and seroquel, an antipsychotic medication.A clinical record review of Resident #6's EHR failed to reveal consent obtained for any of the medications prior to administration. Additionally, no progress notes or assessments revealed education was provided of the side effects, risk vs benefits of psychotropic medications, or offering of any alternative treatments. 3. The MDS Assessment for Resident #7 dated 3/4/26 documented diagnoses which included depression and insomnia. The MDS recorded an admission date to the facility of 3/8/24. The MDS identified a BIMS score of 15 out of 15 which indicated cognition intact.The MAR for Resident #7 for August 2025 reflected that the resident received a new order for Zaleplon, a hypnotic medication on 8/4/25.A clinical record review of Resident #7's EHR failed to reveal consent obtained for the medication prior to administration. Additionally, no progress notes or assessments revealed education provided of the side effects, risk vs benefits of psychotropic medications, or offering of any alternative treatments. 4. The MDS Assessment for Resident #43 dated 4/23/26 documented diagnoses that included: Non Alzheimer's dementia, anxiety, and depression. The MDS recorded an admission date to the facility of 10/22/24. The MDS identified a BIMS score of 15 out of 15, which indicated cognition intact. The MAR of Resident #43 for July of 2025 reflected the resident's order for Mirtazipine, an antidepressant, was increased from 7.5 mg to 22.5 mg. The MAR for August 2025 documented an additional increase of Mirtazapine to 30 mg daily. A third increase of the medication was documented in January of 2026 to 45 mg daily. Resident #43 was additionally ordered Aripiprazole, an antipsychotic medication on 10/30/25 at a dose of 2 mg daily, which was increased on 12/29/25 to 5 mg daily. Resident #43 received an order for Ambien, a hypnotic medication, on 12/17/25 at a dose of 5 mg, then raised to 10 mg on 3/3/26, which was discontinued on 3/9/26. Resident #43 then began a new order for Trazodone, also an antidepressant medication on 3/10/26 at a dose of 25 mg daily. A clinical record review of Resident #43's EHR failed to reveal consent being obtained for any of the above medications prior to administration. Additionally, no progress notes or assessments were revealed of education provided of the side effects, risk vs benefits of psychotropic medications. or offering of any alternative treatments. On 5/7/26 at 1:17 pm, the Director of Nursing (DON) stated the facility Nurse Practitioner often would provide education when she ordered new psychotropic medications. The expectation for the facility was to notify the resident and resident representative of the order, the information about the medicine, and obtain consent at that time. She added staff should then monitor for effectiveness and report findings to the provider. The undated facility policy titled Use of Psychotropic Medications documented the following:Point 9: Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.Point 10: The resident has the right to accept or decline the initiation or increase of a psychotropic medication.Point 11: The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on observation, resident interview, and staff interview the facility failed to maintain a sanitary, orderly, and comfortable interior in facility dining room [ROOM NUMBER] of 2 dining observations, ensure furniture (chairs) in good condition in 1 of 2 entrance areas, and failed to ensure a clean environment in a resident's room (Resident #43). The facility reported a census of 47 residents. Findings include: 1.On 5/05/2026 9:18 AM, observed chairs in the main entrance areas. Noted two wooden dining arm chairs with brown vinyl back of chair and chair seat. The dining room chairs showed significant signs of wear and tear. The varnish was worn, indicating that the finish had faded. Additionally, the arms were loose. Two arm chairs were also in this area, one was light green and the other was brown. Visible peeling and cracking of the upholstery noted on the seat, arms and backrest of the chairs. 2.On 5/05/25 at 1:00 PM, observation in the North dining room (DR) revealed five dining chairs. Five of Five dining chairs had cracked or peeling vinyl upholstery. Noted visible imprints or indentation on the seats. The varnish of the chairs was worn. On 5/6/26 at 3:30 PM, the Administrator verbalized his expectation was that the furniture was in good repair. The policy titled Quality of Life-homelike Environment, last revised May 2017, stated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belonging to the extent possible. The Policy interpretation and implementation revealed, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: 2(a) clean, sanitary and orderly environment 2(c) inviting colors and decor. 3. The Minimum Data Set (MDS) revealed Resident #43 had diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and diabetes. The Brief Interview for Mental Status score of 15 out of 15 indicated intact cognition. On 5/4/26 at 10:09 AM, Resident #43 relayed gets weekly housekeeping. The resident reported staff only swept and did toilets, do not clean any tables. The resident pointed to table, multiple sticky rings. On 05/05/26 at 4:05 PM, Maintenance, Staff E conducted tour in absence of housekeeping supervisor, relayed did not have a current housekeeping manager, and further relayed were some budget cuts and staff changes. On 5/7/26 at 10:30 AM, the Administrator explained was actively looking for a housekeeping manager to replace the one that left to improve housekeeping.

Based on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assessment Assurance (QAA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impacted quality of care, quality of life, and resident safety. The facility reported a census of 47 residents.Findings include: The Centers for Medicare and Medicaid Services(CMS) 2567, dated 12/15/25 listed, in part, the following concerns:F584 and F688The current survey, conducted 5/4/26 to 5/7/26, also identified the above concerns.On 5/7/26 at 2:28 p.m., the Administrator, stated the facility had no documentation related to QA activities targeted at restorative services and staffing. The facility QAPI and QAA Plan, revised 1/2/25, stated the facility would gather QAPI data from sources such as survey findings. The facility carried out systematic action and analysis in order to achieve the desired outcome.

Based on review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assessment Assurance (QA), the facility failed to carry out quarterly QA meetings to identify issues with respect to QAA activities.Findings included: Review of QAPI Meeting Attendance Logs from the period of the last survey on 5/8/25 to the current survey on 5/4/26 revealed the facility lacked documentation of a QAPI meeting from 6/26/25 to 12/31/25. The facility QAPI and QAA Plan, revised 1/2/25, stated the facility would establish Performance Improvement Plans (PIPs) and staff would review them no less often than quarterly.On 5/7/26 at 1:42 p.m., the Administrator stated the facility conducted QA monthly meetings but it was clear some months (in the last year) were missed.

Based on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to interviews, observations clinical record review and policy review, the facility failed to be honor resident request, that those that entered the room wear a mask to prevent further respiratory complications for 1 of 1 resident reviewed for choices (Resident #5). The facility reported a census of 47 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure. The Brief Interview for Mental Status scored 15 out of 15 indicating intact cognition. The Care Plan revised on 3/18/26 for Resident #5 documented, potential for infection related to history of pneumonia and influenza. Interventions included that Resident #5 prefers to have staff wear a mask, please ask her before entering room. On 5/4/26 at 10:20 AM, Registered Nurse (RN) Staff B observed leaving Resident #5 room without a mask, quired if was required due to the signage on the door. Staff B responded that is only for strangers. On 5/4/2026 at 12:55 PM, Resident #5 relayed wanted staff to wear a mask, understood it to be hard when staff come in and out of the room, had asked staff to put on a mask and asked staff to bring masks to have, never received any and assumed would have to self-pay for them. Resident #5 relayed asked for sign to be on the door, reading, Please wear a mask. Thank youOn 5/5/26 at 12:50 PM, Licensed Practical Nurse (LPN) Staff B observed leaving resident room wearing a mask, quired about the mask, Staff B responded Resident #5 wanted masks worn for her protection.On 5/7/26 at 8:50 AM Resident in bed utilizing oxygen, relayed again preference for masking before entering the room, relayed varies some do and others don't, varied with compliance despite sign on the door. Resident relayed felt wearing masks is beneficial due to respiratory complications.On 5/7/26 at 10:30 AM The Administrator, Staff H relayed resident preference should be supported, was aware of the sign on the door of Resident #5 room that requested those entering to wear a mask, had supplies of masks and would expect staff to respect resident choice.Policy provided Resident Rights dated 2026 documented, the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on personnel file review, policy review, and staff interview, the facility failed to conduct a criminal background check prior to hire for 1 of 2 newly hired employees. The facility reported a census of 47 residents.Findings included:The facility undated New Hire List and Roster listed a hire date for Staff J Certified Medication Aide as 8/14/25.Staff J's personnel file lacked documentation of a criminal background check completed upon hire. On 5/7/26 at 9:20 a.m, Staff H Interim Administrator stated that he had no other employee file documentation. He stated he was aware there were concerns with the files.On 5/7/26 at 11:36 a.m., the Director of Nursing(DON) stated criminal background checks should be done before hire.The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated 3/18/26, stated the facility would carry out criminal record checks on all prospective employees .

Based on clinical record review, policy review, and staff interview, the facility failed to provide bed hold information for 2 of 2 residents admitted to the hospital(Residents #8 and #49) and failed to notify the ombudsman of hospitalizations for 1 of 2 residents admitted to the hospital(Resident #8). The facility reported a census of 47 residents.Findings included: 1. The Minimum Data Set(MDS) assessment tool, dated 4/23/26, listed diagnoses for Resident #8 which included end stage renal(kidney) disease, blindness, and abnormalities of breathing. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 12/26/25 General Progress Note stated the resident transferred to the Emergency Room. A 1/6/26 General Progress Note stated the resident returned from the hospital. A 1/9/26 General Progress Note stated the resident transferred to the Emergency Room. A 1/13/26 General Progress Note stated the resident returned to the facility. The facility lacked documentation of bed hold information provided to the resident and ombudsman notification for the above hospitalizations. The facility Transfer Notice/Bed-hold Notice Policy, updated 6/10/24, stated the facility would notify the resident of their rights regarding holding a bed when transferred to the hospital. On 5/7/26 at 11:36 a.m., the Director of Nursing(DON) stated staff should provide bed hold information when residents transfer to the hospital. She stated they did not provide Resident #8 bed hold information because he transferred to the hospital directly from dialysis. On 5/7/26 at 12:38 p.m., via email, the interim Administrator stated the facility did not have a specific policy for ombudsman notification but he expected the facility to notify in accordance with the regulation. 2. The census line of the Electronic Health Record (EHR) for Resident #49 reflected an initial admission to the facility on [DATE]. The resident's status was reflected as unpaid hospital leave on 1/27/26, and returned on 2/3/26. The resident's status was again changed to unpaid hospital leave on 2/8/26, returning to the facility on 2/19/26. The resident was then again sent to the hospital on 3/8/26. Review of Progress Notes revealed a bed hold form was sent with the resident for his 2/8/26 hospitalization only. The EHR failed to document whether a bed hold was completed for the hospitalization beginning 1/27/26 or the hospitalization beginning 3/8/26. On 5/6/26 at 1:48 pm, the interim Administrator stated the facility staff had recently learned there was no process in place for ensuring bed holds were completed. He clarified they were working on a plan to resolve the issue.

Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit a Comprehensive Minimum Data Set (MDS) Assessment following a significant change within federal guidelines for 1 of 1 resident (Resident #6) reviewed for Hospice Admission. The facility reported a census of 47 residents.Findings include:The Census Line portion of the Electronic Health Record (EHR) of Resident #6 documented the resident enrolled in hospice care on 4/14/26. The MDS section of the resident's EHR documented a Significant Change MDS for Resident #6 as in process (incomplete), with an Assessment Reference Date (ARD) of 5/6/26. On 5/6/26 at 2:26 pm, the MDS Coordinator stated nobody had informed her Resident #6 had enrolled in hospice, so therefore, she had not set up or completed a Significant Change assessment. She stated the facility needed better communication and other staff were supposed to notify her. She added she regularly checked the census line of facility residents but if she did not catch a change and was not informed by other staff then the assessment could get missed. According to the 2024 RAI, a Significant Change (comprehensive) assessment, the ARD must be no later than the 14th calendar day after determination that a significant change in the resident's status occurred. The RAI stated a Significant Change MDS is required to be performed when a terminally ill resident enrolls in a hospice program. The undated facility policy titled MDS 3.0 Completion, documented the following: Point 2d: Significant Change in Status Assessment (SCSA) - a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter 2 of the Version 3.0 RAI Manual.ii. A SCSA is required when a resident enrolls in a hospice program or changes hospice providers and remains in the facility, or a resident in the facility receiving hospice services discontinues those services (known as revocation of hospice care) and remains in the facility.

Based on clinical record review, facility policy review, and staff interview, the facility failed to ensure 2 of 4 residents reviewed for activities of daily living received adequate bathing assistance (Resident #11 and Resident #27). The facility reported a census of 47 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool, dated 3/17/26, listed diagnoses for Resident #11 which included hemiplegia (one-sided paralysis), stroke (a condition in which blood flow to part of the brain was interrupted), and bipolar disorder (a chronic mental health condition characterized by severe mood swings). The MDS stated the resident required substantial/maximal assistance with bathing and listed her Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. On 5/4/26 at 10:55 a.m., Resident #11 stated staff did not assist her regularly with showers. She stated a week had elapsed between showers and this made her feel dirty and stinkin'. She stated staff was stretched too thin to complete the showers. On 5/5/26, the Director of Nursing (DON) provided the completed paper shower sheets which documented resident showers. She stated she had no additional sheets. Review of the Paper Shower/Skin Check Sheets for the period of 4/1/26 to 4/30/26, combined with review of the electronic health record April 2026 Documentation Survey report revealed Resident#11 had baths on the following dates for the month: 4/3/26, 4/8/26, 4/11/26, 4/12/26, 4/13/26 and 4/29/26. The sheets indicated the resident declined a shower on 4/7/26.The facility lacked documentation of additional baths given during the month of April 2026 and lacked documentation staff re-approached the resident later when she declined a bath.Care Plan entries, dated 2/28/25, stated the resident required the assistance of 1 staff for bathing and directed staff to encourage bathing twice per week. 2. The MDS assessment tool, dated 4/7/26, listed diagnoses for Resident #27 which included heart failure, diabetes, and seizures. The MDS stated the resident required partial to moderate assistance with bathing and listed her BIMS score as 13 out of 15, indicating intact cognition. On 5/4/26 at 10:33 a.m., Resident #27 stated that two weeks elapsed between showers. She stated this was normal around here. She stated Staff L Certified Nursing Assistant (CNA)told her that she would not be able to have a shower today because there were only two aides. The resident stated this made her feel dirty. Review of Paper Shower/Skin Check Sheets for the period of 4/1/26 to 4/30/26, combined with review of the electronic health record April 2026 Survey Report revealed Resident #27 had baths the following days: 4/3/26, 4/10/26, 4/11/26, 4/12/26, 4/13/26, 4/17/26, 4/24/26, and 4/28/26. The facility lacked documentation of additional baths given during the month of April 2026 and lacked documentation staff re-approached the resident later when she declined a bath.Care Plan entries, revised 5/8/25, stated the resident required the assistance of 1 staff for bathing and directed staff to encourage bathing twice per week.On 5/7/26 at 10:35 a.m., Staff C, CNA stated baths were not completed due to staffing issues. She stated on 5/4/26, baths did not get done because she was the shower aide and had to work on the floor. She stated baths were missed before. She stated both Residents #11 and #27 will take a shower if you asked them to.On 5/7/26 at 10:49 a.m., Staff N, Certified Medication Assistant (CMA) stated staffing was terrible and affected care because staff could not get showers done or answer call lights in a timely manner. On 6/7/26 at 10:55 a.m., Staff O, CNA stated residents missed baths because of staffing. She stated staff took care of other residents so could not complete baths.On 5/7/26 at 11:09 a.m., Staff L, CNA stated that staffing was rough and residents missed showers due to this. She stated both Residents #11 and #27 had told her they had to go days without a shower. On 5/7/26 at 11:36 a.m., the Director of Nursing (DON) stated if a resident missed baths, they received it on another day.The facility policy Resident Showers, dated 2024, stated it was the practice of the facility to assist a resident with bathing to maintain proper hygiene, stimulate circulation, and prevent skin issues. The policy stated staff would provide showers per request or per facility schedule.

Based on clinical record review, policy review, and staff interview, the facility failed to provide a restorative program in order to maintain mobility for 1 of 3 residents reviewed for restorative services (Resident #11). The facility reported a census of 47 residents.Findings included:1. The Minimum Data Set (MDS) assessment tool, dated 3/17/26, listed diagnoses for Resident #11 which included hemiplegia(one-sided paralysis), stroke (a condition in which blood flow to part of the brain was interrupted), and bipolar disorder (a chronic mental health condition characterized by severe mood swings). The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. On 5/4/26 at 1:44 p.m., Resident #11 stated she had a decline every time she finished with therapy services. She stated she walked with Physical Therapy (PT) but after she finished, staff did not walk with her. She could not recall when she walked last.Care Plan entries, revised 6/20/25, stated the resident had a self-care deficit and required assistance with walking. A Care Plan entry, revised 9/17/25, stated the resident required the assistance of 1 staff for walking. The Care Plan directed staff to utilize an upright walker, ankle-foot orthosis (AFO, a splint used to assist in walking), and a strap for the left lower arm for walking up to 50 feet. A PT Discharge summary, dated [DATE], stated at discharge(3/13/26), the resident walked 75 feet with contact guard assist(CGA-a level of assistance in which staff provided constant, light hand contact for safety). The summary stated a functional maintenance program was not indicated at this time. The resident's clinical record lacked documentation staff walked with her from her PT discharge date of 3/13/26 to current(5/7/26). On 5/6/26 at 11:12 a.m., Staff K Physical Therapy Assistant (PTA) stated Resident #11 walked 80 feet in February 2026. She stated the therapists should have made restorative program recommendations. She stated they did not do so because the facility did not have staff to carry out a restorative program. She stated the facility started a new restorative program last week.On 5/7/26 at 10:35 a.m., Staff C Certified Nursing Assistant (CNA) stated the facility started a restorative program 2 weeks ago but there was not one prior to this. She stated she did not walk with Resident #11 and only saw therapy do this. She stated she did not receive direction to walk with her. On 5/7/26 at 11:36 a.m., the Director of Nursing (DON) stated the restorative program at the facility was new and she did not know why there was not one prior. She stated she would expect a restorative program in place at all times. The facility policy Restorative Nursing Programs, dated 2025, stated the facility would provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.

Based on clinical record review, policy review, and staff interviews, the facility failed to assess a dialysis (a treatment which filters waste and fluid from the blood when the kidneys failed) access site (a surgically created location allowing blood removal and return for cleansing) on non-dialysis days for 1 of 1 residents reviewed for dialysis care (Resident #8). The facility reported a census of 47 residents.Findings include:The Minimum Data Set (MDS) assessment tool, dated 4/23/26, listed diagnoses for Resident #8 which included end stage renal (kidney) disease, blindness, and abnormalities of breathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 1/25/25 Care Plan entry directed staff to complete a dialysis flow sheet daily to observe for access site complications.The April and May 2026 Medication Administration Records (MARs) directed staff to assess the resident's dialysis access site on Mondays, Wednesdays, and Fridays(dialysis days) to check for signs and symptoms of infection or bleeding. The MARs directed staff to remove the site pressure dressing on Tuesdays, Thursdays, and Saturdays. During the time frame of 4/1/26 to 5/4/26, the MAR lacked documentation staff assessed the arm every Sunday including 4/5/26, 4/12/26, 4/19/26, 4/26/26, and 5/3/26.The facility policy Hemodialysis, dated 2025, stated the facility would carry out ongoing assessment and oversight of the resident before, during, and after dialysis. The nurse would check the dialysis access site every shift.On 5/5/26 at 1:40 p.m., the Assistant Director of Nursing (ADON) stated she could not locate documentation of site assessments on non-dialysis days. On 5/5/26 at 1:50 p.m., Staff F Registered Nurse (RN) stated staff checked the access site before and after dialysis treatments but did not assess the site on non-dialysis days. 5/7/26 at 11:00 a.m., Staff A Licensed Practical Nurse (LPN) stated they completed a site assessment on dialysis days but did not complete this on non-dialysis days. She agreed if assessments were not completed, there would not be a way to determine if complications occurred. On 5/7/26 at 11:36 a.m., the Director of Nursing (DON) stated staff should assess the access site on non-dialysis days.

Based on personnel file review, policy review, and staff interview, the facility failed to verify Certified Medication Assistant (CMA) certification validity prior to hire for 1 of 1 newly hired CMAs. The facility reported a census of 47 residents. Findings included:1. The facility undated New Hire List and Roster listed a hire date for Staff J CMA as 8/14/25.The facility lacked documentation of verification of Staff J's CMA certification. The facility policy License Verification, revised 2025, stated the facility would verify all personnel certifications.On 5/7/26 at 11:36 a.m., the Director of Nursing(DON) stated CNA verification and criminal background checks should be done before hire.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure the functioning of a wanderer alert device worn by a resident with a known history of leaving the building, in order to prevent an elopement for 1 of 3 residents reviewed for elopement (Resident #3). Resident #3's wanderer alert device was not in functioning order allowing Resident #3 to exit the facility on [DATE] and staff only became aware of the elopement when another resident observed Resident #3 walking down a highly traveled street in front of the facility. The facility also failed to check the wanderer alert device on a regular basis to know the resident's wanderer alert device was not in working order due to the fact the device was expired. Staff who were interviewed stated they had minimal training as to what to check regarding wanderer alert devices and were checking for placement but not function. This failure resulted an Immediate Jeopardy (IJ) to the safety of a resident who resided at the facility. The facility reported a census of 53 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated [DATE], listed the Resident #3's Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition. The MDS dated [DATE], listed diagnoses for Resident #3 which included non-Alzheimer's dementia, difficulty walking, and muscle weakness. The MDS documented the resident was independent with transfers and walking. The MDS section on cognitive patterns was blank and lacked documentation regarding the resident's cognitive status. The MDS dated [DATE], lacked documentation staff completed the assessment. A [DATE] Progress Note stated the resident eloped from the building around 8:00 a.m. and a Certified Nursing Assistant (CNA) heard the alarm sounding and found the resident walking up the driveway. A [DATE] Progress Note stated the facility received an order for a WanderGuard (an electronic wanderer alert device). The resident's Elopement Risk, dated [DATE], stated the resident was at high risk for elopement. [DATE] Care Plan entries directed staff to check the placement and function of the WanderGuard each shift and stated if the resident was actively exit seeking staff should redirect his attention or walk with him outside. A [DATE] Progress Note stated the resident exited the facility and a nurse and CNA saw him and ran and caught him. A [DATE] Progress Note stated the resident had increased wandering in the halls and into other resident rooms and stated staff redirected him multiple times. The [DATE] Treatment Administration Record (TAR) directed staff to check the placement and function of the WanderGuard every shift. The TAR included Staff A's, Licensed Practical Nurse (LPN) initials documented for 3 shifts and Staff C's, LPN initials documented for 12 shifts. The TAR lacked staff initials to indicate the completion of the checks for 13 shifts. A [DATE] Progress Note stated another resident notified the facility by phone that Resident #3 was walking up the street. The Note stated staff immediately went up the street in a car and saw the resident approximately 5 blocks to the left of the facility walking on the sidewalk. The staff members drove him back to the facility. A [DATE] Care Plan entry stated the resident required 1:1 supervision. An [DATE] Progress Note stated the resident remained on 1:1 supervision. An [DATE] Progress Note stated the resident remained 1:1 for supervision. An [DATE] 12:43 p.m. Progress Note stated the facility applied a new WanderGuard to the resident and it was activated and tested prior to placement. An [DATE] 12:47 p.m. Progress Note stated the resident's WanderGuard worked properly and 1:1 supervision was discontinued. During an observation on [DATE] at 4:00 p.m., Staff F, Licensed Practical Nurse (LPN) checked Resident #3's WanderGuard bracelet with the WanderGuard Universal Tester and the tester flashed green. The undated WanderGuard Universal Tester Operating Instructions, utilized as education by the facility, stated it was important to test WanderGuard bracelets before putting into use and daily thereafter. The instructions stated failure to do so could result in injury or death and instructed staff to hold the tester within one foot of the bracelet. The instructions stated if the bracelet was operational, the LED would flash green four times. The facility policy Elopement dated [DATE], stated the facility would evaluate residents for the risk of elopement and Care Plan appropriately. During an interview on [DATE] at 12:49 p.m., the Maintenance Supervisor stated when Resident #3 eloped the WanderGuard system on the door was working but the resident's bracelet was not due to being outdated. He stated there were 3 residents who had the bracelets and they were all outdated and stated after the elopement the facility ordered new bracelets but could not get them right away due to the facility having an outstanding bill with the WanderGuard company. He stated he checked the doors daily but the Nursing Staff checked the WanderGuard bracelets. During a phone interview on [DATE] 1:13 p.m., Staff A, LPN stated there were 3 residents who had a WanderGuard bracelet. She stated the orders directed staff to check the placement of the bracelets. She stated she did not look that closely at the WanderGuard and she just made sure it was on. Staff A reported she knew there was a remote to check the function but she was not walked through that process. She explained after Resident #3 eloped, corporate made a procedure of what to if anyone eloped but stated she was not sure if there were any instructions on how to use the remote to check function. Staff A stated on the day Resident #3 eloped she had just started her shift. She stated someone notified the nurse that someone saw the resident out on [street name in front of the facility] past the 4 way stop. She stated she got in the car with Staff D, former Interim Director of Nursing (DON) and Staff B, CMA (Certified Medication Aide) and the staff members picked up the resident. During an interview on [DATE] at 1:31 p.m., Staff B, stated the facility had a device to check the WanderGuard bracelets to see if they were working. She stated staff was supposed to check this every day but she had not seen it done. She stated she was working the day that Resident #3 eloped. She stated when Resident #12 returned back to the facility after an outing, stated he saw Resident #3 walking down the street. Staff B stated, she, along with Staff D and Staff A got into Staff A's car and drove down [name of street in front of the facility] and picked the resident up in the car. She stated she thought the resident got out the front door but she did not hear it alarm. She stated when they brought the resident back to the facility his WanderGuard bracelet did not work. During an interview on [DATE] at 2:21 p.m., Resident #12 stated on the day Resident #3 eloped he was on a bus coming back to the facility. He stated he was about a mile away and saw Resident #3 on [street name]. He stated the resident looked disheveled and had no shoes on. Resident #12 stated he was not exactly sure where the resident was but it was not within walking distance. He stated he reported it to facility staff when he returned to the facility and stated staff started to leave and look for the resident on foot but he informed them they needed a car because it was not in walking distance. During a phone interview on [DATE] at 10:17 a.m., Staff C, LPN stated she was not sure who checked the WanderGuard bracelets. She reported she did not have to do this and did not know how staff checked the bracelets for functionality. During a phone interview on [DATE] at 11:26 a.m., Staff E, former DON stated at some point between May and October of 2022, the facility ran out of WanderGuards and stated the company would not send them new ones because of outstanding bills. During a phone interview on [DATE] at 12:55 p.m., Staff D, former Interim DON stated on the day of the resident's elopement after they returned to the facility with the resident, his WanderGuard was not functioning and she did not know why. During an interview on [DATE] at 12:19 p.m., the Director of Nursing(DON) stated she reeducated staff regarding the WanderGuards and answering the door alarm in a timely manner. The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 11:30 a.m. The facility removed the Immediate Jeopardy on [DATE] through the following actions: 1. Resident #3 was assessed by Director of Nursing (DON)/Designee upon return to the facility on [DATE] with no injuries noted and placed on one-on-one supervision. 2. A resident head count was completed by DON/Designee on [DATE] and all residents were accounted for. The DON or designee completed an audit on [DATE] of door alarms and residents with wander guard devices to ensure alarms and devices are functioning properly. Residents at risk for elopement received new wander guard devices on [DATE]. 3. Staff received re-education on or before [DATE] by DON/Designee on missing Resident protocol. Licensed Nurses and Certified Medication Aides (CMA's) will be educated on how to check function and placement on wander guard devices beginning [DATE]. Any staff that have not receive this education by [DATE] will receive this education prior to the beginning of their next shift. 4. DON/Designee will complete audits weekly for 4 weeks and then monthly for 2 weeks to ensure staff continue to check the function and placement of wander devices as required and continue to follow the missing resident protocol. Results of these audits will be presented to the Quality Assurance and Performance Improvement (QAPI) meeting monthly for 3 months for review and recommendations as needed. The DON is responsible for monitoring and follow up as needed. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures.

Based on record review, observations and interviews the facility failed to ensure residents received appropriate treatment and care in healing and preventing infection of pressure sores. Resident #1, #13, #8, and #35. The facility reported a census of 64. 1. The Admission Record dated 7/10/18 revealed Resident #1 had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairments. The MDS revealed Resident #1 required extensive assistance of two staff with bed mobility, transfers and bathing. The MDS revealed Resident #1 had one Stage I Pressure Ulcer and one unstageable Pressure Ulcer. The Braden Scale dated 5/24/17 revealed Resident #1 scored 13. The scored placed the resident at moderate risk. The Plan of Care revealed Resident #1 had an ulcer on the left medial heel on admit. The Plan of Care directed the staff to off-load Resident #1's heels when in bed, mechanical lift for transfers, inspect skin daily, keep skin clean, apply moisturizing lotion, provide incontinence care as needed, can leave the premises without supervision, provide supervision with smoking. The Progress Note dated 4/24/18 revealed Resident #1 had a shallow open area to the right buttock caused by moisture and shearing. The area measured 4.0 centimeters (cm) (length) by 2.0 cm (width) by 0.1 cm (depth). The center dark pink/red and open. The wound nurse will evaluate today and suggest treatment. Currently on Ensure, alternating air low air loss mattress, pressure reducing chair cushion, frequent turns and incontinence care including application of barrier cream. Will discuss with doctor after wound nurse makes recommendation. The Skin Grid for All Other Skin Impairments dated 4/24/18 revealed Resident #1 had a moisture shear area to the right buttock. The sheet revealed the area not present on admission, pink and red in color and had granulation present. The sheet directed the staff to complete weekly. The sheet contained no weekly assessments after 4/24/18. The Treatment Administration Record sheet from 1/4/18 at 4/30/18 revealed an order dated 4/25/18 to cleanse the right buttock with normal saline, dry, apply collagen and cover a dressing one time a day. The Treatment Record sheet revealed an order dated 4/27/18 to increase the treatment to twice a day. The sheet revealed omissions in the treatment on 4/27, 4/28, 4/2 and 4/3. The Treatment Administration Record sheet from 5/1/18 to 5/31/18 revealed omissions in the treatment on 5/1, 5/4, 5/7, 5/10, 5/13, 5/14, 5/17, 5/19, 5/20, 5/22, 5/23, 5/25, 5/26, 5/28, 5/29, 5/30. The Initial Wound Clinic Progress Note dated 5/18/18 revealed Resident #1 had an unstageable Pressure Ulcer to the right gluteus that measured 4.1 cm (length) by 3.5 cm (width) by 1.2 cm (depth). The note revealed the pressure ulcer had a large amount of drainage with a relatively strong odor. The entire wound bed is covered with necrotic tissue, adherent slough and eschar. Resident #1 had an excisional debridement of the wound. The Treatment Administration Record dated 6/1/18 to 6/30/18 revealed the omissions in the treatment on 6/1, 6/3, 6/5, 6/6, 6/7, 6/8, 6/9, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17 and 6/18. The Wound Clinic Progress Note dated 6/19/18 revealed Resident #1's Stage IV Pressure Ulcer measured 6.0 cm (length) by 6.0 cm (width) by 3.0 (depth). The sheet revealed the staff able to probe down in at least two different areas. The wound had a large amount of serous sanguineous drainage with a strong odor and wound bed covered with necrotic tissue. The Wound Clinic Staff consulted the Hospitalist who admitted Resident #1 to the hospital for further work up. The Nursing assessment dated [DATE] revealed an Admission Skin Sweep with no documented skin concerns. The Progress Notes dated 6/27/18 at 11:44 p.m. revealed Resident #1 returned to the facility with a wound vac. Review of the Progress Notes from 4/24/18 to 6/19/18 revealed Resident #1 refused his/her treatment on 5/15/18. An interview on 7/12/18 at 8:48 a.m. Staff G reported Resident #1's pressure ulcer started as a scratch. Staff G reported he/she is aware of the omissions on the treatment records. An interview on 7/18/18 at 2:50 p.m. Staff J (Charge Nurse) reported the nurses work 8 hour shifts. Staff J reported at times the nurse cannot get all of the treatments completed and pass them on to the next shift. Staff J reported at times he/she can stay late to get the treatments completed. Staff J reported Resident #1 goes out to of the facility at times and refuses to lay down. An interview on 7/13/18 at 1:20 p.m. Wound Clinic Clinical Manager reported Resident #1 does not staff comply with staying off his/her pressure area and is not a candidate for a skin flap. 2. The Admission Record dated 7/19/18 revealed Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 cognitively intact. The MDS dated [DATE] revealed Resident #13 required extensive assistance of one staff with bed mobility, dressing and hygiene. The MDS dated [DATE] revealed Resident #13 had no pressure ulcers. The Plan of Care revealed no skin impairments. The Braden Scale dated The Progress Notes dated 4/10/18 revealed Resident #13 continued with an open area to the left heel. The note revealed the open area circular and moist with a loose flap of skin attached to the lower part of the wound. Gauze applied to wound and Resident #13 complained of pain to the area. Soft boot placed on left foot and [MEDICATION NAME] administered. The Progress Note dated 4/25/18 revealed the left heel wound measured 3.5 cm by 4.0 cm by undetermined. The physician wrote an order to cleanse the wound with normal saline, apply skin prep around the wound, apply calcium alginate AG to wound bed and cover with semiperiable dressing. The Nursing Admission Data Collection sheet dated 5/8/18 revealed Resident #13 had a Stage I pressure area to the left heel that measured 4.2 cm (length) by 3.4 cm (width). The Skin Grid for All Other Skin Impairments sheet dated 5/22/18 revealed an area on the left heel not present on admission. The area measured 3.0 cm (length) by 2.0 cm (width) by 0.3 cm (depth). The sheet revealed assessments dated 6/5/18, 6/12/18, 6/21/18, 6/25/18, 7/2/18, 7/6/18 and 7/8/16. The (MONTH) (YEAR) Treatment Administration Record revealed an order dated 4/25/18. The order directed the staff to cleanse the left heel with normal saline, dry, apply skin prep around the wound, apply calcium alginate AG to the wound and cover. The (MONTH) (YEAR) Treatment Administration Record revealed the order changed on 5/8/18. The order directed the staff to apply [MEDICATION NAME] cream to the left heel and cover. The Treatment Record revealed omissions in the treatment on 5/7, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18, 5/19, 5/20, 5/22, and 5/23. The (MONTH) (YEAR) Treatment Administration Record revealed the order changed on 6/15/18. The order directed the staff to cleanse the left calcaneus with normal saline, apply skin prep, apply [MEDICATION NAME] Wound/Burn dressing pad to wound and change every three days. The Treatment Record revealed omissions in the treatment on 6/1, 6/6, 6/7, 6/9, 6/11, 6/12, 6/13 and 6/14. The Wound Clinic note dated 6/26/18 revealed Resident #13 had an unstageable pressure ulcer to the left heel. The area measured 3.5 centimeters (cm) (length) by 2.8 cm (width) by 0.1 cm (depth). Observation on 7/20/18 at 2:10 p.m. revealed Staff G removed the dressing to Resident #13's left heel. The dressing had a moderate amount of serous drainage. Staff G measured the wound. The wound measured 4.2 cm (length) by 4.7 cm (width) by 0.2 cm depth. Staff G cleansed the wound and applied [MEDICATION NAME] AG foam and secured with gauze. An interview on 7/20/18 at 9:34 a.m. Staff L reported he/she noted the first nursing assessment for Resident #13's heel on 5/8/18. Staff L reported treatments started on 4/25/18. Staff L reported concerns with weekly assessments not being completed and documentation of treatments being completed. Staff L reported Resident #13's pressure ulcer was not identified on list of pressure ulcers and that was updated. The Skin Care & Wound Management policy dated 6/2015 revealed the components of the skin care program include, but are not limited to, the following: identification of residents at risk for developing pressure ulcers, implementation of prevention strategies to minimize the potential for developing pressure ulcers and skin integrity issues, weekly monitoring of resident skin status, daily monitoring of existing wounds, application of treatment protocols based on clinical best-practice standards for promotion of wound healing, interdisciplinary review of identified skin impairments, monitoring for consistent implementation of interventions and effectiveness of interventions, review of modification of treatment plans as applicable and analysis of facility pressure ulcer data for quality improvement opportunities. 3. According to the Minimum Data Set, dated dated dated (MONTH) 30, (YEAR) Resident #8 had [DIAGNOSES REDACTED]. The resident required supervision of 1 person for transfers, walking and limited assistance for toilet use and extensive assistance for dressing and eating. The resident had a BIMS (Brief Interview for Mental Status) of 10 which indicated moderate cognitive ability. The assessment revealed the resident did not have pressure sores but had skin tears. Review of the care plan revised on 7/5/18 the staff failed to formulate a specific care plan for the prevention and care of the resident's pressure sore. The facility staff failed to update the residents care plan after the discovery of an open area on 712/18. Review of the care plan dated 7/18/18 indicated the resident had actual skin impairments related to fragile skin and impaired mobility with an acquired area on the left buttock. The plan directed the staff to monitor/document location and size, pressure relief mattress on bed and padding to chairs complete treatments of the left buttock as ordered and use caution during transfers and bed mobility. Review of a Skin Grid for Other Skin impairments dated 7/12/18 Staff G-RN record Resident #8 had an abrasion to the left buttock measuring 4 centimeters by 4 centimeter and appeared superficial. Review of the Skin Grid for Other Skin impairments dated 7/18/18, Staff G-RN recorded Resident #8 had a pressure sore to their left buttocks which measured 2.2 x 3 centimeters and with a depth of 0.3 centimeters. During the assessment of the left buttock wound on 7/18/18 at 2:00 p.m. an additional area noted directly below the original pressure sore which measured 0.5 x 0.5 centimeters and described as superficial. Staff G indicated the original pressure sore which started as an abrasion is now progressed to a pressure sore and she did not know the resident had an additional open area on the left buttock. Review of the Progress Notes dated 7/18/18 at 10:50 p.m. Staff H-RN noted the resident had a Stage 11 pressure ulcer to the left inner buttocks which measured 2.0 x 1.0 x depth of 0.1 centimeters and the current [MEDICATION NAME] treatment is unchanged. Review of Resident #8 (MONTH) (YEAR) Treatment Record the resident had an order for [REDACTED]. Observation on 7/18/18 at 7:05 a.m. with Staff C-LPN she stated the resident refused the treatment earlier today and told her to get out. At this time she reattempts to complete the dressing, the resident at this time was compliant with the dressing change. Staff C had the resident roll to their right side, the area on the left buttock did not have a dressing in place and noted to have white exudates on and surrounding the wound. The resident is noted to have on 2 incontinence briefs. The staff completed the dressing change and provided incontinence cares. During this process of wound care and provision of cares Resident #8 was complaint and cooperative with staff assistance. Review of the Progress Notes from (MONTH) 13-July 18, (YEAR) revealed the resident refused his treatment on (MONTH) 14 at 10:20 a.m. but no further refusals noted in the notes. During an interview with Staff I- CNA on 7/17/18 at 8:43 a.m. the staff indicated they didn't know the resident had wounds but thought he had an reddened area on his buttock they apply cream to and stated she didn't think he had any dressings to buttocks area. During an interview with Staff G-RN on 7/18/18 at 7:05 a.m. Staff G stated she assessed the buttock wounds yesterday and they are considered pressure areas. She discovered a new area directly below the original pressure sore and stated she didn't know it was there. Staff G stated the wound to buttocks is worse than last week when she measured it. During an interview with Staff F-RN on 7/19/18 at 10:35 a.m. Staff F stated the second open area discovered yesterday is described as a pressure sore. 4. The Quarterly Minimum Data Set (MDS) Resident assessment dated [DATE] documented that Resident#35 had scored a 14 out of 15 on the Brief Interview for Mental Status questions. The MDS documented that the resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS documented that the resident had been frequently incontinent of bowel and bladder. The MDS documented that the resident had [DIAGNOSES REDACTED]. The MDS documented that the resident had unhealed pressure areas, and that included three unstageable areas due to non-removable dressings. The Braden Scale (Skin Risk Assessment) dated 6/7/18 documented that the resident had been chairfast, slightly limited with mobility, occasionally moist skin, and had potential problems for friction and shear. A Skin Grid for Pressure Ulcers documented that a right posterior thigh skin concern had the identification date of 2/22/18. The clinical record lacked an assessment until the date 5/29/18. A Skin Grid for Pressure Ulcer documented that the tip of the right third toe skin concern had the identification date of 4/12/18. The clinical record lacked an assessment until the date of 5/22/18. A Skin Grid for Pressure Ulcer documented that the right foot arch skin concern had the identification date of 4/12/18. The clinical record lacked an assessment until the date of 5/22/18. A Skin Grid for Pressure Ulcer documented that the right fourth toe tip skin concern had the identification date of 4/12/18. The clinical record lacked an assessment until the date 5/22/18. A Skin Grid for Pressure Ulcer documented that the right posterior heel skin concern had the identification date of 4/12/18. The clinical record lacked an assessment until the date of 5/22/18. The Nurses Note Dated 4/12/2018 at 1:21 p.m. documented that a wound nurse entered the residents room to assess skin areas, measurements completed and weekly assessments for each area initiated. The residents doctor had been notified and treatment orders received. Areas were documented as follows: right 5th toe- dark purple scare (eschar) measured 0.3x0.4 centimeters (cm) with no depth, right great toe-under tip dark purple eschar measured 1x1cm with no depth, right 2nd toe tip measured 1x1.5cm with no depth purple intact blister-fluid filled, right post heel brown eschar 1.2x1.2cm 0 depth, right great toe and knuckle measured 0.7x0.5cm with no depth dark brown eschar, right 4th toe tip dark purple escahr measured 1x1cm with no depth, right 3rd toe tip stage 3 measured 1.5x1.3cm with 0.1cm depth- wound bed left pink tissue with 0.3x0.6cm yellow slough to center and flap of skin attached to inferior aspect of wound coming up over about 0.2cm of open area- edges defined and attached no visible drainage, to plantar surface of right foot in center of the arch- upon initial observed area is 7.5x5cm dark brown/purple with 0 depth with a flap of dead calloused skin in the center measured 5x1.7cm; the flap and remainder of skin uniform in color and tissue type, able to remove flap by gently pulling. Flap of dead tissue separated from foot fairly easily leaving intact lighter colored skin roughly 5x1.7cm. Remainder of thick dry brown/purple tissue attached to foot at this time. No complaints of pain when the tissue had been removed. This area non-pressure. All remaining areas are skin deep tissue injury except the area to 3rd toe which is a stage 3 pressure area. Treatment orders as follows: To all areas on toes except 3rd toe stage 3, apply skin prep twice a day, to area on 3rd toe apply [MEDICATION NAME] and cover daily, and to area on right plantar surface- apply hydrogel and cover daily with gauze. Nurses Notes reviewed from 4/12/18 to 7/24/18 lacked documentation of complete assessment of the residents pressure areas, and other skin concerns that had been documented on for the date 4/12/18. The Treatment Administration Record (TAR) dated 4/1/18 to 4/30/18 directed the staff with a physicians order start date of 4/12/18 as follows: apply Skin Prep Wipes topically to the pressure ulcers on the right great toe, second toe, fourth toe, fifth toe, and the posterior right heel twice a day. The TAR lacked documentation that these treatments had been completed twice a day for the following dates; 4/18/18, and 4/21/1. The TAR also directed the staff with a physicians order start date of 11/30/17 as follows; apply [MEDICATION NAME] cream to both lower legs twice a day. The TAR lacked documentation that these treatments had been completed twice a day for the following dates; 4/9/18, 4/17/18, 4/18/18, 4/19/18, and 4/29/18. The TAR directed staff with a physicians order start date of 4/13/18 as follows; Apply [MEDICATION NAME] to the right foot and wrap with gauze daily for wound management. The TAR lacked documentation that this treatment had been completed on 4/24/18. The TAR directed staff with a physicians order start date of 11/08/17 as follows; Waffle cushion to chair at all times every shift for off load pressure. The TAR lacked documentation of this intervention being completed every shift on the following dates; 4/9/18, 4/17/18, 4/18/18 and 4/29/18. The TAR dated 5/1/18 to 5/31/18 directed staff with a physicians order start date of 11/08/17 ; Waffle cushion to chair at all times every shift for off load pressure. The TAR lacked documentation of this intervention being completed every shift on the following dates; 5/3/18, 5/7/18, 5/8/18, 5/11/18, 5/13/18, 5/16/18, 5/17/18, 5/20/18, 5/22/18, 5/25/18, 5/26/18, 5/27/18, and 5/28/18. The TAR directed the staff with a physicians order start date of 4/12/18 as follows: apply Skin Prep Wipes topically to the pressure ulcers on the right great toe, second toe, fourth toe, fifth toe, and the posterior right heel twice a day. The TAR lacked documentation that these treatments had been completed twice a day for the following dates; 5/3/18, 5/8/18, 5/11/18, 5/12/18, and 5/17/18. The TAR directed the staff with a physicians order start date of 11/30/17 as follows; apply [MEDICATION NAME] cream to both lower legs twice a day. The TAR lacked documentation that these treatments had been completed twice a day for the following dates; 5/3/18, 5/7/18, 5/8/18, 5/11/18, 5/14/18, 5/16/18, 5/17/18, 5/20/18, 5/22/18, 5/26/18, and 5/28/18. The TAR directed staff with a physicians order start date of 4/12/18 as follows; clean the right third toe pressure ulcer,apply Silver [MEDICATION NAME] Cream 1% topically and cover daily. The TAR lacked documentation that the treatment to the third toe had been completed daily on the following dates; 5/3/18, 5/11/18, and 5/16/18. The TAR directed staff with a physicians order start date of 4/13/18 as follows; apply [MEDICATION NAME] to the right foot and wrap the with gauze for wound management daily. The TAR lacked documentation that the [MEDICATION NAME] treatment had been completed on the following dates; 5/3/18, 5/10/18, 5/18/18, and 5/26/18. The TAR dated 6/1/18 to 6/30/18 lacked documentation the physicians order for the waffle cushion had been in place every shift 15 out of 90 shifts. The TAR also lacked documentation that the treatment to the residents right toes had been completed 3 out of the 60 times required. The TAR also lacked documentation that the [MEDICATION NAME] treatment had been completed 16 out of the 60 times required. The TAR lacked documentation that the Silver [MEDICATION NAME] Cream treatment to the right third toe had been completed 3 out of 30 times. The TAR lacked documentation that the [MEDICATION NAME] treatment to the right foot had been completed 2 out of the 30 times required. The TAR dated 7/1/18 to 7/23/18 lacked documentation the physicians order for the [MEDICATION NAME] treatment to the right foot had been completed 4 out of the 24 required times. The TAR lacked documentation that the Silver [MEDICATION NAME] Cream treatment had been completed to the third right toe three of the 24 required times. The TAR lacked documentation that the Skin Prep treatments had been completed 3 of the 48 times required. During an observation on 07/23/18 at 1:04 p.m. Staff Y, R.N. (Grapetree Staffing) placed dressing supplies directly on the bedside table after removing the residents lunch tray from the bedside table. She then washed her hands and put on gloves then opened [MEDICATION NAME] swabs wrapper. She then cleaned the right foot on the lateral area (side of foot) and the mid arch with the [MEDICATION NAME]. She then covered the area cleaned with the [MEDICATION NAME] with two by two inch gauze pads, and then wrapped it with a Kling dressing that had been laying directly on the bedside tab. The staff member did not complete any dressings to the residents toes. The tops of the toes appeared tan in color and dry to the right foot. During an interview on 7/23/18 Staff Y, Register Nurse reported that the treatment record reported there had been an order for [REDACTED]. During clinical record review on 7/24/18 the nurses notes lacked documentation that the nurse had contacted the physician to change or discontinue the treatment to the residents toes for the date of 7/24/18 or 7/25/18. During an observation on 7/23/18 at 1:40 p.m Staff W, Certified Nurses Aide (C.N.A) and Staff I C.N.A provided the resident with incontinence care. Staff W, C.N.A applied [MEDICATION NAME] cream to the residents mid upper posterior thigh that had a quarter sized open area with a beefy red center that had a circular shape. During an interview on 7/23/18 at 1:40 p.m. Staff W, CNA and Staff I CNA both reported that they were directed to put [MEDICATION NAME] on it. Both staff also reported that the resident had been on bed rest for treatment of [REDACTED]. Upon clinical record review there lacked documentation of an open area to the right posterior thigh. During an interview on 07/25/18 at 7:58 a.m. Staff P, Nurse Regional Consultant reported that there are several system failures at the facility. She also reported that she could not find all the documentation for the residents skin issues. A Health Status Note dated 6/25/18 from the Physician directed that the resident had been required to remain on bed rest with check and change every 1 hour until her posterior right thigh open areas were resolved. Upon Clinical record review of the nurses notes dated 6/25/18 to current the nurses notes lacked documentation that the resident refused to be repositioned. The Care Plan with initiated date of 4/14/17 documented that the resident had the potential and actual skin impairment related to fragile skin, diabetes, and obesity. The Care Plan directed staff to complete skin treatments as ordered. The Care Plan further directed the staff to identify, document location, size and treatment of [REDACTED]. On 7/19/2018, the facility abated the Immediate Jeopardy by providing education to the professional nursing staff on appropriate pressure sore assessments. The facility also assessed all resident's skin to ensure all current assessments were updated. The scope and severity of the deficiency was lowered from a K to a E with the need for ongoing monitoring of facility's took for weekly monitoring of pressure sores.

Based on clinical record review, facility policy review, physician, resident and staff interview, the facility failed to perform Cardio [MEDICAL CONDITION] resuscitation (CPR) for one of nine residents that requested full code status (Resident #269) and failed to formulate an advance directive for two residents without a code status (Resident #21 and #119). The facility census was 64 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #269 had [DIAGNOSES REDACTED]. The Care Plan dated [DATE], lacked any direction to staff for advanced directives. The Iowa Physician order [REDACTED]. The Medication Administration Record [REDACTED]. The Daily Nursing Assignment sheet dated [DATE], listed Staff Z, Licensed Practical Nurse, LPN and Staff AA, Certified Nurse Aide, CNA working the 10 PM- 6 AM shift on the Hall the resident resided. The Daily Nursing Assignment sheet dated [DATE], listed Staff FF, LPN and Staff EE, CNA working the 6 AM - 2 PM shift on the Hall the resident resided. A Progress Note dated [DATE] at 10:19 a.m., documented a CNA alerted staff at 7:15 a.m., that the resident passed away. The resident was found in bed with the call light in reach, with no apical pulse, no respirations and no blood pressure detected. The Registered Nurse verified the condition and at 7:42 a.m., staff notified the on call Physician and the guardian and called the Medical Examiner at 7:46 a.m. Staff notified the funeral home at 10:00 a.m. and the CNA prepared the resident. Progress notes lacked identification of the resident's code status, lacked a description of the body temperature, description of the body color and description of the body tone. The Record of Death dated [DATE], documented the time of death as 7:15 a.m. During interview on [DATE] at 10:22 a.m., Staff AA, CNA confirmed working the 10 PM- 6 AM shift on [DATE]. Staff AA stated doing rounds every 2 hours and doing a visual check on all residents. Staff AA reported last rounds was completed at 5:30 a.m., and no concerns or problem was reported about the resident. During interview on [DATE] at 12:41 p.m., Staff Z, LPN verified working 10 PM -6 AM on [DATE]. Staff Z stated the CNA's made the rounds and did not report anything abnormal about the resident. During interview on [DATE] at 7:07 p.m., Staff FF, LPN reported a CNA came and said the resident passed away. Staff FF revealed the resident lacked a pulse and lacked breathing. Staff FF reported getting Staff DD, Registered Nurse, RN in the building to double check the resident for a pulse and respirations. Staff FF stated the resident lacked any dependent lividity (purple/reddish skin coloring), or rigor (body stiffness). At 7:28 p.m., Staff FF reported the facility's CPR policy was if a resident was a full code then you do CPR. Staff FF continued to state letting the RN take over and that the resident was gone. Staff FF revealed not doing CPR on the resident. Staff FF reported a residents code status was found in the electronic health record and the paper record. Staff FF indicated as a newer employee letting the experienced RN take over the situation. During interview on [DATE] at 11:04 a.m., Staff EE, CNA reported coming in to work late at about 7:00 a.m., on [DATE]. Staff EE reported finding the resident deceased . Staff EE revealed running to the nurse to report the death. Staff EE stated the nurse confirmed the resident passed away and the nurse directed the CNA's to continue getting other resident up and then come back and prepare the resident for the funeral home transfer. Staff EE described the resident as pale, not stiff and with no mottling. During interview on [DATE] at 4:33 p.m., Staff DD, RN reported not doing CPR on anyone for years, and nothing stands out as memorable on [DATE] during the ,[DATE] shift. During interview on [DATE] at 2:08 p.m., Staff X, CNA reported not seeing the resident before they found the resident not breathing. Staff X stated the ,[DATE] staff reported all the residents were ok at the end of the ,[DATE] shift. Staff X reported helping clean the resident before the funeral home came. Staff X revealed the residents body was cool and limp, easy to move and the resident's skin lacked any reddish/purple skin discoloration. During interview on [DATE] at 7:10 p.m., the Medical Director reported the facility left a message at about 11:00 a.m., on [DATE] that the resident passed away. During interview on [DATE] at 8:15 a.m., Agency Staff CC, licensed practical nurse, LPN stated when a resident was found with no pulse and not breathing the first thing to do was check the resident's code status. If the resident wanted CPR, they would start CPR and have other staff call 911. During interview on [DATE] at 8:49 a.m., Staff C, LPN, Unit Manager revealed they expected staff to start CPR on the resident and call the Physician or 911. During interview on [DATE] at 8:55 a.m., Staff P, Regional Nurse Consultant stated if a resident was found with no breath or pulse staff was expected to check the code status and if they are a full code to started CPR and call 911. During interview on [DATE] at 8:52 a.m., the Administrator stated all staff was educated on [DATE], in person, or over the phone and a plan was in place to educate all new agency staff. The facility provided a policy titled Code Status Orders & Procedure dated ,[DATE], directing the facility provides Basic Life Support (BLS) CPR only. The physician's orders [REDACTED]. Advanced Directives will be honored during the code process. Page 3 directs the 1st person on the scene: 1. confirm cardiac and or respiratory arrest. 2. Call for help. 3. Check the airway and pulse and connection to oxygen if available while awaiting the emergency cart. 4. Check the medical record for the code status. 5. Begin CPR and continue CPR while the AED is being set up for shock if the AED is assessable and utilized by the facility- ensure resident is on a firm surface. The 2nd person role is to assist the 1st responder as necessary and be the coordinator of the event. The 2nd responder is directed at point #3 a. Notifies 911, 3 b. notifies the family and the Physician. 2. The Admission Record Sheet dated [DATE], documented Resident #119 had [DIAGNOSES REDACTED]. The care plan dated [DATE], revealed the resident was a new admit to the facility and was alert and oriented to person, place and time and had some recall difficulty. The goal for the resident was to make his own choices as able. Nursing staff was directed to assist the resident as needed with decision making if the resident was unsure of what to do or asking for guidance. Offer the resident choices; allow him time to make his own decisions and respect his choices. Further review of the care plan revealed no documentation to indicate staff discussed with the resident the choice to have CPR done or not if found unresponsive. The Order Listing Report form contained orders for the resident to have activities as tolerated and admit to skilled nursing facility (SNF) level of care, medications to take and to continue orders for 90 days unless otherwise noted dated [DATE]. No orders noted in regards to code status for the resident. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Social/Psychological Data Collection Tool dated [DATE], revealed an Advanced Directives section. The directions for the section was to check yes if completed and present in the medical record and reviewed with the resident/responsible party. All the areas under that section was marked no. During an interview on [DATE] at 3:35 p.m., Staff R, Certified Nurse Aide (CNA) reported worked at the facility about one year. Staff R stated would look in the CNA electronic charting for the information to know if a resident is DNR or Full Code (CPR) status. Staff R stated she had not been educated on what to do if neither is documented for a resident and not sure what is to be done. Staff R reported to be CPR certified, but that not all CNA's are, more the Nurses are trained. During interview on [DATE] at 4:01 p.m., the Social Services Director (SSD) reported they usually try to do an IPOST on admission for new residents and the admitting Nurse will also do a CPR/DNR Form when a resident is admitted . The SSD stated she was gone at the time of the resident's admit, but the Admitting Nurse would have been here to ask about CPR/DNR code status. The SSD indicated with no indication of code status for the resident, staff would treat the resident as a full code. The SSD further stated with no paperwork in the electronic file or on file in the resident's chart, it appears the CPR/DNR Form was not completed. During interview on [DATE] at 3:53 p.m., the resident reported being asked at the local hospital about being a DNR or CPR code status. The resident stated they were not asked since coming to the facility. The resident stated he would want staff to try and resuscitate him if found unresponsive. 3. The MDS assessment dated [DATE], documented Resident #21 had [DIAGNOSES REDACTED]. The Social/Psychological Data Collection Tool dated [DATE], revealed the source of information came from other. The form noted to have an Advanced Directives section. The directions for the section was to check yes if completed and present in the medical record and reviewed with the resident/responsible party. The areas marked no were Health Care Surrogate, Living Will and IPOST which was completed to notify staff if a person is a CPR or DNR status. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Order listing Report dated [DATE]- [DATE], did not list an order for [REDACTED].>On [DATE], the facility abated the Immediate Jeopardy by providing education to the professional nursing staff on appropriate resusitation policy. The scope and severity of the deficiency was lowered from a J to a D with the need for ongoing monitoring of facility's policy.

Based on record review, observations and interviews the facility failed to ensure residents received accurate assessments and timely interventions. Resident #4, #6, #10, #12 and #19. The facility reported a census of 64. Findings include: 1. According to the Admission Record dated 7/10/18 Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 at risk for skin break down. The MDS revealed Resident #4 had no wounds, ulcers or skin problems. The MDS revealed Resident #4 at risk for pressure ulcer development. The Braden Scale dated 3/14/18 revealed Resident #4 low risk for skin break down. The Plan of Care failed to reflect Resident #4 had skin impairments. The Nursing Admission Data Collection dated 3/14/18 revealed the Admission Skin Sweep revealed no skin impairments present. The Skin Grid for All Other Skin Impairments sheet dated 3/14/18 revealed Resident #4 had an excoriation above the rectum on admission. The sheet directed the staff to complete weekly assessments. The sheet revealed one assessment dated [DATE]. The sheet revealed the area healed. The Skin Grid for All Other Skin Impairments sheet dated 3/14/18 revealed Resident #4 had a bleb with an open area. The sheet revealed one assessment dated [DATE]. The sheet revealed the area healed. The Progress Notes dated 5/4/18 at 10:40 revealed a nurse aide reported Resident #4 had an open area on his/her buttocks and two areas of excoriation. One area Stage III. The wound started bleeding and pressure applied. Resident #4 transferred to the emergency room . The (MONTH) (YEAR) (MONTH) Treatment Administration Record sheet revealed an order dated 5/9/18 to apply [MEDICATION NAME] AG to sacrum wound every other day. The sheet revealed omissions in the treatment on 5/9, 5/17 and 5/21. 2. The Admission Record dated 7/24/18 revealed Resident #6 had [DIAGNOSES REDACTED]. The Plan of Care directed the staff to encourage resident to report changes in his/her skin, observe skin during cares for signs of breakdown and weekly skin sweeps. Observation on 7/10/18 at 2:15 p.m. revealed Resident #6 had a dressing on the left forearm dated 7/7. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The staff documented the treatment competed on 7/6 and 7/9. An interview on 7/11/18 at 9:20 a.m. the Assistant Director of Nurses (ADON) reported he/she observed Resident #4's dressing yesterday and noted it was dated 7/7. The ADON reported the treatment was signed out as completed but it doesn't look like it was changed as it was dated 7/7. An interview on 7/11/18 at 1:32 p.m. Resident #6 reported the staff changed his/her dressing this morning and prior to that it was four days ago. 3. The Admission Record dated 5/14/18 revealed Resident #10 had [DIAGNOSES REDACTED]. The Progress Note dated 3/29/18 at 10:14 p.m. revealed Resident #10's right great toe had dark brown discoloration, some breakdown, swelling, redness and warmth. The staff left a note for the Physician to look at the toe in the morning. An interview on 7/20/18 at 1:30 p.m. revealed Staff P (Nurse Consultant) reported Resident #10 had an area on the right great toe. Staff P reported a skin sheet could not be located for the right great toe. Staff P reported Resident #10 received antibiotic treatment in June. Staff P reported the facility had incomplete assessments for the other areas of Resident #10's. The Skin Care & Wound Management policy dated 6/2015 revealed the components of the skin care program include, but are not limited to, the following: identification of residents at risk for developing pressure ulcers, implementation of prevention strategies to minimize the potential for developing pressure ulcers and skin integrity issues, weekly monitoring of resident skin status, daily monitoring of existing wounds, application of treatment protocols based on clinical best-practice standards for promotion of wound healing, interdisciplinary review of identified skin impairments, monitoring for consistent implementation of interventions and effectiveness of interventions, review of modification of treatment plans as applicable and analysis of facility pressure ulcer data for quality improvement opportunities. 4. According to the Minimum Data Set (MDS) dated (MONTH) 27, (YEAR) Resident #19 has [DIAGNOSES REDACTED]. The MDS revealed the resident independent in transfers, walking, dressing and toilet use. The resident had a BIMS score of 11 which indicated moderately impaired cognitive ability. The resident did not have any skin impairments. Review of Resident #19's care plan revised on 1/9/18 indicated the resident had a skin tear to their hands but were resolved. The care plan failed to identify the resident had a wound to their feet and failed to direct staff in the care of the foot wound. Review of a Nursing Home visit note dated (MONTH) 9, (YEAR), the resident's physician indicated the resident had [MEDICAL CONDITION] on his left great toe which developed some evidence of gangrene on the end of the toe. The physician transferred the resident to the local hospital and diagnosed for infection and vascular disease involving his left great toe. The hospital evaluated the wound and performed a left femoral endarterectomy for [MEDICAL CONDITION]. The notes indicate the resident returned to the facility but needed close follow up with Vascular Surgery as he may need amputation of the left great toe in the future. Review of the Progress Notes dated 4/27/18 the resident returned from the hospital after left great toe amputation, his toe is bandaged. A progress note dated 5/1/18 indicated the nursing staff received a new order from the local hospital surgical department to pack the resident's left great toe with a Dakins solution and wrap with a bandage. On 5/2/18 the resident transported to the local emergency with high temperatures and infection in left foot. The resident admitted to the hospital for antibiotic therapy and subsequently was discharged from the facility due to a prolonged hospitalization . Review of the Order Listing Report for Resident #19, it indicated the resident had an order for [REDACTED]. Review of the (MONTH) (YEAR) Treatment Administration Records directed the staff to complete weekly skin checks, which were not completed as ordered. The treatment records directed staff to paint the left dorsal great toe with [MEDICATION NAME] twice daily with a start date of 2/26/18, was on hold from 3/4-3//18. The staff failed to complete the treatments as ordered. Review of the March, (MONTH) and (MONTH) Treatment Administration Records revealed under the section, unscheduled other orders, it stated wound care to left great toe, keep wound clean and dry and may shower. Review of the 3 treatment records failed to reveal a specific place for this order to be signed off as completed. The electronic treatment record failed to prompt to staff to complete the treatment. During an interview with Staff L-RN on 7/18/18 at 10:00 a.m. Staff L reviewed the treatment records for Resident #19. Staff L stated the orders for the wound care were not transcribed appropriately and were omitted from the treatment records for March, (MONTH) and (MONTH) (YEAR). Review of the treatment records revealed the staff failed to complete treatments for the resident's left great toe. During an interview Resident #19's family member on 7/18/18 at 1:26 p.m., the family member shared the resident remains in the hospital and has had three surgical amputations on their left leg. During an interview with Resident #19's physician on 7/18/18 at 11:18 a.m. the physician stated he was aware the staff were not completing the wound dressings as ordered, he stated he directed them to complete the dressings but they didn't comply. He stated the resident had vascular disease and had gangrene to their left great toe and said the lack of wound care did not help the resident's situation. 5. According to the Admission Record dated 6/6/18, Resident #12 had a admission date of [DATE] and discharged on [DATE]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the Progress Notes revealed a late entry dated 6/9/18 at 1:00 a.m., the agency nurse charted the aide called her into the resident's room and found the resident laying on the floor on her left side. The aide said the resident threw a shoe at her, lost her balance and fell to the floor. The nurse asked the aide if she felt the resident fell or the resident lowered herself to the floor. The nurse indicated the resident lowered self to the floor. The aide and the nurse assisted the resident to her feet and placed her back into bed. Review of a Progress Note dated 6//9/18 at 8:50 a.m. the former Director of Nurses stated she was told by the night aide that the resident fell during the night. The former D.O.N. completed an assessment and found abnormalities and the resident complained of severe left leg pain. The staff called 911 and the resident transferred to a local emergency room . Review of a Progress Note dated 6/10/18 revealed the resident admitted to a local hospital with a left [MEDICAL CONDITION]. During an interview with Staff O-CNA, she said she worked the night shift with Resident #12. She reports the resident became upset with her about 12:30 a.m., stood up and threw a shoe at the aide. The resident lost her balance and fell on the floor, hitting her head on the floor. Staff O contacted the agency nurse on duty. The agency nurse came into the room, stood over the resident and stated she looks fine to me the agency nurse and C.N.A. got her up off the floor and into bed, the aide indicated the resident had a limp when they walked her back to be. The aide stated the nurse failed to assess the resident prior to getting her off the floor. Staff O stated in the morning the resident requested help getting out of bed, when she provided assistance the resident was unable to stand, complained of severe leg pain and bear weight on her left leg. The aide clocked out and called the Director of Nurses to report the fall and lack of interventions. An interview with Staff F-RN on 7/17/18 at 1:52 p.m. revealed the staff failed to formulate an initial care plan upon admission to the facility. During an interview with Staff D-Interim Administrator on 7/17/18 at 12:35 p.m. she indicated she was called on 6/9/18 about 10:00 a.m. by the former D.O.N. She reported they sent out Resident #12 to the hospital after a fall. The former D.O.N. called the agency nurse to return to document the fall. Staff D stated the agency nurse failed to assess the resident after the fall on 6/9/18. Review of a Fall Risk Reduction and Management Policy dated (MONTH) 2013 directed the staff to provide immediate care and services to the resident with a fall to identity and treat any injuries. To avoid moving the resident until injury evaluation is completed and evaluate for additional injuries. The policy directed the staff to review the care plan and update with any new or revised interventions as indicated.

Based on observation, record review and staff interviews, the facility failed to appropriately assess Resident #1 and Resident #2 following a change of health condition and then implement interventions. The facility identified a census of 63 residents. Findings include: Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS identified the resident's [DIAGNOSES REDACTED]. The MDS revealed the resident with a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 reflected the resident had no cognitive impairments. The MDS indicated the resident required extensive assistance of two staff members for bed mobility, transfers, dressing, and toilet use, and required the assistance of one staff member for walking and personal hygiene. The MDS documented the resident used a wheelchair as a mobility device. The Care Plan, with an initiated date of [DATE], identified a focus area that identified the resident had ADL (activities of daily living) self-care performances skills due to a [MEDICAL CONDITION] and weakness. The interventions included and directed the staff to do the following: Staff are to assist the resident with use of the toilet, Staff are to assist the resident during transfers with a front wheeled walker and gait belt, Staff are to encourage the resident to participate to the fullest extent possible with each interaction. Review of the Progress Notes dated [DATE] at 7:48 pm indicated Resident #1 was seen at the medical clinic today and given an antibiotic medication for a chest cold. Review of physician encounter nursing home visit dated [DATE] indicated Resident #1has a recent course of [MEDICAL CONDITION] and receiving antibiotics for this. The note indicated the resident feels he still does have a bit of a productive cough. The resident denies fever, chills and the resident's appetite is good, bowels are working fine and pain is adequately controlled. The Progress Notes indicated the following: On [DATE] at 3:05 am, Resident #1 continued on antibiotic for upper respiratory infection. Resident in bed with eyes closed, blood pressure ,[DATE] (normal), pulse 76 (normal ,[DATE]), and temperature 97.8 (normal 98.6). Fluids encouraged when awake, no apparent distress noted, will continue to monitor. (The note did not identify the respiration rate or lung sounds). On [DATE] at 2:09 pm Resident #1 had no adverse reactions noted to the antibiotic therapy. Resident has no shortness of breath and lungs sounds are diminished. Resident respirations are even and unlabored on room air. Resident is able to make needs known and call light within reach. The resident resumed smoking and reeducated on the risks of continued smoking. The resident declined a nicotine patch. On [DATE] at 12:51 pm indicated the Assistant Director of Nursing, (ADON), approached the nurses' station and observed the resident sitting with the charge nurse on duty. The resident wore and receiving oxygen. The note indicated the ADON asked the charge nurse what was happening and the charge nurse reported Everyone says the resident is jaundice (a yellow tint to the skin). The note indicated the charge nurse reported the resident's oxygen saturation between ,[DATE]% (normal ,[DATE] percent). The resident on room air and vitals are stable (although no vital signs documented). The ADON questioned the resident if he felt short of breath and the resident denied this and any pain or discomfort. Instead the resident stated he felt tired. The charge nurse reported she gave the resident a nebulizer treatment (breathing treatment) because resident's oxygen saturation was low between ,[DATE]% (normal ,[DATE]%). The charge nurse again stated she thought the resident to be jaundice and that is why she put the resident on oxygen. The charge nurse reported oxygen on at 2 liters for ,[DATE] minutes. The note indicated the ADON questioned the charged nurse if she obtained a physician order [REDACTED]. The ADON, under better lighting assessed the resident. The resident's skin and sclera (white part of eyes) noted no jaundice. Skin noted to be pink and warm, lung sounds with very faint wheezing noted to the upper left lung, no coughing noted. The resident's bilateral feet and legs noted to be tight with 1 to 2 plus [MEDICAL CONDITION] (swelling with excessive fluid in tissue) per resident's baseline. Again the resident denied shortness of breath. Resident began propelling self in wheelchair in the halls visiting with other residents without any distress noted. Resident did go to dining room for lunch. On [DATE] at 5:30 pm Resident #1 in bed and refused supper. The resident reported being short of breath earlier in the day. This nurse told resident as a diabetic he needed to take something in (eat). Resident given chicken broth and two glasses of cranberry juice per request and took a couple sips of chicken broth and drank one glass of cranberry juice. The nurse assisted the resident with lifting legs into the bed. The resident did not complain of shortness of breath and took nebulizer breathing treatment at this time. The resident voiced he went outside to smoke earlier but would not be going out at 7 pm to smoke. On [DATE] at 7:45 pm the resident's vital signs are temperature 96.6, pulse 88, respiration rate 32 (elevated), and blood pressure ,[DATE]. The resident is taking antibiotic for upper respiration infection. The note indicated the resident spoke of going to the hospital. The ADON put resident on oxygen at 2 liters per nasal cannula and this nurse going to page the physician on-call. On [DATE] at 7:50 pm (the next entry) indicated the physician was paged at this time. Resident #1 rested comfortably in bed at this time, call light in reach. On [DATE] at 8:45 pm Resident #1sitting on the bed and took off the oxygen. The resident stated I left the oxygen on for 5 minutes and it is uncomfortable. Think I just want to go to the hospital. On [DATE] at 8:50 pm the nurse paged the physician again. A call came back and update given to physician. Physician ordered for Resident #1 to be treated and evaluated in the emergency room . The nurse contacted the hospital and spoke with the hospital administrator and emergency room department for transfer of the resident. The nurse contacted the ambulance for transfer (to hospital emergency room ). On [DATE] 9:05 pm Resident #1 in bed and assisted with putting on a gown on pending arrival of ambulance. Resident told this nurse Just don't feel good, think there is a problem. Resident thanked the nurse for getting him ready. On [DATE] at 9:15 pm the ambulance crew here and CNA (certified Nurse Aide) called out that the resident not responding. CPR (Cardiopulmonary Resuscitation) initiated. On [DATE] at 10:09 pm. Physician notified at this time, resident is a full code but despite CPR continuously all this time no response. Order given to cease CPR and resident pronounced (death) at this time. ADON notified and medical examiner called. Review of the Ambulance Prehospital Care Report dated [DATE] indicated they received a call to respond to the facility for a resident with difficulty breathing to be transported to the emergency room . In route without delay. Upon arrival, nurse is giving us report that resident has been on antibiotic for a week for [MEDICAL CONDITION]. Resident was seen by personal medical provider on Friday. Resident complaining of difficulty breathing all day today and oxygen via nasal cannula had been attempted. Resident refuses to leave oxygen on and continues to smoke. Resident last set of vital signs were blood pressure ,[DATE], pulse 88, temperature 96.6, respirations 32, and oxygen saturation 91% on room air. Nurse stated resident demanded to go to the hospital at 8:10 pm. Resident is a full code. As nurse finished the report, staff yelled from the resident's room that resident is unresponsive. Resident is unresponsive, pale, pulseless and apneic (temporary cessation of breathing). The resident was moved to the floor with the assistance of 4 attendants and CPR initiated. After 30 minutes, physician called and declared time of death. On [DATE] at 12:06 p.m. Staff B, Licensed Practical Nurse (LPN) was interviewed and stated she worked the day shift on [DATE] and assigned to care for Resident #1. Staff B stated that morning the resident was in therapy and one of the therapist came to her and reported the resident looked jaundice. Staff B stated she took the resident's vital signs and the vitals were normal but did not recall if she documented the vital signs. Staff B stated the resident did not appear jaundice and normal. Staff B stated after that, the resident was preoccupied with wanting to go to the emergency room for jaundice. Staff B, educated the resident about liver function and contacting his physician tomorrow to get lab testing. Staff B, stated the resident asked her ,[DATE] times about going to the emergency room . Staff B, stated she told the resident she would send him but first let's figure out want is wrong. Staff B stated she asked the ADON to assess the resident also and the ADON reported resident's vital signs are normal, color is okay, and she talked to the resident about lab work for the liver. Staff B stated the resident is normal, had no signs or symptoms of anything wrong and the resident seemed to be preoccupied with jaundice. Staff B, stated she reported this to the oncoming nurse. On [DATE] at 2:17 pm and [DATE] at 3:14 pm Staff A, Licensed Practical Nurse (LPN) was interviewed and stated she came into work on [DATE], second shift (2:00 p.m.) and assigned to care for Resident #1. Staff A stated she did not get a report from the off going nurse, Staff B, regarding anything going on with Resident #1. Staff A stated the resident did not wear oxygen when she came in at 2 pm and the resident went out to smoke at that time. Staff A reported at 5:30 pm, the resident told her he was not going to supper due to not feeling well, no shortness of breath, just feeling tired. Staff A, LPN, stated resident told her he was short of breath earlier, but it had resolved, but had not been feeling good all day. Staff A stated at 7:45 pm, she assessed the resident's vital signs and noted respiration rate at 32 (elevated), oxygen saturation at ,[DATE]% (low) on room air, and resident complained of shortness of breath. Staff A stated the ADON went into the resident's room to assess the resident. Staff A stated the ADON told the resident he is on an antibiotic, and to stay here and try the oxygen. The resident okay with that. Staff A stated she paged the on-call physician twice and received an order to send the resident to the emergency room . Staff A stated when the ambulance arrived a CNA, called out that resident is not responding and she and the ambulance crew initiated CPR. Staff A stated later Staff B, LPN, told her Resident # had problems all day with shortness of breath and that she had put oxygen on the resident. On [DATE] at 8:46 am Staff D, Certified Nurse Aide (CNA) was interviewed and stated on [DATE] she came into work at 2 pm and received report from the off going CNA. The off going CNA informed her that Resident #1 did not feel well and has been requesting to go to the hospital. Staff D stated she saw the resident and he did not look so good and the resident stated he felt bad. Staff D stated she reported this to Staff A (nurse) what the resident told her and was instructed by Staff A to do extra cares for the resident. Staff D, stated the resident refused to eat his supper and she reported this to Staff A. On [DATE] at 2:51 pm Staff C, Certified Nurse Aide (CNA) was interviewed and stated she came into work at 2 pm and saw Resident #1 at the nurses' station telling Staff A that he wasn't feeling well and wanted to go to the hospital. Staff C stated she heard Staff A tell the resident she was doing all she could for him and she didn't have time to deal with him. Staff C stated she noted resident's color was a little greyish in color. On [DATE] at 3:18 pm with Staff E, Certified Nurse Aide (CNA) stated she came into work at 4 pm on [DATE] and noted the resident at the main entrance. Staff E stated resident told her that he did not feel well and has tried to go to the emergency room all day. Staff E stated she knew he did not feel well because his skin color was pale/yellowish and not normal. Staff E stated she did not recall if she reported this to the nurse or not. On [DATE] at 10:09 am Assistant Director of Nursing (ADON) was interviewed and stated she came into the facility the first time on [DATE] around 10:00 or 10:30 pm. The ADON stated at 12:00 or 12:30 pm she saw Resident #1 at the nurses' station with Staff B and noted the resident had oxygen on. The ADON stated Staff B told her the resident's oxygen saturation was ,[DATE]% and vital signs were normal and that everyone is saying resident is jaundice in color. The ADON stated she assessed the resident's color and did not note abnormal color and she removed the oxygen and after 10 minutes assessed resident's oxygen saturation to be ,[DATE]% on room air. The ADON stated she instructed Staff B she needed a physician order [REDACTED]. The ADON stated she left the facility and returned again around 5:30 or 6:00 pm and went to her office. The ADON stated around 7 pm Staff A came to her stating there is something truly wrong with Resident #1. The ADON stated she went to the resident's room and noted the resident to be short of breath, purse breathing through his lips, and requesting to go to the hospital. The ADON stated she went and got the oxygen and put it on the resident and assessed his vital signs and Staff B called the physician on-call. The ADON stated she spent about a half hour with the resident and then left the facility around 9 or 9:15 pm when the ambulance was on its way. The ADON stated she never talked to any other staff members besides Nurse A and Nurse B. On [DATE] at 10:34 am an interview was conducted with the resident's physician. The physician stated he has done some education with the facility after this with staff members. The physician stated he instructed them if a resident needs to go to the hospital to send them. The physician stated he reviewed the resident's chart and it appeared there's a disconnect in assessment with staff members. 2 . Resident #2 had a MDS assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS) score of 15 out of 15. The MDS indicated the resident required limited assistance of 1 staff member for bed mobility, dressing, locomotion, and toilet use, and extensive assist of one staff member for personal hygiene. The MDS documented the resident used mobility devices of a walker and a wheelchair. The MDS indicated the resident receives a pain medication regimen, both scheduled and as needed and receives non-medication intervention for pain. The MDS documented frequent pain in the last 5 days that rates a 9 on a scale of 0 to 10. The scale is 0 being no pain and 10 as the worst pain. A Care Plan, with an initiated date of [DATE], identified a focus area with chronic pain related to cervicalgia. The interventions directed staff to: Staff are to anticipate the resident's need for pain relief and respond immediately to any complaints of pain. Staff are to monitor and record pain characteristics every shift and as needed, severity 1 to 10 pain scale. The resident's pain is alleviated/relieved by rest and medication management. Review of the MAR (Medication Administration Record) dated [DATE], identified an order for [REDACTED]. Review of the Controlled Medication Utilization Record for [MEDICATION NAME] revealed one tablet administered at 9:00 am on [DATE], leaving the count of the medication at zero. Review of the Controlled Medication Utilization Record for [MEDICATION NAME] revealed 60 tablets received and two tablets administered at 2 am on [DATE]. On [DATE] at 11:53 am Staff G, LPN (Licensed Practical Nurse), was interviewed and stated she administered 1 tablet of [MEDICATION NAME] to the resident around 9 am on [DATE] and that was the last tablet. Staff G stated she did not know how to order the pain medication for the resident and the resident complained of pain. Staff G stated she worked from 6 am to 10 pm on [DATE]. Staff G stated the resident's family was here and upset the resident did not have pain medication. Staff G stated she did not call the pharmacy or the resident's physician about not having pain medication for the resident. Staff G stated she administered Tylenol as ordered for the resident's complaints of pain. On [DATE] at 3:14 pm with Staff A, LPN (Licensed Practical Nurse), was interviewed and stated the resident approached her the afternoon of [DATE]. The resident expressed being upset,d in pain and no pain medication available. Staff A stated she called the pharmacy and ordered the medication for the resident and was told it would take 6 hours for the medication to be delivered. Staff A stated the facility's medication emergency kit did not have the resident's pain medication in it. Staff A reported she instructed Staff G to give the resident Tylenol for pain. Staff A stated she never called the resident's physician. On [DATE] at 10:09 am the ADON (Assistant Director of Nursing) was interviewed and stated she was informed the facility ran out of the resident's pain medication, [MEDICATION NAME]. The ADON stated she did education with staff members. The ADON stated she expected staff to have ordered the pain medication before they ran out, to check the emergency kit to see if medication is available for resident, to call the pharmacy and order it immediately, and or call the resident's physician to see if another pain medication that can be ordered for the resident and available in the facility's medication emergency kit immediately. Review of the Clinical Change in Condition Management dated ,[DATE] included assessment of residents clinical status when a change in condition is identified. This may include but is not limited to: vital signs, lung sounds, pulse ox, mental/neurological status, bowel sounds, skin color, turgor, temperature, pain. Contact the physician and provide clinical data and information about the resident condition. Document this notification of the physician in the resident's medical record and physician response. Initiate any new physician orders.

I. Based on record review, facility policy and staff interviews, the facility failed to administer [MEDICATION NAME] (blood thinner) medications as ordered by the physician for 1 of 2 residents reviewed (Resident #9). Record review identified staff administered [MEDICATION NAME]/[MEDICATION NAME] Sodium medication incorrectly to Resident #9 for multiple days. Resident #9 required treatment with Vitamin K for anticoagulation reversal to address his/her elevated INR (International Normalized Ratio) level. The facility reported a census of 67 residents. Findings Include: Record review of Minimum Data Set (MDS) for resident #9 dated 3/4/17 reveals a [DIAGNOSES REDACTED]. Resident #9 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive test, indicating he/she cognitively intact. The resident's care plan dated 2/13/17 revealed he/she required the used of [MEDICATION NAME] medication and would have no complications from anticoagulant therapy. Staff will administer medications as ordered. The signed (physician's) Order Summary Report dated 4/11/17 documented an order for [REDACTED]. The order called for 7.5 milligrams (mg) of [MEDICATION NAME] administered in the evening every Sunday, Tuesday, Wednesday, Friday and Saturday. Record review of Resident #9's Medication Administration Record for April 2017 revealed both 10 mg of [MEDICATION NAME] and 7.5 mg of [MEDICATION NAME] had been administered (signed out) for Monday 4/17/17 and Tuesday 4/18/17. (Resident #9's physician's orders [REDACTED].) The MAR and Progress Notes dated 4/19/17 identified the correct dose of [MEDICATION NAME] had been administered on 4/19/17 by Staff H, Registered Nurse. The MAR for Thursday 4/20/17, Friday 4/21/17, Saturday 4/22/17 and Sunday 4/23/17 revealed staff administered both the 10 mg of [MEDICATION NAME] and the 7.5 mg of [MEDICATION NAME] daily. (The MAR showed Resident #9 received 17.5 mg of [MEDICATION NAME] daily from 4/20/17- to 4/23/17.) The State surveyor noticed the [MEDICATION NAME] medication errors on the MARs on 4/24/17. On 4/24/17 at 12:45 p.m. an interviewed with Staff F, Registered Nurse (RN) and Assistant Director of Nursing (ADON) about dose of [MEDICATION NAME] medication currently being administered. Staff F (RN) verified the wrong dose of medication had been administered with nurses. Staff F stated the medication error(s) related to data entry in the electronic Medication Administration Record. She contacted the physician and received order to check Resident #9's International Normalized Ration (INR). The Progress Notes written by Staff F dated 4/24/17 at 4:29 p.m., revealed the following: On 4/16/17, the ([MEDICATION NAME]) order accidently changed in MAR to give both [MEDICATION NAME] does daily, 10 mgs ordered for Monday and Thursdays and 7.5 mg [MEDICATION NAME] the other five days (Tuesday, Wednesday, Friday, Saturday and Sunday). The error(s) brought to nurses attention, and lab results were obtained for INR, with the results at 6.4. (Resident #9's prior INR laboratory results dated [DATE] revealed a therapeutic level of 2.4.) (A therapeutic INR range is normally under 4.) The same progress notes identified the physician ordered 5 mg of Vitamin K1 Solution subcutaneously and to hold the [MEDICATION NAME] and daily check the resident's INR. Progress Notes dated 4/25/17 revealed Resident #9 INR's at 4.0 and the physician was notified. Interview with Staff G, (RN) 4/25/17 at 7:40 a.m., admitted she gave 17.5 mg [MEDICATION NAME] that was on electronic medication administration record (EMAR) on 4/22/17. When asked whether if she questioned the large dose of medication, Staff G responded, yes and stated she gave it anyways. Interview with Staff H, (RN) 4/25/17 at 10:50 AM did verify that only gave the 7.5 mg dose of [MEDICATION NAME] on 4/19/17 which was the correct dose, stated did not notify anyone that EMAR was incorrect. Interview with Director of Nursing (DON) 4/25/17 at 7:30 a.m., regarding [MEDICATION NAME] medication administered to Resident #9, she stated the Assistant DON had entered the order wrong into the computer system. The DON stated the nurses administering the medication should have questioned the dosage and the pharmacy label did not match the eMAR. The DON reported all other [MEDICATION NAME] orders were verified. The facility provided guidelines for medication administration dated 1/13. Policy/Procedure to verify medication administration according to physician's orders [REDACTED]. If there is a discrepancy, check the original physician's orders [REDACTED]. II. Based on record review, staff interview and policy review, the facility nursing staff failed to implement non-pharmacological interventions prior administration of as needed (PRN) antianxiety medications on 3 of 3 residents reviewed (Residents #3, #5, and #6). The facility reported a census of 67 residents. Findings Include: 1. Resident #5's Minimum Data Set (MDS) 30-day assessment completed 3/30/17 had documentation of the following [DIAGNOSES REDACTED]. It also identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, required extensive assistance of 1 to 2 staff with most activities of daily living. The care plan with the revision date of 4/25/17 identified the resident with a mood disorder and a goal that the resident will have improved mood state (Specify: happier, calmer appearance, no signs or symptoms of depression, anxiety or sadness). The nursing staff directed to administer medications as ordered, assist the resident to identify strengths, positive coping skills and the Certified Nurse Aide (CNA) to reinforce these. Monitor/record/report to the doctor mood patterns, signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of the Medication Administration Record (MAR) for March 2017 displayed an order for [REDACTED]. Noted the order date to be 3/2/2107 on the resident's admitted . Further review of the MAR shown the PRN [MEDICATION NAME] recorded to be given to the resident 19 times in the month with no non-pharmacological interventions documented as attempted prior administration. Review of the Progress Notes for the resident in that time frame also revealed lack of documentation any non-pharmacological interventions attempted prior the medication given and nothing charted that the resident requested the PRN antianxiety medication at those times. Review of the MAR for April 2017 displayed the same order for Resident #5 of [MEDICATION NAME] (an antianxiety medication) 1 milligram, 1 tablet by mouth every 6 hours as needed (PRN) for anxiety. Further review of the MAR indicated the staff administered the PRN [MEDICATION NAME] to the resident 13 times in the month between the dates of 4/1/17 to 4/24/17 without non-pharmacological interventions attempted prior administration. Review of the Progress Notes for the resident in that time frame revealed lack of documentation of non-pharmacological interventions attempted prior the administration of medication and staff failed to charted the resident requested the PRN antianxiety medication at those times. 2. Resident #6's Minimum Data Set (MDS) admission assessment completed 2/10/17 had documentation of the following [DIAGNOSES REDACTED]. It also identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, required extensive assistance of 1 to 2 staff with most activities of daily living. The care plan with the revision date of 2/18/17 identified the resident with a goal of the resident to remain free of signs and symptoms of distress, depression, anxiety or sad mood. The nursing staff directed to administer medications as ordered and monitor/document side effects and effectiveness. Also to monitor document/report to the nurse or doctor signs /symptoms of depression, anxiety, repetitive anxious or health-related complaints. The resident needs time to talk and encourage the resident to express feelings. Review of the MAR for February 2017 displayed an order for [REDACTED]. Noted the order date to be 2/3/2107 on the resident's admitted . Further review of the MAR revealed the staff administered PRN [MEDICATION NAME] given to the resident 11 times in the month without no non-pharmacological interventions documented prior to administration. Review of the Progress Notes for the resident in that time frame also revealed lack of documentation of non-pharmacological interventions attempted prior the medication given and also nothing charted that the resident requested the PRN antianxiety medication at those times. Review of the MAR for March 2017 displayed the same order for Resident #6 of [MEDICATION NAME] (an antianxiety medication) 5 milligram, 1 tablet by mouth every 6 hours as needed (PRN) for anxiety. Further review of the MAR showed the staff administered PRN [MEDICATION NAME] to the resident 23 times in the month without no non-pharmacological interventions documented prior to administration. Review of the Progress Notes for the resident in that time frame revealed lack of documentation of non-pharmacological interventions attempted prior the medication given and also nothing charted that the resident requested the PRN antianxiety medication at those times. Review of the MAR for April 2017 displayed the same order for Resident #6 of [MEDICATION NAME] (an antianxiety medication) 5 milligram, 1 tablet by mouth every 6 hours as needed (PRN) for anxiety. Further review of the MAR showed the PRN [MEDICATION NAME] recorded given to the resident 7 times in the month between the dates of 4/1/17 to 4/25/17 with no non-pharmacological interventions documented as attempted prior administration. Review of the Progress Notes for the resident in that time frame lack documentation of non-pharmacological interventions attempted prior the medication given and also nothing charted that the resident requested the PRN antianxiety medication at those times. During an interview on 4/26/17 at 2:16 p.m., Staff E, Licensed Practical Nurse reported prior to administering a PRN antianxiety medication to a resident interventions should be attempted such as giving the resident a snack, reposition the resident, offer toileting or just talk to the resident. Staff E demonstrated how the PRN medications are checked off and charted on in the facility's computer system when given. Review of the Medication Management Policy dated 5/14 stated the resident/patient's medication regimen is managed and monitored to promote and/or maintain his/her highest practicable, mental, physical, and psychosocial; well being. The nursing staff directed to verify indications for the use of medications are documented in the resident/patient medical record and include medication related goals, parameters for monitoring resident/patient condition in the care plan to include non-pharmacological interventions as indicated. 3. The MDS assessment tool, dated 1/29/17, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene and bathing and extensive assistance of 2 staff for bed mobility, transfers, and toilet use. The MDS listed the resident's BIMS(Brief Interview for Mental Status) score as 14 out of 15, indicating intact cognition. The April 2017 MAR(Medication Administration Record) displayed an order for [REDACTED]. The record indicated the resident received the medication 14 times during the period of 4/2/17-4/24/17. The facility lacked documentation during the period of 4/2/17-4/24/17 of non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. During an interview on 4/25/17 at 2:44 p.m., the Director of Nursing stated she expected the nurses to attempt and chart 2-3 non-pharmacological interventions prior to the administration of as needed anti-anxiety medications.

Based on clinical record review, facility policy and staff interviews the facility failed to timely report a resident to resident altercation for 2 of 11 residents reviewed (Resident #2 and #3). The facility reported a census of 67 residents. Findings include: On 10/27/2016, the facility reported to DIA (Department of Inspections and Appeals) an incident that involved a physical altercation between Resident #2 and Resident #3 on 10/23/16. The facility reported they were investigating a scratching incident between the residents. According to the MDS (Minimum Data Set) dated 10/31/2016, Resident #2 had no cognitive impairment, required extensive assistance of two staff to transfer and ambulate, used a wheel chair for locomotion and had [DIAGNOSES REDACTED]. Review of Resident #2's progress notes dated 10/23/2016 documented the resident left the dining room before breakfast and Resident #3 told the resident he/she could not leave as they had not eaten yet. Resident #2 became agitated and grabbed Resident #3's arm, Resident #3 refused to let go of the wheel chair and Resident #2 scratched Resident #3's arm. Staff noted Resident #3 had two scratches to the right forearm. Review of an incident report dated 10/23/2016 documented Resident #2 left the dining room and Resident #3 grabbed his/her wheel chair and attempted to stop him/her. Resident #2 became agitated and grabbed Resident #3's arm, scratching his/her forearm. According to the MDS dated [DATE], Resident #3 had severe cognitive impairment, required assistance to transfer and failed to ambulate. The resident had [DIAGNOSES REDACTED]. The Care Plan identified Resident #3 had dementia and had exit seeking behaviors and increased combativeness. The resident required assistance to transfer and used his/her wheel chair for independent locomotion. Resident #3's progress notes dated 10/23/2016 documented Resident #2 left the dining room before breakfast and Resident #3 told the resident he/she could not leave due to they had not eaten yet. Resident #2 became agitated and grabbed Resident #3's arm, Resident #3 refused to let go of the wheel chair and Resident #2 scratched Resident #3's arm. Staff noted Resident #3 had two scratches to the right forearm. The Incident Report dated 10/23/2016 at 9:31 a.m., indicated Resident #2 left the dining room and Resident #3 grabbed his/her wheel chair and attempted to stop him/her. Resident #2 became agitated and grabbed Resident #3's arm and scratched his/her forearm, receiving 2 scratches. During an interview on 12/6/2016 at 9:30 a.m., Staff D, Administrator indicated he/she heard about Resident #3's scratches. A nurse charted Resident #3's scratch on 10/23/16. The Administrator then indicated Staff E from dietary heard the commotion and observed Resident #3 put his/her hand on Resident #2 forearm, not wanting him/her to leave. Staff E alerted Staff F, CNA that Resident #3 had his/her hand on Resident #2's wheel chair handle. Staff separated the two residents and observed the scratches on Resident #3's forearm. During morning meeting on 10/27/2016 the Administrator said he/she became aware of the incident. During an interview on 12/6/2016 at 11:40 a.m., Staff E, Dietary said he/she worked in the dining room and witnessed Resident #2 leaving the dining room via wheel chair. Resident #3 entered the dining room via wheel chair. Resident #3 held Resident #2's arm and told the resident he/she could not leave and he/she needed to turn around. Staff E went to get help and Staff F, CNA came to assist the residents. During an interview on 12/6/2016 at 10:45 a.m., Staff F, CNA reported he/she assisted Resident #2 and #3 get up from bed that morning on 10/23/2016 and Resident #3 did not have scratches on his/her arms. At approximately 7:00 a.m. Staff F heard Resident #3 yell out Quit that! Stop doing that! No, No, Stay here! . Staff F entered the dining room area and Resident #3 had his/her arm on Resident #2's wheel chair handle and Resident #3 held his/her hand back. Staff F pulled Resident #3's wheel chair back and observed the scratches on Resident #3. The facility Risk Management Policy revised August 2016 included: Each employee is responsible to immediately report any suspected abuse but not to exceed 24 hours. When a nursing facility receives an allegation of abuse, they must report immediately as soon as possible but not to exceed 24 hours, separate the alleged

Based on observation, record review, interviews with staff and the Advanced Registered Nurse Practitioner and review of the manufacturer ' s recommendations for lift usage, the facility failed to provide Resident #6 with adequate supervision to ensure against hazards and failed to correctly apply an appropriate mechanical lift sling under the resident which resulted in a fall from the sling, multiple fractures and death. The facility failed to sometimes not use the mechanical lift when transferring Resident #4 and would transfer with staff and a gait belt. The sample consisted of 6 residents and the facility reported a census of 65 residents. Findings include: 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS identified the resident scored a 15 on the Brief Interview for Mental Status (BIMS). A score of 15 identified the resident did not have any cognitive problems. The MDS identified the resident needed extensive physical assistance of 2 or more staff members for transfers. The current Care Plan identified the resident had the following [DIAGNOSES REDACTED]. The Care Plan identified the resident had a focus area for a deficit with self-care and activities of daily living. The approaches directed the staff to provide one to two staff assistance to turn and reposition in bed every two hours, provide assistance of one to two staff for toileting upon resident request, encourage resident to use call light to summon assistance and the resident required a mechanical lift with two staff assistance for transfers. The Nurse's Notes dated [DATE] at 2:29 p.m. and written by the Director of Nursing (DON) reflected the staff called the nurses to the resident ' s room. The resident had slid approximately 24 inches from a wet sling and onto to the floor landing directly on his/her bottom. The DON documented the resident had just returned to his/her room from a shower. Upon entering the room the nurse observed the resident lying on back and slightly to the left side. The nurse saw the resident's left leg slightly rotated outward and the resident voicing complaints of pain to that side. The staff documented the resident could not move left side per baseline after CVA (stroke). The staff documented the nurse notified the primary care provider of the fall. The staff sent the resident to the hospital for an evaluation and treatment. At 6:31 p.m. the DON documented the facility contacted the hospital and informed the resident had sustained a left femur fracture with possible left tibia involvement. On [DATE] at 12:22 p.m. the DON documented the resident's family had notified them the resident had not been able to undergo surgical repair of the fracture and resident had chosen palliative care. Review of the emergency room notes dated [DATE] revealed the resident had presented to the emergency room after a 5 foot fall from a Hoyer (mechanical) lift prior to arrival with complaints of severe left hip pain radiating into the left buttock and left knee pain that began after the fall. Review of the radiology results noted the fall had resulted in: 1. Horizontal fractures extend through tibia and fibula (lower leg bones) and the left femur (thigh bone). 2. A minimally displaced fracture involving the fibula near the level of the syndesmosis. Additionally a mildly displaced fracture of the medial malleolus (ankle). 3. Multiple fractures were noted within the mid foot, with fractures of the second, third, fourth and fifth metatarsal shifts without significant displacement but mild angulation of the fourth and fifth metatarsal fractures, extensive soft tissue swelling. On [DATE] at 10:30 a.m. the Director of Nursing stated the resident had not returned to the facility following transfer to the hospital post fall and had expired in the hospital a few days later. The DON stated on [DATE] at 9:13 a.m. the facility had not received any information regarding the cause of death from the hospital despite repeated request. On [DATE] at 2:15 p.m. Staff A and Staff B, certified nursing assistants (CNA) demonstrated the transfer techniques used on [DATE] with Resident #6. The staff utilized a colleague to act as a resident. Staff A obtained a black whirlpool chair and placed the chair in the resident's room. Staff A placed the sling on the chair and the colleague sat on the chair. The staff connected the sling to the lift arms, and Staff B ran the controls to raise the colleague from the whirlpool chair. Staff A stated they used the sling meant for toileting residents. The lift sling straps did not cross between the colleague ' s legs but cradled the resident. Staff A stated Resident #6 had slipped forward on the whirlpool twice before the attempted transfer. Staff A stated Staff C, CNA helped her to reposition the resident the first time but left the room to continue his duties but then Staff B came into the room to assist with the transfer. Staff A stated that as they raised Resident #6 to clear the shower chair, the resident's legs came forward. Staff A demonstrated how she reached down to grab Resident #6's legs but the resident's momentum pulled him/her out of the sling and onto the floor. Staff B stated Resident #6 was approximately 48 inches from the bed when the resident slipped out of the sling. When asked if they knew Resident #6 had not been positioned correctly in the sling, why they did not stop and get another staff to help with repositioning the resident, Staff A stated "guess we should have but we just wanted to get the resident out of the sling and onto the bed". Review of the facility Safe Resident Handling and Mobility Program reflected the objective of the program is to: 1. Ensure that residents are cared for safely while maintaining a safe work environment for employees. 2. Facilitate the safe use of transfer aides and equipment. 3. Provide an objective, easy to understand, consistent means of evaluating resident transfer needs. 4. Provide consistent techniques for the assisting, repositioning or transfers of residents. 5. Encourage maximum participation within a Lift-Free program. The program identified the Director of Nursing/Administrator as the person responsible for overall coordination, administration and implementation of the Safe Resident Handling and Mobility Program and designated as the program coordinator. The program noted all employees shall receive education and competency in safe resident handling and mobility will be completed for the following circumstances: 1. All new hires, regardless of experience upon initial employment 2. After all transfer related incidents 3. After an employee had been off of work on a leave longer than 90 days 4. Annually. Review of the manufactures information for use of the full-body mesh commode sling noted the sling contained quick drying mesh fabric that offered full head and neck support and to be used with a four point spreader option. The accompanying picture for correct use shows a resident in a cradled sitting position. The patient lift sling guide noted the access/toileting sling is designed specifically to facilitate the toileting procedure by allowing the removal of clothing and the patient must be in a sitting position to use the sling. The manufactures information did not state if the sling should be used wet or under a resident during a shower/bath. The toileting sling referenced a wide back strap that went around the resident ' s back and under the arms with a nice wide leg strap that wrapped around the thigh of the leg and up and between the resident ' s legs. The sling did not have a head support and the resident must be able to support self from the shoulders up. On [DATE] at 10:50 a.m. the resident ' s Primary Care Provider (PCP) was interviewed and noted the resident had been oriented and alert, participating with life in the facility. The PCP stated although the resident had been obese, his/her health condition had been overall stable with medication. She noted the resident did require a mechanical lift transfer from bed to wheelchair and back but had been mobile with the wheelchair. The PCP stated that in her opinion the fall did contribute the resident's death. The PCP stated the surgeon had felt that the resident's chronic pulmonary disease made him/her unstable for surgery so the family and resident chose palliative care. Review of the Hospital Discharge Summary of a deceased Patient dated [DATE], noted the resident had been admitted to the hospital Hospice on [DATE]. The notes reflected the resident expired on [DATE] with a primary cause of death of cardiorespiratory failure. The notes reflected the conditions directly contributing to the resident ' s death had been the fall that resulted in a closed periprosthetic femur and tibia fractures. On [DATE] at 4:10 p.m. Staff C, CNA stated he had been working on [DATE] putting laundry in resident rooms when Staff A called out and asked him to assist her reposition Resident #6 in the whirlpool chair because the resident had slumped down to the edge of the chair. Staff C stated he helped Staff A to adjust the resident back into the sling on the chair. Staff C stated he continued with his duties of putting laundry in other resident rooms. Staff C stated a short time later he heard a page on the radio for staff assistance to Resident #6's room. Staff C stated when he entered the room he observed the resident on the floor. He stated the lift sling appeared wet and it did have feces on the sling and that may have made the sling and chair slippery. On [DATE] at 9:20 a.m. Staff B, CNA stated on [DATE] she had just come in for her afternoon shift when Staff C passed her in the hallway and stated Staff A needed assistance to transfer Resident #6. Staff B stated when she entered the resident's room; Resident #6 had been sitting on the shower chair (whirlpool) on a wet sling. Staff B stated Staff A had started connecting the sling to the lift. Staff B stated after getting the sling hooked to the lift, Staff A made a remark that the lift did not look right, unhooked the right side of the sling and attempted to tug the sling down under the resident, then reconnected the right side to the lift. Staff B stated she ran the controls and lifted the resident from the chair as Staff A had been standing behind the whirlpool chair. Staff B stated after she had raised the resident about [DATE] feet above the chair, Staff A pulled the chair from the resident as she started to pull the resident toward the bed. Staff B stated she noticed the resident had been starting to slip forward in the sling, and the resident ' s bottom had not been positioned back against the sling. Staff B stated she told Staff A, who had still been located behind the chair to get hold of the resident's legs. Staff B stated by the time Staff A got around the chair the resident had already slipped out of the sling and onto the floor about a foot from the bed. Staff B stated the resident had a bowel movement on the floor after the fall and not prior to the fall as had been reported. On [DATE] at 9:55 a.m. Staff A, CNA, was interviewed and stated they (the facility) had been short staffed so showers and baths were running late. She stated she stayed over from her shift to give Resident #6 his/ her whirlpool bath. She noted that her partner for the day (did not remember who it was) had helped her to transfer the resident from the wheelchair to the whirlpool chair, then the partner had to leave. Staff A stated after she had wrapped the resident in a sheet, she noted the resident had slid down in the whirlpool chair to the edge. She stated she peeked out the door and noticed Staff C in the hall passing laundry and asked him to come and help reposition the resident in the chair. She stated they boosted the resident in the chair and she propelled the resident to the south hall way to the whirlpool room. She stated when she attempted to lock the whirlpool chair onto the whirlpool tub it would not lock. She stated she went to the DON ' s office and told the assistant director of nursing (ADON) she could not get the chair to lock in. She stated the ADON and another aide came to the whirlpool room to see if the chair had been positioned correctly. She stated they could not get the chair to lock in so told her to shower the resident. She stated she propelled the resident in the Whirlpool chair back to the east hall shower room but it had already been in use. She stated she took the resident to his/her bedroom to wait until the shower room became free. She stated by that time the resident had been getting upset first not getting the whirlpool bath, then having to wait for the shower room to be free. Staff A stated they waited in the resident's room for about 10 to 15 minutes until the shower room became free. She stated she took the resident to the shower room and gave the resident the shower, dried him/her off, wrapped a sheet around the resident and propelled the resident to the bedroom still in the whirlpool chair on the wet sling. She stated she had left the resident on the sling during the shower stating she didn't know they were supposed to remove the sling prior to the shower. She stated Staff C saw her bring the resident back to the bedroom and she told Staff B (coming in for her ,[DATE] shift) that Staff A needed assistance to transfer the resident. Staff A stated Staff B came into the room to assist but she noticed the resident had started to slide to the edge of the whirlpool chair again as she started to connect the sling to the lift arms. She stated she told Staff B the lift did not look right so they attempted to pull the sling down to get it under the resident. She stated they hooked the sling to the lift, Staff B running the controls and began to raise the resident up from the chair. She stated as the resident came up she noticed that the resident's legs were dangling down like a standing position instead of a sitting position with the bottom against the sling. Staff A stated as Staff B pulled the resident away from the chair, she noticed the resident had started to slide forward and fell out of the sling onto the floor. Staff A acknowledged they should have stopped the transfer when they noticed the lift did not look right and should have gotten another staff to assist them reposition the resident prior to the transfer. 2. Resident #4 had a MDS assessment with a reference date of [DATE] which identified the resident had a score of 15 for the Brief Interview for Mental Status (BIMS). A score of 15 identified the resident as having no cognitive impairment. The MDS reflected the resident needed extensive physical assistance from two staff members for transfers. Resident #4 had [DIAGNOSES REDACTED]. The Care Plan, with a goal date of [DATE] reflected a focus area identified the resident had delusional thinking and could be easily distracted and have disorganized thinking. Another focus area determined the resident to have deficits with self-care performance due to weakness and limited mobility dated [DATE] and revised on [DATE]. The staff were directed to provide one to two staff assistance to turn and reposition in bed, provide assistance of one to two staff for toileting and instructed staff to use a stand lift due to the resident ' s increased complaints of pain with transfers. On [DATE] at 4:20 p.m., Resident #4 was interviewed and stated the staff have been with him/her several times when fallen or transferred inappropriately which caused a fall. The resident stated the staff are to use a stand lift for transfers but do not always use the lift. On ,[DATE] at 2:00 p.m. Staff I, CNA stated normally Resident #4 is transferred with a gait belt and 2 staff members. Staff I stated she was unaware this transfer level had been changes to use a stand lift. On [DATE] at 2:40 p.m. Staff K, CNA stated she does not work on Resident #4's hallway very often but thinks he/she is transferred by 2 staff and a gait belt. On [DATE] at 2:50 p.m. Staff G, CNA stated Resident #4 is normally transferred with gait belt and two assistance and stated the resident complains when they use a gait belt. Staff G stated they do not use a stand lift with the resident. On [DATE] at 8:20 a.m. Staff H, CNA stated the staff always use a stand lift and two people while transferring Resident #4. Staff H stated the stand lift transfer is needed due to the level of the resident ' s pain and accusations of staff hurting the resident during transfers. On [DATE] at 8:40 a.m. Staff D stated Resident #4 had been a transfer with a gait belt and 2 staff assistance but it had been changed to a stand lift because of accusations against staff hurting him/her during transfers. On [DATE] at 8:55 a.m. Staff J stated Resident #4 is transferred with a stand lift and 2 staff assistance because of the pain level when trying to transfer with a gait belt.