Every finding on record at Ivy at Davenport

Based on observations, staff interview and policy review the facility staff failed to serve food under sanitary conditions to prevent cross contamination and potential food borne illness during 1 of 2 meals. The facility identified a census 59 residents.Findings include: During observation of the lunch meal service in the back dining area on 7/13/26 starting at 12:19 PM, the Dietary Manager (DM) gave instructions to Staff A, Dietary Cook, that he needed to use tongs when he served bread and he did not have to wear gloves unless he was preparing ready to eat foods. Staff A began plating food on plates as he wore gloves. Staff A placed a scoop of noodles on a plate and held his opposite hand to guard/guide noodles in place on the plate, then poured a white sauce over the noodles and placed a scoop of green beans and a chicken breast on the plate, touching the utensils with the same gloves. Staff A continued to wear gloves, lifted the lid over a pan of hotdogs, picked up a hotdog and placed the hotdog in a bun on the plate. Staff A held the sack with hotdog buns in his gloved hand, spun the bag around to close the bag and sat the bag of buns on the counter. During the meal service, Staff A continued to touch utensils and plate food including the same process of shielding noodles as he poured the noodles onto the plate wearing the same gloves. Staff A placed a hotdog bun on the plate with his gloved hand, lifted the lid on the pan of hotdogs and placed the hot dog in the bun on the plate. Staff A continued to wear the same gloves as he plated food for other residents. In an interview on 7/16/26 at 9:05 AM, the DM reported staff do not need to wear gloves when serving food unless touching or serving raw food. Staff should use tongs for serving bread. The DM reported she expected gloves removed and hands washed after food touched to prevent cross contamination.A Food Safety Requirements policy reviewed/revised 3/26/25 revealed food served in accordance with professional standards for food service safety and in ways to prevent foodborne illness. Gloves used when touched ready to eat foods. Staff shall exhibit appropriate use of gloves.

Based on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to provide accommodate the need for a bariatric shower chair for 1 out 5 residents (Resident #2) reviewed for baths. The facility reported a census of 59 residents. Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The list of diagnoses morbid obesity, cerebrovascular accident (stroke) and hemiplegia (one sided paralysis). The MDS indicated Resident #2 independent with bathing and personal hygiene. Review Resident #2's Care Plan revealed a Focus area to address The resident is at risk for falls r/t medications that may cause dizziness, loss of balance, or impaired judgement, weakness, FUNCTIONAL IMPAIRMENTS which causes safety issues with transfers and/or walking. The Care Plan did not address activities of daily living such as bathing or personal hygiene. During an interview on 7/13/26 at 11:55 AM, Resident #2 stated the leg on a shower chair broke the last time he took a shower in the beginning of June. Resident #2 stated that time, staff have given him a bed bath or used wipes, and then a dry shampoo shower cap to wash his hair. He stated his wheelchair is new and facility staff wanted him to use it in to get into the shower. Resident #2 stated he refused to do that as he did not want the dirt from his body to rinse off onto the wheelchair. The resident stated facility staff have told him a shower chair is on order but it has yet to arrive. He added maintenance told him it will be here but it has never arrived. Resident #2 stated since Memorial Day I have only had 2 maybe 3 showers. He stated he gets frustrated because I really would prefer to have a shower than a bed bath or get cleaned with wipes. Upon request, the facility provided a purchase order dated 6/30/36. The purchase order initiated by the Maintenance Director, and approved by the Administrator the same day. The order status pending approval from the corporate office. On 7/15/26, the State Agency informed of a second purchase order for a bariatric shower chair. The maintenance director submitted the order on 7/15/26 at 12:09 PM, the Administrator approved it at 1:58 PM, and it is currently pending approval by the corporate office. During an interview on 7/16/26 at 10:01 AM, the Maintenance Director stated he became aware of the need for a bariatric shower chair the day after the leg broke off the previous chair. He stated he submitted a purchase order for it on 6/30/26 and it still has not been approved. He added he did resubmit the order again yesterday and it has not been approved. He explained anything that is over $500 needs to be approved. The MD stated the Administrator approved the request, however the corporate office has yet to give approval. He stated there is no other bariatric shower chair in the facility. During an interview on 7/16/26 at 11:30 AM, the Director of Nursing (DON) stated she did not know anything about a bariatric shower chair. She explained the facilty had a big long bed that is used for residents to take showers. She stated she is not aware of Resident #2 not getting his showers. The DON stated she has seen shower sheets for Resident #2 but was not aware he was not getting actual showers, and was not aware he preferred to get a shower over a bed bath. She stated that is not acceptable for staff to only offer bed baths and the staff should have let management know his preference. The DON added it can take some time to get things approved from corporate.During an interview on 7/16/26 at 11:57 AM, the Administrator stated she only became aware of the bariatric shower chair issue yesterday when the State Agency asked about a replacement chair. She stated she approved a purchase order right away and then maintenance submitted a request again. The Administrator explained when she found out about needing a new bariatric shower chair she reached out to the owner and they said they would approve immediately. The Administrator stated she did not know how long it should take to get the approval, adding it should be as soon as possible for a need like that.Review of the facility policy titled Residents Rights dated of 3/4/25, revealed, in part: The resident has the right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the facility.

Based on personnel file review, facility policy review, and staff interview, the facility failed to ensure all employees had a criminal and abuse registry background checks completed prior to the start of employment for 1 of 7 employee files reviewed. The facility identified a census of 59 residents. Findings include:Review of a New Hire Date report dated 1/1/26 to 7/18/26 revealed Staff K, former Administrator had a hire date of 6/8/26. Review of Staff K's personnel file confirmed a hire date of 6/8/26, and found no documentation that a criminal and abuse registry background check had been completed. During an interview on 7/15/26 at 3:06 PM, Staff P, Human Resources (HR)/Corporate Compliance stated Staff K did not have a SING (Single Contact Repository) background check completed. Staff P stated she found out after Staff K's 6/8/26 start date that Iowa requires the SING, and it had not been done. Staff P stated she now understands the SING needs to be completed before an employee starts work.During an interview on 7/16/26 at 11:57 AM, the current Administrator stated the SING should be done before date of hire and start of employment for all employees. Review of the facility policy titled Abuse, Neglect and Exploitation Policy revised 4/22/25, included a Policy Explanation and Compliance Guidelines section which directed, in part:The components of the facility abuse prohibition plan are discussed herein:I. Screening:A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.2. Screenings may be conducted by the facility itself, third-party agency or academic institution.3. The facility will maintain documentation of proof that the screening occurred.

Based on observations, resident and staff interviews and policy review, the facility failed to ensure sufficient nursing staff were available to provide timely care and answer call within a 15-minutes of activation for 3 of 5 residents reviewed for sufficient staffing. The facility reported a census of 59 residents. Findings include: 1. During observation on 7/13/26 starting at 3:55 PM, two call lights noted to be activated on the A Hall. At the time, Resident #11 sat in a large broda chair in his room and reported he wanted to lay down. The resident reported his call light had been on for at least 10 minutes. He explained he had completed therapy and his bottom was getting a little sore from sitting. At 4:05 PM, a Certified Nursing Assistant (CNA) entered the resident's room, shut the call light off and walked down the hall to another resident's room.At 4:09 PM, Staff C, CAN and Staff D, CNA, entered another a resident room across from Resident #11's room to assist with a transfer from a motorized wheelchair to bed.At 4:16 PM, the call light above Resident #11's room re-activated back on. At 4:23 PM, Staff D entered Resident #11's room and shut the call light off. At 4:25 PM, Staff D took a pair of gloves from a box on the wall in the hallway, then entered Resident #11's room. At 4:27 PM, Staff C entered Resident #11's room. Staff C and Staff D connected a sling under Resident #11 to a mechanical lift and transferred the resident from the broda chair to the bed. A total of 32 minutes elapsed from time light initially activated until Staff C entered room to assist with the two person transfer. 2. During observation on 7/16/26 starting at 10:55 AM, two call lights observed on in A Hall. Staff F, Licensed Practical Nurse, heard telling another staff person that one CNA was in the shower and Staff B, CNA, was on break. At 11:00 AM, Resident #11 reported his call light had been on for at least 5 minutes. He reported his incontinence brief needed changed. At 11:19 PM, Staff E, CNA, entered Resident #11's room, shut the call light off, then left the room to go to another room. During confidential resident interviews on 7/14/26 starting at 10:15 AM to 12:51 PM, three out of five interviewable (based on a Brief Interview for Mental Status each had a score of at least 13 out of 15) residents reported lengthy call light response times. The residents reported they had to wait 20 to 45 minutes for staff to come whenever they put their call light on. Two of the three residents said that staff came in the room, shut the call light off and say they would be back but the staff did not always come back. The residents reported they turned their call light on again. One resident reported it depended on the staff person working and how many staff were scheduled to work. Some of the staff acted like they did not want to be at the facility and there had been times when a staff person just walked out. Sometimes the nurse came in and asked the resident what he needed but then the nurse turned the call light back on for the CNA to come to the room and do what was needed. One resident reported the shower aide got pulled to work on the floor when the facility was short-handed and then the resident did not get his scheduled shower.During an interview on 7/16/26 at 9:00 AM, the Director of Nursing (DON) reported she expected the resident call lights to be answered within 15 minutes. She expected the nurse to answer the call light if the CNA could not get to the call light during that time. The DON stated anyone from any of the departments could answer a call light to see what the resident needed. Review of the facility policy titled Call Light Accessibility and Timely Response reviewed/revised 6/1/25 revealed a Policy statement which declared: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident' 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 Policy Explanation and Compliance Guidelines sections directed, in part:a. All staff members who see or hear an activated call light are responsible for responding.b. Process for responding to call lights:1. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel.

Based on personnel file review, facility policy review, and staff interview, the facility failed to assure all Certified Nursing Aides (CNA's) had a current, active certification prior to working in the facility for 1 of 7 employee's sampled. The facility identified a census of 59 residents. Findings include: Review of Staff L, Certified Nursing Aide (CNA) Iowa Single Contact Repository (SING) result summary dated 2/26/26, revealed: Professional Licensing. Final Result Date: 2/26/26. Final SING result: Record Not Found. This individual is current ineligible to work in Iowa. Based on the License Number and SSN (Social Security number) that was entered into SING, this individual was not found on the Iowa Nurse Aid Registry. You may verify this response through the Direct Care Worker registry at www.dia-hfd.iowa.gov professional licensing record not found. Review of the Iowa Nursing Aide Registry revealed: Certifications - Certified Nurses Aide: Status: No Employment. Currently Employed: No. Certification Date: 10/22/2020. Expiration Date: 10/22/22. Review of the facility provided report titled Active Employee Report (active as of 7/13/26) revealed Staff L listed as a full-time employee in the Nursing Department with the Position of CNA. The facility provided an offer of employment letter addressed to Staff L which indicated an anticipated first day of employment date of 2/27/26. Review of a document titled Timecard Detail Report revealed Staff L worked at the facility during the months of March, April, May, June and July 2026.During an interview on 7/15/26 at 3:06 PM, Staff P, Human Resources stated on 3/2/26 the facility completed on-boarding with Staff L, and gave her an offer letter on this date. Staff P stated the SING had already been ran which showed the CNA license was not valid. Staff P explained the facility expected Staff L to start on 2/27/26 and the skills checklist was done on 2/27/26 for a CNA position. Staff P stated Staff L did work after those dates as a CNA and is currently employed as a CNA at the facility. During an interview on 7/16/26 at 11:57 AM, the current Administrator explained in February 2026 she was not the Administrator, and the Administrator at the time was running license verifications. She stated she would expect all CNA's and nursing staff to have the current certifications or licenses while working at the facility.

Based on observation, staff interview and policy review the facility failed to prepare medication in a sanitary manner to prevent cross contamination for 1 of 4 residents (Resident #10) observed during a medication pass. The facility reported a census of 59 residents. Findings include: During observation on 7/14/26 at 8:39 AM, Staff B, Certified Medication Aide (CMA), checked the computer and prepared medications for Resident #10. Staff B punched out the following medications: colchicine, aspirin, metoprolol, furosemide, gabapentin, and two tabs of metformin from the prepared bubble packs into his bare hand and placed the pills/capsules into a medication cup. Staff B then punched sertraline, oxybutynin and bupropion from the bubble packs directly into the medication cup. At 8:44 AM, Staff B took the cup of medications and gave them to Resident #10. During an interview on 7/16/26 at 10:55 AM, Staff F, Licensed Practical Nurse (LPN), reported the process of preparing medications for a resident: use hand sanitizer, check the computer, remove the medication card from the cart, hold the medication card over the medication cup and pop out the pill into the medication cup. Staff F stated it would not be ok for staff to punch out the pills into their bare hand and then place the medication into a cup because it was not sanitary. During an interview on 7/16/26 at 11:30 AM, the Director of Nursing (DON) reported staff should punch the pill out of the medication card into a medication cup. She added the pills should not be touched with bare hands or fingers. A Medication Administration policy reviewed/revised 4/9/25 revealed medications are administered in accordance with professional standards of practice and in a manner to prevent contamination or infection.

Based on observation, resident and staff interviews, pest control statements, pest control company interviews, and policy review the facility failed to ensure an effective process in place to deter and mitigate pests in resident rooms and common areas. The facility reported a census of 59 residents. Findings include: Observations revealed the following: a. On 7/13/26 at 11:55 AM, mouse glue traps were observed in various resident rooms on the floor in the bathroom and under the radiator/furnace vent and storage rooms on Hall A and Hall B. b. On 7/15/26 at 10:50 AM, a mouse sticky pads and bait box were located in Room B14. The bait box had a grayish colored object protruding from the side. c. On 7/16/26 at 10:55 AM, a metal cage/box for rodents placed on the floor under the cabinet by the back nurse's station. A white bait box placed under the vent at the end of Hall A. In an interview on 7/15/26 at 8:25 AM, Resident #13 reported she saw mouse droppings in the bathroom in her room. She had only resided in the room for two weeks and she had observed mouse droppings in her bathroom ever since she moved into the room. She also had seen a mouse drop out of the heat vent in the bathroom while she sat on the toilet. She told maintenance about it. Maintenance brought in glue traps. Resident #13 confirmed three mice had been caught so far. The resident reported she thought the mice traveled through the heating vents in the room and the building. In an interview on 7/14/26 at 9:55 AM, Staff J, Certified Nursing Assistant (CNA), stated she had seen rodents in the front and back dining rooms and in the resident rooms. Recently when she worked, she saw two mice in the front dining room (near the front door to the facility) running back and forth. In an interview on 7/14/26 at 3:40 PM, Staff I, CNA, reported she has seen mice at the facility. On the night shift, when staff sat in the back dining room between rounds, she saw mice run in and out of the heat vents in the dining room. Staff I reported the staff would leave the lights on to deter the mice from coming out. Staff I stated she had not seen any mice in the residents' rooms. A Pest Control Service Report dated 2/5/26 and 5/13/26 revealed services entailed the exterior structure perimeter was treated per scope. The product used was a mice and rat repellent to target mice. The report also revealed prior service dates on 9/17/25, 11/18/25 and 1/15/26. The Pest Control Service Report dated 5/13/26 revealed a recommendation to patch small holes due to observation of gaps, and placement of solid bait in common areas and bedrooms. A Statement from the facility's former Pest Control company dated 7/14/26 revealed a general pest control program for dates 11/1/25, 12/1/25, 1/1/26, 2/1/26, 3/1/26, 4/1/26 and 5/1/26. The statement revealed the account was 225 days past due and services may be placed on hold or cancelled due to non-payment. In an interview on 7/14/26 at 2:50 PM, the pest control technician confirmed he came to the facility to provide pest control services. He recently provided a bed bug treatment. A few months ago around March or April, an exterior rodent spray was added to their service. He had not seen activity of pests or rodents when he came to the facility. When he spoke with the Maintenance Director, the Maintenance Director told him he had not seen any activity of rodents either. In an interview on 7/14/26 at 4:00 PM, the former Pest Control Service reported they had done monthly service and performed exterior treatment such as a barrier for insects and spiders, rodent control and overall monthly inspections. He applied chemicals based upon inspections and the reports from staff. When he was at the facility, some of the kitchen areas were cleaned and serviced monthly but they relied on reports from the facility about any activity or citing of bugs or rodents on the units or in the resident rooms. A technician came to the facility but no technician was sent in to service the facility in the past couple of months due to nonpayment for services provided. The last time a technician was at the facility was 4/2026. Per the technician's report in 3/2026, mice were caught in the break room, mechanical room and the vending area. In 4/2026, there were three mice caught on the outside (inside the bait boxes) and no mice caught on the inside. The feeding and exterior stations were heavy which meant the stations were doing their job outside. In an interview on 7/15/26 at 10:50 AM, the Maintenance Director reported he had worked at the facility for 11 months. The facility used a Pest Control services including spray and glue traps. He checked the glue traps and bait boxes throughout the facility daily. A Stick-em is placed under the baseboards, register and dark areas. The mice like to hide in the edges of the room. The pest control company sprayed outside and inside the facility once a month and whenever needed. The pest control company also checked the traps biweekly. The Maintenance Director reported the facility is strictly using the new pest control company since the facility had a change in Administration. In an interview 7/16/26 at 9:55 AM, the Administrator reported the Maintenance Director took care of pest control services. The Administrator reported they switched to a different pest control company because they did not feel the former pest control company were effective in dealing with the issues they had with pests. In an interview on 7/16/26 at 10:10 AM, the Maintenance Director reported the facility switched to a different pest control company because he did not feel the services they were getting were helping. The new pest control company came to the facility since 4/2026 and came to the facility every two weeks or whenever the facility called them. The surveyor inquired why the new pest control company was coming every two weeks. The Maintenance Director stated there had been more citing's of mice. The pest control company came to check the traps and also to treat the interior and exterior areas. In an interview on 7/16/25 at 12:40 PM, Staff P, Human Resources and Compliance Officer, reported none of the staff or maintenance went with or followed the former pest control company around the facility when they came to the facility to perform pest control treatments so the facility was not sure if the company performed the treatments or what areas were treated. The facility ended up switching to another pest control company because they had concerns that the former pest control company's services were not effective. Maintenance now went with the technician since the new pest control company started coming to the facility, and Maintenance shared concerns with what they were seeing at the facility. A Pest Control Program Policy reviewed/revised 4/2/25 revealed it is the facility's policy to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. The facility will ensure that appropriate chemicals are used to control pests. The facility will also maintain a report system of issues that may arise in-between scheduled visits with the outside pest service, and treat pests as indicated.

Based on employee file review, staff interviews, and facility policy review the facility failed to ensure 1 of 5 staff members completed the Dependent Adult Abuse training every 3 years. The facility reported a census of 59 residents. Findings include: Review of Staff's M, Registered Nurse (RN) employee file found no documentation of a current Dependent Adult Abuse training. During an interview on 7/15/26 at 3:06 PM Staff P, Human Resources (HR) stated Staff M did have Dependent Adult Abuse training, and she had just sent Staff M a copy of the certificate. Staff P added she is not sure how often staff need to update the training but guessed it was annually.On 7/16/26 at 11:30 Am the Director of Nursing (DON) stated Dependent Adult Abuse education should be completed every 3 years. She stated the facility offers the training through a website and normally the DON or Human Resources would track when the training needs to be updated.During an interview on 7/16/26 11:57 AM, the Administrator confirmed dependent adult abuse education should be completed every 3 years for staff. On 7/16/26 at 12:25 PM Staff P, Human Resources informed the State Agency the facility did not have documentation that Staff M had current Dependent Adult Abuse training. The facility's policy titled Abuse, Neglect and Exploitation Policy revised date of 4/22/25, directed Employee Training, in part: a. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation.b. Existing staff will receive annual education through planned in-services and as needed.

Based on clinical record review, facility policy review, resident and staff interview the facility failed to safely transfer a resident when staff did not utilize the correct size sling for a sit to stand mechanical lift, and failed to ensure two nursing staff assisted a resident with a mechanical lift for 1 of 4 residents (Resident #3) reviewed for falls. The facility reported a census of 59 residents. Findings include: Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had diagnoses of right knee pain and obesity. A Brief Interview for Mental Status score of 15 out of 15 indicated intact cognition. The MDS documented Resident #2 dependent on staff for chair/bed-to-chair transfers, and had no falls. Review of Resident #3's Care Plan dated 5/6/26 revealed a Focus area to address the resident is at risk for falls d/t (due to) impaired mobility, non-ambulatory status and daily use of antidepressant medications. Interventions included, in part:a. 2 assist large sling, full body sit to stand lift for all transfers. Date Initiated: 6/16/26.b. Dycem (brand name for a non-slip material which provides grip and improves stability) to the edge of the bed. Date Initiated: 6/16/26.During an interview on 7/14/26 at 10:15 AM, Resident #3 reported she had a fall a couple of weeks ago. The resident explained she was in the sit to stand lift, the back strap (on the sling) was too big and she slipped through it. Resident #3 stated she did not incur any injuries from the fell. Review of the electronic health record revealed:a. A Post Fall Note entered on 6/15/26 at 2:14 PM: CNA (Certified Nursing Assistant) reported to nurse that the resident slid from the edge of the bed to the floor during a transfer with a [NAME] lift (sit to stand lift). A full skin assessment revealed no injuries or bruises noted. Resident denied pain. Neuro checks and range of motion WNL (within normal limits). A Dycem stay put non-slip material added to the mattress. CNA educated on proper positioning.b. A Post Fall Review Note entered on on 6/16/26 at 1:00 PM: A fall occurred on 6/15/26. The fall was witnessed. The resident sustained no injury related to the fall. Resident to be a Hoyer (brand name for a full body mechanical) lift at this time because of lack of strength to use a [NAME] lift. A physical therapy referral recommended.c. MDS Note entered on 6/16/2026 at 4:32 PM: Resident admitted to facility from the hospital on 3/26/25. Diagnosis included knee pain, weakness and obesity. Resident requires two assist sit to stand with large sling for all transfers. Resident was evaluated for fall risk on admission and care plan was initiated with interventions implemented. Resident had witnessed fall on 6/15/26. Resident states they were transferring her with a sit to stand lift to her bed and she slipped when being lowered to the bed. Resident reported she slid off of the mattress onto the floor. Resident reports no pain or injury as a result of this. Plan of care was updated to include a Dycem to the edge of mattress and the CNA was provided education on transfers and positioning.Review of an Incident Audit Report revealed, in part: At 6/15/26 at 3:47 PM: Nursing Description: CNA reported to nurse that during resident transfer with a [NAME]-lift to bed, the resident slid to the floor from the bed. Resident Description: Resident states she was sitting on her bed and started to slide to the floor. Resident states she is unsure how ti happened but slid to the floor. She reports no pain or injury.During an interview on 7/15/26 at 2:45 PM, Staff G, CNA, reported she had four days of orientation when she began to work at the facility. Staff G stated Resident #3 used the sit to stand lift for transfers, and had had one fall, which occurred when she assisted the resident. She explained the resident fell because the wrong sized sling was used and during the transfer Resident #3 slid out of the sling. Staff G stated an extra-large sling had been left on the sit to stand device and she thought that was the sling Resident #3 used. She stated Resident #3 uses a large sized sling. Staff G stated she was the only staff who assisted Resident #3 during this transfer.During an interview on 7/16/26 at 8:50 AM, Staff G, CNA, reported she had worked at the facility for 1 year. She explained she looked at the Kardex (care plan) to know what a resident needed done or how the resident transferred. Her orientation entailed staff showed her around the facility, how to work the equipment, the location of supplies, and how things are done. She looked at the Kardex banner to see what size sling a resident needed. The tag on the sling had a hole punched next to the size, and that is how she knew the size of the sling. Staff G reported the facility had a lot of regular slings for lifts but not a lot of slings for the sit to stand. Staff G took the State Agency to the closet with the slings and showed the tags on the sling with a punch indicating the size of sling. Staff G reported only two residents used the sit to stand lift. Resident #3 used a large sling and a sit to stand lift. During an interview on 7/16/26 at 9:00 AM, the Director of Nursing (DON) reported she expected staff to follow the Kardex to know how a resident transferred and the size sling needed for transfers with a mechanical lift. She updated the Care Plans recently with the sling sizes for each resident. There were two slings for each resident. The DON reported she worked the floor on the day Resident #3 had a fall but was not involved in any follow up related to the resident's fall or the staff involved. During an interview on 7/16/26 at 10:45 AM, the DON reported that two staff were required for all transfers with a mechanical lift including a sit to stand lift. During an interview on 7/16/26 at 10:50 AM Staff H, CNA, reported she looked at the Kardex to know what size sling a resident used. Staff H stated she sized up the resident to ensure the sling fit properly. Staff H stated she tells by looking at the sling if it's the correct size and if the sling will fit the resident, adding it is just common sense when you see the size of the person and what size sling to use. Staff H explained the sling had a tag that indicated the size of the sling, and the facility provided training on the slings and mechanical lifts about 2 weeks ago. She explained there was a demonstration on making sure staff knew how to fit the resident for the sling, use of the mechanical lift machines, including the sit to stand lift, and where to place the strap on the resident. During an interview on 7/16/26 at 11:00 AM, Staff E, CNA, reported she looked at the Kardex to know if a resident needed to use a lift for transfers and what size sling to use for that resident. She stated she would also check with the ADON (Assistant Director of Nursing) if needed. Staff E explained the sling size is marked on the back of the sling, or there is a yellow dot on the tag of the sling to indicate if the sling was a medium, large or extra-large sling. She stated the facility provided education two weeks ago about how to use the stand lift and went over the proper sling sizes to use. During an interview on 7/16/26 at 11:30 AM, the DON reported she saw something related to education or counseling in the former DON's office for Staff G, CNA. She will look for it and provide to the State Agency. No documentation was provided to the State Agency. Review of a Sit to Stand Mechanical Lift Validation Checklist signed by Staff G, CNA on 3/20/26 revealed the following procedural steps: a. Review the resident's care plan.b. Gather needed supplies. Ensure the sling is the correct size and in good working condition. c. Ensure two staff members present.d. Position the resident on the appropriately sized sling according to the resident's care plan. e. Position the lift.f. Attach the sling straps to the lift.g. Gently raise the resident up and ensure the sling straps are secure.h. Transfer resident to surface and gently lower the resident.i. Remove the sling.Review of the facility policy titled A Safe Resident Handling and Transfer Policy reviewed/revised on 6/1/25 revealed: It is the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Mechanical lifts may include equipment such as a full body lift and a sit to stand lift. Staff will inspect the equipment prior to use to ensure functionality. Residents measured correctly as per the manufacturer's instructions on the proper sling sizing. Resident lifting and transferring will be performed according to the resident's individual plan of care. Two staff members must be utilized whenever a resident transferred with a mechanical lift.

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to implement individualized interventions related to positioning in bed for a dependent resident at high risk for falls for 1 of 4 (Resident #1) residents reviewed for safety. The facility reported a census of 62 residents.Findings include:Review of Resident #1's Minimum Data Set (MDS) admission assessment dated [DATE], revealed no score for the Brief Interview for Mental Status. The list of diagnoses included seizure disorder, anoxic brain damage not elsewhere classified, cognitive communication deficit and severe cognitive impairment. The MDS indicated Resident #1 dependent for all activities of daily living (ADL's), and due to medical condition did not attempt rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. The MDS dated [DATE] indicated Resident #1 dependent for rolling left and right, chair/bed-to-chair transfer. The MDS documented Resident #1 had No Falls Since Admission.Review of Resident #1's electronic health record (EHR) revealed an admission packet from a previous long term care facility. The Care Plan included an undated Focus area to address Resident is at risk of falls r/t (related to) needs assist of 2 and Hoyer Lift (a brand of mechanical lift) for all transfers; with a Goal dated 12/11/25, to Minimize risk for falls throughout next review. Undated Interventions included, in part: Assist resident with transfers as needed, she needs assist of 2 and Hoyer lift for transfers; Bed is in low position, when she is in it; and Positioning Device to reposition approx. (approximately) Q (every) 2 hrs and PRN (as needed).Review of the Baseline Care Plan dated 10/30/25 revealed, in part:a. Section G. SAFETY & SKIN Risks.Is the resident at risk for falls: Yes.Fall Care Plan: Focus: Resident is at risk for falls.Interventions:1. Anticipate and meet the resident's needs.2. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.3. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair.4. Maintain safe environment for resident: floors free of clutter/spills, working/reachable call light, bed in low position, personal items in reach.Review of Fall Risk Assessments in the EHR revealed:a. On 10/30/25 a score of 50, which per the scale indicated high risk for falls.b. On 2/6/26 a score of 30, which indicated a moderate risk for falls.c. On 5/30/26 a score of 55, which indicated a high risk for falls.Review of Resident #1's Care Plan revealed the following Focus area's:a. Initiated on 11/05/25: Advanced Directives.b. Initiated on 11/25/25: GERD (gastroesophageal reflux disease, often called heart burn); Risk of pressure ulcers; Bowel incontinence; Indwelling catheter; Risk of constipation; Seizure disorder; Communication problem; Impaired cognitive functioning; Hypertension; Dependent on staff to complete ADL care.c. Initiated on 1/21/26: Allergic to certain medication: Erythromycin.d. Initiated on 2/9/26: Independent and formal group activities.e. Initiated on 3/20/26: Impaired ability to transfer independently.f. Initiated on 3/21/26: Impaired ability to bathe/shower.g. Initiated on 4/9/26: Impaired ability to eat independently; Impaired ability to complete oral and/or personal hygiene; Impaired ability to dress self; Impaired ability to independently toilet; Impaired bed mobility; Impaired ability to bathe/shower.h. Initiated on 4/13/26: Enteral Nutrition (feeding through a tube inserted through the abdominal wall into the stomach); Remain in facility.i. Initiated on 4/30/26: Impaired Ability to complete oral and/or personal hygiene tasks.j. Initiated on 6/1/26: Risk for falls.Review of the EHR revealed the following:a. A General Note entered on 5/30/26 at 4:22 PM: Approximately 1548 [3:48 PM], I was notified the resident was on the floor by staff. I proceeded to find Resident on the right side of her bed face down. I felt for her pulse, she was breathing and responsive. Nursing staff as well as two aids assisted with safely turning her on her back, disconnecting her tube feeding to help prevent aspiration from her feeding. Vitals obtained, BP 97/64, pulse 92, temp 97.0, O2% 96. No open wounds were visualized. No blood noted. Ambulance called, Report given to [Name of hospital redacted]. Left message with [provider name redacted] Hoyer assisted by staff to place the patient on the stretcher with [Name of emergency services redacted] ambulance staff. Resident's POA notified.b. A General Note entered on 5/30/26 at 4:53 PM: Prior to being notified of the resident on floor, I rounded 30 minutes befor and seen resident in her bed. Entered by facility nursing staff.c. A General Note entered on 5/30/26 at 11:43 PM: Resident admitted to the [name of hospital redacted].d. A Change of Condition note entered on 6/1/26 at 11:05 AM:Resident observed on floor adjacent to bed following an unwitnessed fall from bed. Resident is a quadriplegic with significant mobility limitations and is dependent on staff for all transfers, positioning, and activities of daily living. Resident receives nutrition via G-tube and has multiple comorbidities contributing to elevated risk for injury and complications.Upon assessment, resident was awake and responsive to baseline level of cognition. Head-to-toe assessment completed immediately. No visible injuries noted. No bruising, swelling, lacerations, deformities, or bleeding observed. Range of motion unchanged from baseline limitations. Skin assessment completed with no new areas of concern identified. Vital signs obtained and documented. Neurological assessment completed with findings consistent with resident's baseline status. Resident denied pain/discomfort (or unable to verbalize pain; assessed utilizing facility-approved pain scale).Physician notified of incident. Responsible party/family notified. Neurological monitoring initiated per facility protocol. Resident transferred from floor utilizing appropriate mechanical lift and staff assistance with EMS. Resident monitored closely for delayed signs or symptoms of injury.Following further medical evaluation, resident was transferred to the hospital for assessment and treatment of acute medical conditions including urinary tract infection, hypothermia, and aspiration pneumonia. At the time of transfer, there were no identified injuries related to the fall event. Clinical presentation and transfer were related to acute medical concerns requiring hospital evaluation and treatment.Resident remains at high risk for falls and injury due to quadriplegia, inability to independently reposition, dependence for mobility, and complex medical status. Care plan reviewed and updated. Interdisciplinary team notified for follow-up and ongoing monitoring.e. A Risk Meeting Note entered on 6/1/26 at 11:06 AM: Post-Fall Interventions:1. Maintain bed in lowest position at all times unless direct care is being provided.2. Place bilateral floor mats at bedside when resident is in bed.3. Continue Q2-hour rounds for safety, positioning, comfort, toileting needs, and environmental assessment.4. Continue scheduled repositioning at minimum every 2 hours and as needed 5. Ensure call light and personal items remain within reach when resident is able to utilize them.6. Utilize pressure-relieving mattress, or perimeter mattress and positioning devices (wedges) to maintain proper alignment and reduce migration within bed.7. Evaluate need for wedge cushions, positioning bolsters, or specialty equipment to reduce risk of rolling or sliding from bed.8. Educate staff regarding resident-specific transfer, positioning, and safety precautions.9. Review Kardex and care plan with direct care staff.10. Complete post-fall neurological assessments per facility protocol.11. Monitor for delayed signs/symptoms of injury, pain, altered mental status, skin changes, or decline in condition. 12. Continue G-tube safety precautions and aspiration precautions as ordered.13. Interdisciplinary review of fall event including nursing, therapy, provider, and risk management as indicated.14. Review hospital findings upon return and revise care plan based on any new recommendations.f. A Risk Meeting Note entered on 6/1/26 at 11:30 AM: Resident reviewed in risk meeting for follow up of fall on 5/30/26. She had no injury from fall. Interventions were to make sure bed is to floor and fall mat. Care plan reviewed, updated and currently meets resident needs. Resident receiving PT/OT services at time of fall. Resident sent to ER for post fall evaluation.g. A General Note entered on 6/2/26 at 10:35 PM: Resident arrived back to the facility via medical transport 1800. 16 F foley in place, patent and draining.Review of a Hospital Discharge summary dated [DATE], revealed, in part.assessed in the Emergency Department on 5/30/26 after a fall at the nursing home, no injuries were identified related to the fall. During an observation on 6/3/26 at 8:50 AM, Resident #1 in bed and covered with a blanket. The resident is positioned on her back leaning towards her right side with the head of bed elevated, and the bed in a low position. Fall mats placed on the floor, on both sides of the bed. The residents head positioned on a pillow, protective boots on her feet, and the call light positioned on resident's chest.During an observation on 6/4/26 at 8:40 AM, Resident #1 in bed, with her eyes closed, covered with a blanket and positioned on her back. The call light positioned on the resident's chest, with fall mats positioned on floor on both sides of the bed. The resident's bed in the low position, with the head of the bed elevated. Four (4) green wedges in place for positioning support on both arms and legs. During an interview on 6/2/26 at 3:38 PM, Staff A, Registered Nurse (RN), stated was on duty and assigned to the resident's hall on the 6 AM to 6 PM shift on 5/30/26. Staff A explained Resident #1 is non-verbal, she had a traumatic brain injury (TBI) and was total care. She added the resident might move her arms towards her during stimulus, her legs might quiver if she was uncomfortable. Staff A stated she had last seen the resident on her back in bed with the head of the bed up 10 to 15 minutes before she was found on the floor. Staff A stated the height of Resident #1's bed had not been changed and the top of her mattress was at the nurse's waist level, she stated she was 5'2 tall. She assessed her for injury did not identify any physical injuries and she did not have seizure activity. She carefully rolled her to her back with staff assistance, no physical injuries were found. She called the provider for orders and called 911. She didn't know how she fell and the staff on duty didn't know how she fell.During an interview on 6/3/26 at 11:54 AM, Staff B, Certified Nursing Assistant (CNA), stated if Resident #1 was on her back in bed she could move towards her right, or would end up in that direction, she sort of leaned that way. She checked on the resident often, every time she walked past the room, and they check/change her/repositioned Resident #1 at least every 2 hours. If positioned correctly she thought the resident would be okay. Staff B reported on 5/30/26, she saw Resident #1 between 2 and 3 PM. She described Resident #1 having been in bed, on her back with the head of the bed up. Staff B stated the resident's bed had been kept bed at waist height to her [Staff B] and she was 5'7 tall. She stated the bed was not in the low position. Staff B explained when she went past the resident's room around 3:30 PM, she saw the resident was not in bed. Staff B stated she found the resident face down on the floor with the blanket under her [Resident #1]. During an interview on 6/3/26 at 12:18 PM, Staff C, CNA, stated she worked on the resident's hall on the 6 AM. to 2 PM shift on 5/30/26. Lately it seemed like the resident moved more, and her eyes moved more. Staff C stated when the resident was in bed, she would stay in the position left in. Staff C stated the resident didn't move her head off the pillow until 5/30/26. Staff C stated Resident #1 moved her head more that day and she told the nurse. Staff C explained when she moved her head her shoulders and upper torso did not move. Staff C stated the resident's bed was kept at her waist level, and she reported stood 5'3 tall. Staff C stated she last checked on the resident at 2 PM on 5/30/26, recalled the resident positioned her on her back, with her head of the bed up. The resident's door had been kept open and Staff C stated she always looked in the room when she went by. Staff C stated it seemed like she moved more but she never thought she would fall off the bed, she was very surprised by that. Staff C added positioning wedges were now in the residents room, and staff were supposed to use them to establish a boundary for the sides of the bed.During another interview on 6/4/26 at 8:58 AM, Staff C, CNA, stated she was on duty the evening of 6/2/26 when the resident came back from the hospital, and how she knew they were supposed to use the wedges to position her. Staff C explained since Resident #1 returned from the hospital they were supposed to keep her bed low, fall mats on both sides of the bed and use the wedges to position her/establish boundaries for the sides of the bed.During an interview on 6/3/26 at 9:59 AM, Staff F, RN, stated Resident #1 could make slight body movements, which were not predictable and not purposeful, Staff F added the resident would end up leaning towards her left side when she'd been positioned on her back with the head of the bed up and with pillows used. During an interview on 6/3/26 at 12:00 PM, Staff G, Physical Therapist (PT), stated there were wedges to be used to position the resident, she thought the resident would be entrapped by side rails and used CMS (Centers for Medicare and Medicaid Services) guidelines about bed rails for that determination. Staff should use the wedges to position her and they could have used a body pillow or something similar to define the border of the bed for the resident's safety. Staff G stated she did not anticipate her fall.During an interview on 6/4/26 at 9:35 AM, the interim Director of Nursing (DON), stated staff had not completed the Fall Risk Assessments correctly, in Section E staff selected impaired gait for the resident, when they should have selected normal and staff were educated on the issue. When asked about the recent changes to Resident #1's Care Plan (low bed, the use of wedges to position the resident and fall mats) the DON stated staff had been educated about the changes during Huddle meetings when they were on duty, not all staff had been educated as of that time, she would continue the education as staff worked during the following days, and staff also received messages about the changes on their phones.Review of the facility policy titled Fall Risk assessment dated [DATE] revealed the following Policy statement: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents.The Policy Explanation and Compliance Guidelines directed: 1. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified.2. The risk assessment will contain the following components:a. Identify environmental hazards and individual risks, including the need for supervisionb. Evaluate and analyze hazards and risks3. An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly.4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident.5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.

Based on observations, clinical record review, facility policy review, lift manufacturer safety instructions, local fire department personnel interviews, and resident and staff interviews, the facility failed to provide staff education on how to select the right size body sling for residents dependent on the use of a mechanical lift, failed to identify a hospital slide sheet as unsafe for use with a mechanical lift, and failed to have correct mechanical lift sling sizes available to meet the needs of a bariatric resident for 2 of 12 residents (Resident #8 and Resident #39) reviewed for mechanical lift transfer. Nursing staff failed to safely transfer Resident #8 when they placed a hospital slide sheet with handles under the resident, attached the handles to the mechanical lift, and engaged the lift. The handles tore from the slide sheet and the resident had to be emergently lowered to a recliner. Resident #8 repeatedly voiced fear of falling. Nursing staff were unable to transfer the resident out of the recliner and called the local fire department for assistance. The fire department personnel attempted to manually transfer Resident #8 with the slide sheet, which again tore. A second unit from the local fire department was called to assist. The State Agency (SA) informed the facility of the Immediate Jeopardy (IJ ) on 3/20/26 at 10:12 AM. The IJ began on 2/26/26, when staff used a hospital slide sheet as a mechanical lift body sling, engaged the lift and the sheet tore from the lift hooks. On 3/23/26, the SA confirmed the immediacy removed effective 3/21/26, through the following actions: 1. The Director of Nursing (DON) and designee(s) trained all nurses and nurse aides on the use of mechanical lift and sit to stand lift. All staff will be trained prior to their next shift.2. The DON and designee(s) reviewed the care plan for each resident who require the use of a mechanical lift or sit to stand lift to ensure resident specific interventions were present. Proper sling size and fit for each resident was added as an intervention, pulling to Kardex (care guide) and care profile.3. The DON and designee(s) re-assessed residents requiring mechanical lifts for transfers via the Mechanical Lift and Sling Size Risk Evaluation.4. The DON and designee(s) trained nursing staff on the location of the sling size and type of mechanical lift or sit to stand lift to utilize for residents requiring lifts for transfers via the Kardex in the POC portion of PCC. This training includes reviewing of Kardex prior to transferring residents as assessments can change based on resident condition changes.5. All facility specific policies and procedures regarding mechanical lifts were reviewed/revised to ensure compliance with manufacturer's recommendations and guidelines. Nursing staff were re-educated on 3/20/26, remaining nursing staff will be educated prior to their next shift.6. The Administrator purchased two slings on 3/5/2026 that will accommodate weight up to 1000 pounds.The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education and procedures.The facility reported a census of 59 residents. Findings include:1. Review of the Minimum Data Set (MDS) for Resident #8, dated 2/17/26 revealed diagnoses which included morbid obesity, anxiety, depression, and acute and chronic respiratory failure with hypoxia (low oxygen levels in body). The MDS identified Resident #8 did not attempt sitting to lying, lying to sitting on the side of bed, sit to stand, or chair/bed-to-chair transfer due to medical concerns or safety concerns. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicated intact cognition. The MDS listed a height of 69 inches, and weight of 535 pounds. Review of Resident 8's Care Plan revealed Focus areas to address: a. Resident is at risk or has actual IMPAIRED ABILITY TO TRANFER INDEPENDENTLY. Date Initiated: 7/31/25. Goal: Resident will FREE FROM COMPLICATIONS related to impaired transfer ability through next review date. Target Date: 4/30/26. Interventions included TRANSFER: The resident is dependent for transfers and requires MECHANICAL LIFT total body lift with 2 HELPERS for transfers. Date Initiated: 7/31/25.b. Resident has a HISTORY OF POTENTIALLY TRAUMATIC EVENTS and is at risk for re-traumatization and/or experiencing a traumatic stress response. Initiated: 8/26/25. Goal: Resident will feel safe and comfortable in direct care situations. Target Date: 4/30/26. Interventions included, in part: Help Resident IDENTIFY TRIGGERS that prompt anxiety or symptoms and evaluate the outcome of these reactions. Date Initiated: 8/26/25. During an interview on 3/15/26 at 11:45 AM, Resident #8 stated it could take 2-3 hours in the evenings before her call light got answered. Resident #8 explained the staff told her they needed to get someone to help and would be back, and then after an hour she would have to activate her call light again. When the staff returned, she would be told the same thing. Resident #8 stated she had called her niece, who then called the facility. Staff would tell her they were about to respond and the nurse was aware. The interview interrupted due to resident care needs. Resident #8 asked for the SA to return to finish the interview. However, later on 3/15/26, the Resident hospitalized and did not return prior to the exit. A review of the electronic health record (EHR) revealed the following:a. A Mechanical Lift & Sling Size Risk Evaluation, dated 2/18/26 revealed: LIFT EVAL: What can the resident do to assist with transfer: Dependent. Sling Size: Most Recent height: 69.0 inches as of 7/25/25. Most Recent Weight: 534.5 Lbs (pounds) as of 2/3/26. Scale: Bariatric Lift. What weight range does the resident fall in: 350-600 lbs Extra Extra (XXL). Which sling size should be used: Extra Extra (XXL)b. A Progress Note, dated 2/26/26 at 11:01PM, entered by Staff Q, Licensed Practical Nurse (LPN) documented Resident #8 complained of indigestion/heartburn and requested to be assisted into her recliner. CNAs hoyered (transferred via mechanical lift) resident to recliner and during the process the hoyer sling straps started to snap resident was lowered into the chair safely, after an hour resident wanted to get back into bed. This nurse had to call the fire department to help assist resident safely back to bed. It took 8 firemen to transfer resident back to bed. c. A General Note entered on 2/27/26 at 9:00 AM revealed Resident #8 reported her right 5th toenail was snagged last night when she was placed in bed. The nurse evaluated and clipped the toenail that was sharp then bacitracin and bandage was applied.d. A General Note entered on 2/27/26 at 9:05 AM, entered by Staff F, LPN Wound Nurse documented Late documentation - Floor nurse and CNA reported to this nurse that during attempt to transfer resident from her recliner to bed, residents sling began to rip. Resident was immediately lowered back into her chair. EMT's (emergency medical team) called to help assist staff to get resident into bed. 3 EMT's arrived and assessed situation. In front of resident EMT's claimed that there was insufficient equipment in the facility to transfer the resident. Of note, Hoyer (full body mechanical lift) sling broke immediately before they were called and prior to this her hoyer sling has been sufficient. These EMT's called fire department in order to get resident into her bed. 6 EMT's voiced to this nurse that they were going to move resident bed in front of her recliner and transfer into her bed manually. EMT's reported that this was successful. As floor nurse in charge of resident was unable to document in progress note, this nurse is documenting today. Will continue to monitor. e. A Nutrition/Dietary Note, dated 3/16/26: RD (Registered Dietician) SIG (significant CHANGE ASSESSMENT: CBW (Current body weight): 574.5 # (pounds)Review of a Grievance/Concern Report, dated 3/2/26, revealed, in part: Resident: [Name redacted, Resident #8] .Description of grievance/concern: (Removing red and yellow? Agree with this) .States Hoyer (a brand name of a type of mechanical lift, often used to describe all brands of mechanical lifts) lift was recently used and it tore so the medics (Fire Department) came to assist.Describe actions taken to resolve the grievance/complaint: Education on Hoyer operation/new sling ordered.Was grievance/complaint resolved: Yes, [name redacted, Resident #8] was happy - new slings arrived. During an interview on 3/17/2026 at 4:25 PM, Staff N, Certified Nursing Assistant (CNA) queried about the mechanical lift sling used to transfer Resident #8. Staff N opened up a closet in the B hallway which contained three shelves of lift slings. Staff N pulled out slings until she located a sling with a blue ribbon and identified it as the sling used for Resident #8. Staff N stated the sling crisscrossed between Resident #8's legs. Staff N stated the sling was an X-large identified by ribbon color. Upon inspection, the tag appeared worn/torn and the size and weight limit were unable to be identified. During an interview on 3/17/2026 at 4:27 PM, Staff O, CNA stated she was hired on 2/11/26. Staff O stated she was educated to get the slings from the closet in the B hallway, and most residents have special instructions in the EHR [brand name of EHR redacted]. Staff O stated the blue-ribbon mechanical lift slings were X-large and green ribboned slings were large. Staff O stated during her shift from 2-10 pm on 2/26/26, Staff M, CNA, and Staff AA, CNA asked her to assist with transferring Resident #8 from bed to a recliner due to complaints of heart burn. Staff O stated the sling used for the transfer was one she had never used before at the facility. She explained it was not netted or cloth, rather it looked like a transfer sling, silver on one side, blue on the other and multiple loops on each of the long sides. Staff O stated the only other sling available was a medium, purple ribboned sling that would not work for Resident #8. Staff O stated this was the first time she had assisted to transfer Resident #8. Staff O stated they put the silver/blue sling with the multiple loops under Resident #8, and attached the second loop from the top and the second loop from the bottom on each side of the sling to the Hoyer. Staff O further explained started to elevate the lift. As Staff O moved the Hoyer away from the bed, she heard the sling rip. Staff O explained the resident said she heard the rip, and she was scared of falling. Staff O stated she had the right side of the sling and the lift controller in her hands. Staff M, CNA stood behind the recliner, pushed it underneath the resident, and grabbed the top of the sling. Staff O stated Staff AA, CNA stood on the left side. Per Staff O, they held on until Resident #8 was lowered into the recliner. Staff O stated it was very scary. Staff O explained the sling then ripped on the bottom of the right side, and the loops pulled away from the sling. Staff O informed Staff Q, LPN of the situation and Staff Q called the DON. The DON directed me to call the fire department for assistance. Staff O further explained three firemen men responded, and Staff O described Resident #8 as looking scared with her arms crossed. The resident did not talk. Staff O stated the fireman suggested they attempted to lift Resident #8 with the lift by attaching the sling on the third loops from the bottom to raise her enough to place the purple sling under the torn sling. Staff O stated when that was attempted, the loops on the left side ripped from the lining. They lowered the resident down to the chair. Staff O explained Resident #8 repeatedly said How are you going to get me back to bed?. The firefighters called the department for additional assistance. When the additional personnel arrived, they took the headboard off the bed, and lowered the bed to the level of the foot of the recliner. The firefighters curled the sides of the torn sling and pulled Resident #8 into bed. Staff O stated Resident #8 reported she was in pain as her toe was run over by the Hoyer. During an interview on 3/17/2026 at 5:05 PM, Staff M, CNA stated the facility did not provide training for the Hoyer or for sling use. Staff M explained there were multiple slings in the chaotic closet. Staff M stated the facility did not provide the equipment for a resident that weighed as much as Resident #8, and they did not have an appropriate sling. Per Staff M, there were not enough staff to provide transfer assistance so Resident #8 did not get up in the evening. Staff M added the resident had been to the hospital several times and was transferred by the fire department with EMT's (emergency medical technicians). Staff M stated on 2/26/26, Staff Q, LPN directed her to transfer Resident #8 from the bed to a recliner. Staff M stated she told Staff Q that she did not feel good about it since there were only three CNAs and a sling that came from the hospital. Staff M described the hospital sling as blue on one side and grey on the other side. Staff M explained she was not familiar with the sling. Per Staff M, Staff Q said she wanted Resident #8 in the recliner so Staff M? had Staff AA and Staff O assist. Staff M stated they placed the sling under Resident #8 and moved her away from the bed. Staff M stated, My heart almost came out, I have never heard a sling tear before. Staff M stated she pushed the recliner under Resident #8 and felt if she would not have been there, Resident #8 would have been on the floor. Staff M stated she notified Staff Q that Resident #8 was stuck in the chair on a ripped sling and it required everyone in the building to turn her, 4 or more staff. Staff M stated she was not asked to assist when the firemen came. Staff M stated management purchased a sling to support 600 pounds to replace the torn sling. Staff M stated she did not think it was wide enough for the resident. During an interview on 3/18/2026 at 11:35 AM, the Fire Chief stated the fire department staff had been called for assistance to transfer Resident #8 from the nursing home to the hospital. The Fire Chief stated the facility did not have the appropriate sling for the resident's weight, and the facility staff asked the crew to run the mechanical lift. The Fire Chief stated he told his staff that facility staff needed to manage their own equipment. The Fire Chief stated he then notified the Administrator. The Administrator assured him that staff were trained on the use of the mechanical lift, the facility had the appropriate slings, and she would take care of it. On 2/26/26, the fire department was notified the nursing home needed assistance. The Fire Chief stated the facility staff used a lift sheet, not a mechanical lift sling, for Resident #8. He stated the sheet ripped during the lift which caused Resident #8 to be stuck in a recliner. The Fire Chief shared two emails regarding emergency services calls to the facility to assist transfers for Resident #8. Email received on 3/18/26 at 12:11 PM. An email dated 2/12/26 from the Fire Chief addressed to the facility Administrator read: This email is a follow up to a previous email sent out by [fire department personnel name redacted] and a conversation which was held by [fire department personal name redacted] and yourself [Administrator] in regards to the bariatric patient in [room number redacted, Resident #8] at the facility. I am requesting information on the actual procedure in which you would like us to follow for the safety of the patient and my crew. I would also like to limit the liability issues which could come about with not having a set procedure in place to handle this patient. The patient we are regularly going to at this facility is well over 500 pounds. The main issues are continually dealing with are split between the staff at the facility and EMS response to this patient. The staff at the facility do not seem to have a clear answer on the use of the Hoyer lift. When responding to these calls they come at different times of day and different staff members present. Each time we get conflicting information how we are to use their equipment and move the patient. I believe they have different styles of lifts and rating. Staff have also stated we are not to use any lifts and want us to manually move the patient. The following are questions for the facility:The Administrator responded to the questions below on 2/12/26 at 9:42 AM. The fire department relayed the answers to their staff on 2/12/26 at 11:06 AM. 1. Is the Hoyer lift they have on the site capable and rated to lift the patient safely? Administrator response: Rated for 1000# (pounds)2. Is the sling used rated and capable of lifting the resident safety? Administrator response Yes, it is specifically for that patient3. Are all employees trained in the use of and selection of the proper equipment in moving the resident? Administrator response: All employees are trained in the use of the lifts and the DON will refresh the employees as well after the conversation with the Administrator. 4. Are they to run the lift and not us? They have stepped away from the lift and stated they didn't know how to use it. Administrator response: They are to run the lift. If they say they don't know how to use it, let me [fire department supervisory staff] know immediately, try to get the name of the staff, and I [fire department supervisor staff] will get in touch with the administrator. During an interview on 3/18/26 at 3:43 PM, the Administrator stated she was unaware of a color coordination to the size of the mechanical lift sling and stated each resident had a mechanical lift sling with their name on it. Per the Administrator, the slings were not shared. The Administrator picked up a resident's sling. It lacked a name on it and the inside label was unreadable. The Administrator notified the DON on 3/18/26 at 4:03 p.m. per phone call, who stated all of the weights and sizes were listed inside of the sling on the label.During an interview on 3/19/26 at 8:29 AM, the Lieutenant of the local fire department stated the fire department staff had been dispatched to the facility multiple times to assist with Resident #8. The Lieutenant stated the time that concerned him the most was on 2/26/26. The Lieutenant stated he was the first to arrive. He found Resident #8 in a recliner with a torn slide sheet under her. The Lieutenant stated Resident #8 told him the slide sheet was torn and she was stuck in the recliner. The Lieutenant stated the staff nurse entered the room and stated she was told at shift change she was to call the fire department when the resident was ready to go back to bed. The staff nurse then left the room. The Lieutenant stated, that was their solution to their problem, that was their plan, to utilize the fire department. The Lieutenant stated two facility staff in the room reported that the slide sheet began to rip while Resident #8 was elevated during the transfer from the bed to the recliner. The Lieutenant stated if those handles would have completely ripped, Resident #8 would have been seriously hurt. Per the Lieutenant, that was his major concern. The Lieutenant stated there was a Hoyer sling on a counter with a label for 500 pounds and he did not know why the staff did not use it. The Lieutenant stated he did not know what the facility had for slings, but during a different dispatch staff weighed Resident #8 at 600 pounds. The Lieutenant wanted safety for the resident and the fire crew. He stated the facility had low staffing on the evenings but that was their patient, and (facility) should not be calling the fire department. The Lieutenant stated on 2/26/26 the first attempt to transfer Resident #8 involved wedging the recliner against the wall. The facility staff lifted her again with the Hoyer, using the lift sheet, so the other sling could be placed under Resident #8. The Lieutenant stated the lift sheet started ripping again, one handle after the other right down the side. Resident #8 was lowered back down in the recliner. The Lieutenant explained he called for three more firefighters to assist. When the additional crew arrived, they lowered the bed, took the head board off, and put the bed at the foot of the recliner. He explained it took all six of the crew to slide Resident #8 into the bed using the torn lift sheet. The Lieutenant stated his crew recognized the torn sheet. Per the Lieutenant, it was a slide sheet/transfer sheet from the hospital and not a Hoyer sling. The Lieutenant stated, This was the most unsafe situation. During an interview on 3/23/26 at 10:25 AM, Staff BB, CNA stated she provided training for new CNAs. Staff BB stated 5 days ago [March 18, 2026], the DON, ADON and the Administrator completed a mechanical lift demonstration and filled out validation forms. Staff BB stated the staff were directed if there was no tag on the sling to identify a maximum weight due to being washed off, staff were not to use it and were to turn it in. Staff BB stated she did not remember all the colored ribbon around the slings to identify the sling size, and management had her organize the closet that contained the slings. During an interview on 3/23/26 at 11:12 AM, Staff AA, CNA stated on 2/26/26, she assisted Staff M, CNA to transfer Resident #8 from her bed to the recliner. Staff AA stated Staff M expressed her concerns about the transfer sling which was blue and grey in color. Staff AA stated it was not like the regular slings and the facility did not have any slings like it. Staff AA described the sling had 6 loop handles on each side. Staff AA explained the bariatric lift was designed for 4 loops. Staff AA stated it was the only sling available. Staff AA stated another CNA [Staff O, CNA] assisted to move Resident #8 away from the bed and the sling began to pop, tearing on the right side at the bottom. Staff AA explained the material tore from the loops and the recliner was away from the bed. Staff AA stated they had to get Resident #8 into the recliner that was not big enough for her, and explained she was squished in. Staff AA notified Staff Q, LPN the predicament she put them in could have hurt everyone involved. Staff AA stated Resident #8 said don't drop me as she was fearful. Staff AA explained if Resident #8 would have fallen, it would have been catastrophic as she was very heavy. Per Staff AA, staff could not turn Resident #8 to place another sling under her, Staff AA explained Staff Q, LPN and Staff F, LPN/Wound Nurse did not enter the room to assist. Staff AA stated she was so irritated as this should not be happening. Staff AA stated the fire department responded, called in back up with 3 [persons] on each side and utilized the torn sheet. Staff AA reported the fire crew identified the sheet as a slide sheet. Staff AA stated the slide sheet was not appropriate to support Resident #8. Per Staff AA, Resident #8 appeared to be nervous, scared and irritated. She just wanted to get to where she was safe. Staff AA did not understand why Staff Q did not assess the resident in bed related to the resident's chest pain. Staff AA stated she felt if facility staff had to call the fire department every time Resident #8 needed to be transferred, then she was not in the right facility to provide the care she needed. On 3/23/26 at 11:16 AM, Staff CC, LPN stated she was worked in a different part of the facility on 2/26/26 and was not asked to assist with Resident #8. Staff CC stated the staff often would call the fire department to assist with Resident #8 transfers to either go to the hospital or to appointments. Staff CC stated staff called the fire department due to safety as Resident #8 was very big. On 3/23/26 at 4:52 PM, Staff Q, LPN stated on 2/26/26, Resident #8 complained of chest pain after she ate supper while lying flat in bed. Staff Q directed the three CNAs on duty to transfer Resident #8 to the recliner. Staff Q stated one CNA reported that they couldn't assist Resident #8 back to bed the same way they got her out of bed. Staff Q stated she was told that they heard a snap and the strap of the sling started to fray. Staff Q stated the sling utilized for the transfer was grey and blue with loops on the bottom. It was not torn through but it was frayed on the right bottom side, where the loop attached to the sling. Staff Q stated Resident #8 could not tolerate the upright position for very long as her legs got tired. Staff Q notified the DON who told her she needed time to think about that. Staff Q stated the DON called back and directed her to call for the medics. The fire department responded and told her they were going to lift Resident #8 up just enough to put another sling under her. Staff Q stated staff tried to lift Resident #8 using the frayed sling with the mechanical lift and had not even moved her off the recliner when they heard it fraying again. Staff Q stated Resident #8 was very scared as she was afraid, they would drop her. Per Staff Q the firefighters did not know what to do so they called for more crew members. Staff Q explained the facility didn't have enough staff on duty, only 3-4 aides and the wound nurse. Staff Q stated she left the room due to more firefighters responding. She explained the fire crew dismantled the bed, placed it at the foot of the recliner and slipped Resident #8 onto the bed. Staff Q stated the Administrator was informed the sling was not completely broken, but was frayed on the right bottom corner. Staff Q stated she was directed not to use that sling again. Staff Q stated she did not want to think about if it gave away. Staff Q stated staff had used that sling to transfer Resident #8 before, when she was sent out to the hospital. 2. The MDS dated [DATE] identified Resident #39 as cognitively intact with a BIMS score of 13 out of 15. The resident had the following diagnoses: multiple sclerosis, paraplegia (paralysis of half of the body) and renal insufficiency (kidney failure). The MDS also identified Resident #39 had an impairment to both legs, and was dependent on staff for assistance with transfers. During an observation on 3/17/2026 at 12:22 PM, Resident #39 was in his electric wheelchair and sat on a mechanical lift sling with a purple-colored ribbon. The identifying tag listed size medium. The rest of the tag was worn too thin to identify the maximum weight limit for the sling.A document titled Mechanical Lift & Sling Size Risk Evaluation dated 1/5/26 revealed Resident #39 was dependent and recommended the total body lift. Resident #39 weighed 248 pounds and required a large size sling. The manufacturer safety instructions for the [Brand Redacted] True Bariatric Lift directed, DO NOT lift a patient if you are not trained and competent to do so. In addition, it directed to ALWAYS check the sling is suitable for the particular patient and is of the correct size and capacity.

Based on observations, kitchen record review, facility policy review and staff interviews, the facility failed to safety store opened food items, maintain temperature logs for the dishwasher, refrigerators, freezers, and for two days of meals, and failed to maintain the cleanliness of the equipment and flooring during two separate observations at varying times. The facility reported a census of 59 residents.Findings include:1. The initial kitchen observation on 03/15/2026 from 9:58 AM - 10:32 AM revealed the following:a. Review of dishwasher temperature logs, revealed from 03/01/2026 through 03/03/2026 temperature checks were completed and the results of the chemical checks were not present. From 03/04/26 through 03/15/2026 temperature and chemical checks results were not indicated. b. Review of three refrigerator temperature logs revealed from 03/10/2026 through 03/15/2026 temperature results not indicated. c. Review of two freezer temperature logs revealed from 03/10/2026 through 03/15/2026 temperature results not indicated. d. Review of food temperature logs revealed on 03/12/2026 and 03/13/2026 no results recorded. e. A freezer contained an open plastic bag of boxed sausages open with 8 sausages exposed. One half of the sausages light brown, the other half darker brown. Multiple sausages had visible ice crystals on them. f. An undated bag of elbow noodles sat open on the top of a dry storage shelf with the contents exposed to air. A cellphone and a half full glass of a pink liquid sat on the shelf below. The baseboards opposite the shelf were covered in a film of grey dust. g. The stove had a thick, black, bumpy substance caked on the burners. The front left burner had a 1-inch by 2-inch orange substance cooked onto its surface. The middle burner had a 3 inch by 1 inch red and yellow chucky substance on the right side. The front right burner had splashes of dried on yellow and off-white substances dried to the top of the black substance. h. Under the door of the Refrigerator #1, a dried, peeling yellow substance approximately 2 inches by 4 inches found on the floor. The vent at the bottom of the refrigerator covered with a greasy substance with bits of food stuck in another sticky substances. Freezer #2 had crushed up yellow and white particles under the door on the floor. The floor under the two sink basins and by the milk refrigerator had light colored particles stuck to the floor. The floor between the sink and the coffee machine had a visible clear tacky substance. During an interview on 3/15/26 at 10:27 am, Staff E, [NAME] after having been asked for a cleaning schedule, and dishwasher temperatures logs stated she could not present them. 2. Observations of the kitchen/dining area on 3/18/26 at 11:04 am, revealed the following concerns: a. Staff U, Dietary Aide had long, artificial-looking painted nails. Staff U passed drinks and fruit cups to residents. b. The vent above the open steam table covered with a thick layer of dust. c. The racks above a prep table which held spoons covered with a thick layer of dust. d. A fire suppression system spigot on the ceiling near the coffee machine covered with a thick layer of dust. e. Four fire suppression system spigots over the stove covered with dust particles. One of the spigots had a clump of a dirt-like substance clinging to it. f. Metal shelving which held pans face down covered with dust particles. g. The ceiling, back wall, right side wall, and light vent of the microwave covered with food debris. h. The top of a drawer handle covered with a long, thick layer of black grime. The drawer contained multiple scoops and spatulas. Multiple scoops contained crumbs. i. The outside of the ice machine in the dining room covered with a thick layer of brown and white build-up. The inside ceiling of the machine had a section covered with a yellow substance. Water dripped from this area into the ice. The Dietary Manager wiped off the substance. When queried regarding the water which dripped down into the ice, he stated he would empty the machine out and clean it. He stated he thought maintenance cleaned the ice machine on a monthly basis. On 3/18/26 at 2:35 p.m. the Dietary Manager stated staffing had been tough but they were getting there. He stated he expected the kitchen to be clean and sanitary. He stated he would talk about the ceiling and stated staff should not have false nails as they can hold bacteria. The March 2026 Daily Cleaning Tasks AM [NAME] schedule included the following areas to clean: microwave and all shelves. The March 2026 Daily Cleaning Log AM Aides schedule included the following areas to clean: ice machine. The March 2026 Daily Cleaning Tasks PM [NAME] schedule included the following areas to clean: microwave and shelves. The facility policy Sanitation Inspection revised 3/26/25, stated the facility would ensure food service areas were clean, sanitary, and in compliance with applicable state and federal guidelines. The facility policies Dietary Employee Personal Hygiene, dated 3/26/25, stated staff should keep fingernails short and artificial nails were not permitted. The facility policy Kitchen Hood Inspection and Cleaning revised 4/2/25, stated the facility would clean and maintain the kitchen hood exhaust system to foster a safe and healthful environment.

Based on clinical record review, facility policy review and staff interviews, the facility failed to complete an updated assessment, notify the physician, and provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for 1 of 3 residents (Resident #40) reviewed for transfer and discharge. The facility reported a census of 59 residents.Findings include:Review of the Minimum Data Set (MDS), dated [DATE], for Resident #40 revealed a list of diagnoses which included diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking and the use of a manual wheelchair. The MDS indicated the resident used of opioid pain medication, antiplatelet medication, insulin and anticonvulsant medication. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The Behavior section of the MDS indicated no physical (hitting, kicking, pushing, etc.) behavioral symptoms directed toward others, no verbal (threatening others, screaming at others, cursing at others) behavioral symptoms directed toward others, and no other behavioral symptoms (hitting or scratching self, pacing, public sexual acts, disruptive sounds) not directed towards others. Review of a letter on facility letterhead, dated 2/17/26, addressed to Resident #40, revealed, in part: This notice is to serve as an immediate involuntary discharge pursuant to 42 C.F.R. 483.15(c)(1)(C) Iowa Administrative Code 481-58. A facility may involuntarily transfer or discharge a resident when: The safety of individuals in the facility is endangered .The effective date of this notice is February 17th, 2026. The expected date of transfer is March 17th, 2026. You will be discharged to: [name and address of homeless shelter redacted]. The discharge notice is unsigned. Review of a letter on facility letterhead, dated 3/13/26, addressed to Resident #40, revealed, in part: This notice is to serve as an immediate involuntary discharge pursuant to 42 C.F.R. 483.15(c)(1)(C) Iowa Administrative Code 481-58.The effective date of this notice is March 13, 2026. The expected date of transfer is March 13, 2026. You will be discharged to: [name and address of homeless shelter redacted (same shelter identified on the 2/17/26 discharge notice]. The discharge notice is unsigned. Review of the Resident 40's Care Plan, dated 10/29/25 revealed Focus areas to address:a. The resident has a diagnosis of depression and anxiety disorder. Interventions included, in part:1. Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness.2. Monitor/document/report PRN any s/sx (sign and symptoms) of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness.Review of the electronic health record (EHR) revealed a Transfer/Discharge Report dated 3/15/26. Chief Complaint (reason for transfer): Behavioral Symptoms (e.g. agitation, psychosis). Miscellaneous Information: Date of Transfer/discharge: [DATE] Time: 15:13 (3:13 PM). Transfer/discharged to: Hospital: [name redacted].Review of the EHR revealed a Progress Note, dated 3/13/26 entered at 2:25 PM which documented Approximately 7:20 AM a staff nurse [Staff A, Licensed Practical Nurse (LPN)] was attempting to give resident (Resident #40) his medications and ask if he wanted needed a pain pill. Resident became verbally aggressive yelling cursing and threatening the nurse and blocked her between him and the meal tray cart and med caret. Resident did eventually reverse in w/c (wheelchair) and nurse went to another room, and the nurse notified would nurse who notified Administrator who called the police to report resident behavior. Police came to the facility and talked with the resident and recommended that resident discharge from facility Gave resident time to pack his belongings. Approximately 1030 AM this nurse and social worker went down to resident room and gave discharge paperwork. Resident continues to yell at staff stating he was on the phone and didn't want to be bothered. Left paperwork with him. Gave resident time to get his belongings packed but refused to leave. Police were called again approximately 2pm. Social Worker and police went down to resident room. Resident being verbally aggressive to social worker and the police. Police escorted resident in hand cuffs and left facility via police car accompanied by police. During an interview on 3/16/2026 at 10:09 AM, the Ombudsman stated Resident #40 left phone messages for her stating the facility was kicking him out because he pushed a pregnant staff member, he denied the action, and reported the police was notified. The Ombudsman stated the facility had not reported the incident, police action or a discharge to the State Ombudsman office. The Ombudsman stated the facility reported an incident during the summer 2025 when Resident #40 illegally hit another resident.During an interview on 3/16/2026 at 2:05 PM, Staff F, LPN stated on 3/13/26 Staff A, LPN reported Resident #40's behavior and called the Administrator who immediately responded. Staff F stated she told Staff A that she would give the resident his medication. Staff F stated the Administrator called the police since Resident #40 did not stop cussing and told them he wanted him to leave. Staff F stated that this was not a normal discharge and she did not call the physician. Staff F stated Resident #40 had refused care from a psychologist on the telehealth. Staff F stated the Administrator offered Resident #40 a ride to the homeless center but he was not going to leave and the facility could not force him to leave. Staff F stated the police returned and arrested Resident #40. Staff F stated the facility conducted interdisciplinary meetings daily and had discussed Resident #40's noncompliance and the need to find somewhere else to transfer him.During an interview on 3/16/2026 at 2:34 PM, Staff B, Social Service Director stated she started her position in the fall of 2025, and had been working with Resident #40 to transfer out of the facility. Staff B stated Resident #40 had multiple denials for placement. She stated Resident #40 received an involuntary discharge notice in February 2026 and was attempting to locate safe housing for him. Staff B stated Resident #40 was in a shelter before his admission to the facility and obtained an infection in his foot that required a surgical removal of his leg. Staff B stated Resident #40 did not meet the level of care for another nursing home and several apartment complexes refused him based on a lack of adequate income. Staff B stated Resident #40 was rude to the Administrator on multiple occasions. Staff B stated when she arrived to work on 3/13/26 at 8:34 AM, police were talking to Resident #40. Staff B stated she had been instructed to give Resident #40 discharge papers to the homeless shelter. Staff B explained she attempted to give Resident #40 the discharge papers, which included the appeal paperwork but Resident #40 stated he did not want to be discharged and refused to sign the paperwork. Staff B stated the Administrator had called the police as Resident #40 was getting verbally aggressive. Staff B stated the aggressive behavior was why he needed to be discharged . Staff B stated the physician was not notified and she did not notify the State Ombudsman office. During an interview on 3/16/26 at 3:22 PM, the Administrator stated on 3/13/26 Staff A, LPN notified her Resident #40 blocked her and she was upset, trying to get around him. The Administrator stated Resident #40 displayed aggressive behavior 2 weeks prior, calling her a racist bitch, and she had to ask him to leave her office. The Administrator stated she responded and Resident #40 would not explain what happened. The Administrator stated Resident #40 was homeless prior to admit, the hospital had surgically removed his leg and she had tried to do everything to help him. The Administrator stated Resident #40 tried to shut the door in her face. The Administrator stated she notified the police and Resident #40 went outside to visit with them, then police came inside and stated he wanted to go to the homeless shelter and they would be back to give him a ride. The Administrator stated Staff B, Social Service Director attempted discharge paper work and he refused, cussed and screamed. The Administrator stated Resident #40 continued to be verbally aggressive so she notified the police were responded and removed him in hand cuffs. The Administrator stated she discharged Resident #40 due to potential for violence and the aggressive behaviors toward staff and residents. The Administrator stated she was made aware another resident's family member picked up Resident #40 after the police released him and took him to the hospital and then the hospital released him. The Administrator stated she was not certain of the whereabouts of Resident #40. A document titled [NAME] County Iowa Sheriff's Office Inmate Listing Resident #40 revealed:a. [NAME] police department booking date 3/13/26 at 2:20 pm.b. Description Trespass Case # [number redacted]c. Release date 3/14/26 at 9:34 am court ordered, self-custody duration 19 hours, 14 minutes.Multiple attempts made to contact Resident #40 on 3/16/26 via cell phone, messages left without a return call.During an interview on 3/16/2026 at 4:47 PM, the Administrator stated she gave the involuntary 30-day Discharge Notice with the right to appeal in February 2026. The Administrator stated Resident #40 refused to sign the discharge and this is the reason she did not notify the State Agency or the Ombudsman. The Administrator explained on 3/13/26 it was an emergent discharge. She stated she did not notify the State Agency or Ombudsman office and she did not know why. The Administrator stated her expectation was that nursing would notify the physician. The Administrator stated she was unsure what a recapitulation of stay entailed but stated there was an incident summary in the computer.Review of the facility policy titled Transfer and Discharge, dated 7/17/23 revealed:a. It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances.b. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because:a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident;b. The resident's health improves sufficiently to allow a more immediate transfer or discharge;c. An immediate transfer or discharge is required by the resident's urgent medical needs; ord. A resident has not resided in the facility for 30 days.e. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge.f. The facility will maintain evidence that the notice was sent to the Ombudsman.g. In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding reason for the transfer or discharge will be provided by a physician, but not necessarily the resident's attending physician.h. Discharge to the Community: Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care. A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following:i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results.ii. A final summary of the resident's status.iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter).iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment.

Based on clinical record review, facility policy review, and staff interview, the facility failed to notify the provider of a significant weight gain for 1 of 2 residents (Resident #8) reviewed for nutrition. The facility reported a census of 59 residents. Findings include:The Minimum Data Set (MDS) assessment tool, dated 2/17/26, listed diagnoses for Resident #8 which included morbid obesity, heart failure, and diabetes (a disease which caused abnormal blood sugars). The MDS listed her Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. Care Plan entries, dated 7/19/25, stated the resident had altered cardiovascular status related to congestive heart failure and directed staff to monitor and report changes in weight.Review of the Weight Summary for Resident #8 revealed the following weights:2/3/26 535.4 lbs (pounds)3/11/26 574.5 lbsThe resident's weight change from 2/3/26 to 3/11/26 resulted in a 7.3% gain.A hospital Medication Administered Report, dated 3/18/26, stated the resident admitted to the hospital on [DATE].The facility lacked documentation of provider notification of the resident's weight gain from 3/11/26 to 3/16/26.During a phone interview on 3/25/26 at 8:04 a.m., the Director of Clinical Services stated she expected staff to notify the provider of a significant weight gain. She stated she was aware that staff did not report Resident #8's weight gain. The facility policy Notification of Changes, revised 12/2/25, stated the facility would promptly inform the resident's physician when there was a change in condition. The facility policy Weight Monitoring, dated 12/2/25, stated a 5% change in weight in 1 month would be considered a significant change.

Based on clinical record review, policy review, and resident representative/staff interviews, the facility failed to exercise reasonable care for the protection of a resident's cell phone from loss for 1 of 1 residents reviewed for missing items (Resident #67). The facility reported a census of 59 residents.Findings include: The Minimum Data Set (MDS) assessment tool, dated [DATE], listed diagnoses for Resident #67 which included heart failure, depression, and anxiety. The Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicated a severe cognitive impairment. Review of the electronic health record (EHR) revealed Resident #67 passed away on [DATE]. The facility lacked documentation of the belongings of Resident #67 that were packed up by staff after her death on [DATE]. The Resident Representative reported the family picked up the belonging within 48 hours.On [DATE] at 10:35 a.m., via phone, the RR stated she sent the resident a cell phone and it went missing after one week. On [DATE] at 9:22 a.m., Staff V, Receptionist stated Resident #67 had a cell phone delivered to her, and the resident spoke to her daughter on the phone. Staff V stated she was not aware that the cell phone was missing. She stated if residents did not have a phone, staff would bring the resident up to the nursing station to utilize the phone. She stated the facility did not have a cordless phone. On [DATE] at 12:51 p.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #67 had a phone but she wasn't aware that it was missing. On [DATE] at 5:16 p.m., the Administrator stated she did not have a list of items Resident #67's family received upon discharge. She stated there were items remaining including clothing and stuffed animals. She stated she did not recall a phone being one of the items. On [DATE] at 8:29 a.m., the Administrator stated she did not remember that Resident #67 had a phone. She stated she would develop a system to document items residents had in their possession. The facility policy Resident Personal Belongings, revised [DATE], stated the facility would ensure that personal belongings were rightfully returned to the resident's representative in the event of the resident's death. The policy stated possessions brought in during the duration of the resident's stay would be added to the resident's inventory listing.

Based on personnel file review, facility policy review, and staff interviews, the facility failed to complete a background check prior to 1 of 3 newly hired staff starting their employment. The facility reported a census of 59 residents. Findings include:The facility New Hire Reporting report listed a start date for Staff L, Certified Nursing Assistant (CNA) as 6/5/25. Review of Staff L, CNA personnel file revealed the most current background checks on file as:a. Single Contract License and Background Check (SING) completed 9/22/21. The Criminal History Background Check Results read: Further research is required. Please await DCI (Division of Criminal Investigations') final response for criminal history. An Approval Notice dated 9/28/21 read, in part .The Iowa Department of Human Services has completed a Record Check Evaluation on the criminal or abuse history of the applicant and the result of the evaluation is that the applicant MAY WORK for your agency .b. Iowa Record Check Request completed on 9/27/21 confirmed a Waiver Signature on File for Staff L, CNA. c. Iowa Criminal History background check completed on 9/27/21. The personnel file lacked documentation of background checks completed after 2021, and prior to Staff L, CNA hire date of 6/5/25.On 3/25/26 at 8:29 a.m., the Administrator stated the facility should complete background checks prior to the staff member's start date. She stated the facility completed this with Staff L but she could not locate the documentation. The facility policy Abuse, Neglect, and Exploitation, revised 4/22/25, stated the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited abuse. The policy stated the facility would complete a background check on potential employees and maintain documentation of the screening.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to maintain accurate and accessible Advance Directive decisions for 2 of 24 residents reviewed (Residents #22 and #27). The facility reported a census of 59 residents.Findings include: 1. Review of the Minimum Data Set (MDS) for Resident #27, dated [DATE] included a list of diagnoses, which included: hypertension, non-Alzheimer's dementia, and anemia. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. Review of the electronic health record (EHR) revealed two Physician Orders for Scope of Treatment forms (commonly referred to an IPOST. An IPOST is a document used to indicate Advanced Directive choices and signed by the resident or a representative and a physician) dated [DATE], signed by the Resident #27 and the physician. a. The first IPOST, dated [DATE] indicated Resident #27 chose: Cardiopulmonary Resuscitation (CPR) - CPR/Attempt Resuscitation; Medical Interventions - Full Treatment; Artificially Administered Nutrition - Long-term artificial nutrition by tube. Medical Decision Maker - Patient. b. The second IPOST, dated [DATE] indicated Resident #27 chose: Cardiopulmonary Resuscitation (CPR) - DNR/Do Not Attempt Resuscitation; Medical Interventions - Comfort Measures Only; Artificially Administered Nutrition - No artificial nutrition by tube. Medical Decision Maker - Patient. Review of the electronic health record (EHR) Physician Orders section revealed an order, dated [DATE], for Full Code/CPR with full treatment and long-term artificial nutrition by tube. The EHR for Resident #27 also included a Code Status area in the banner, which listed the resident as a Full Code/CPR with full treatment and long-term use of artificial nutrition by tube. Review of Resident #27's Care Plan, dated [DATE] revealed a Focus area to address Resident HAS ADVANCED DIRECTIVES on record, with the Intervention: Resident is a DNR. 2. Review of the MDS for Resident #22 dated [DATE] revealed a list of diagnoses which included: schizophrenia, chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort breathing), and myelodysplastic syndrome (a type of blood cancer that occurs in bone marrow). The BIMS score of 14 out of 15 indicated intact cognition. Review of the IPOST document signed by a Nurse Practitioner and Resident #22 on [DATE] IPOST, revealed a Code status of Cardiopulmonary Resuscitation (CPR) - DNR/Do Not Attempt Resuscitation; Medical Interventions - Comfort Measures Only; Artificially Administered Nutrition - No artificial nutrition by tube.Review of the EHR Physician Orders section revealed no order to indicate Resident #22's Advanced Directive decision. The EHR lacked a Code Status area in the banner. Review of Resident #22 Baseline Care Plan, dated [DATE] revealed a Focus area to address Resident/Resident Representative has chosen DO NOT Resuscitate (DNR), with an Intervention For DNR Status: Verify presence of physician's order for DNR. During an interview on [DATE] at 3:52 PM, Staff A, Licensed Practical Nurse (LPN) stated a resident's Code Status could be found in the EHR banner area for each resident. When asked for Resident #22's current status, Staff A looked in the Residents EHR. Staff A stated Resident #22's EHR did not have a Code Status area in the banner. Staff A stated without the Code Status listed in the resident's banner of the EHR it is not immediately apparent the Advanced Directive wishes of the resident. Staff A located Resident #22's IPOST within the Documents tab of the EHR.During the same interview, when asked for the Code Status for Resident #27, Staff A stated the Code Status in the EHR indicated the resident is a Full Code. Staff A checked Resident #27 most recent IPOST in the Documents tab of the EHR and stated the IPOST, dated [DATE] had a Code Status of DNR/Do Not Attempt Resuscitation. Staff A, LPN explained the Administrator uploaded the initial IPOST upon a resident's admission. Staff A stated at the time of admission, Resident #27 had an IPOST, dated [DATE] which had CPR checked. Staff A stated the Social Worker uploaded a new IPOST when changes were made. Staff A stated when the updated IPOST is uploaded there should be an update in the Code Status section of a resident's EHR banner. During an interview on [DATE] at 4:02 PM, Staff B, Social Services Director explained the usual practice is to update the Code Status in the EHR banner immediately after an IPOST has been received or changed. Staff B stated this had not been done for when Resident #27 changed her IPOST. Staff B stated she could not explain why Code Status section of the EHR banner had not been added for Resident #22. Staff B stated the Code Status area of the EHR banner is where staff checked for the Code Status of a resident. Review of the policy titled Cardiopulmonary Resuscitation (CPR), dated [DATE] revealed a Policy statement which declared it is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). The Policy Explanation and Compliance Guidelines section included, in part: If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services and: a. In accordance with the resident's advance directives. B. In the absence of advance directives or a Do Not Resuscitate order.

Based on clinical record review, facility documentation, interviews, and policy review the facility failed to notify a resident and/or the resident's representative of the facility policy for bed hold, including reserve bed payment for 1 of 2 residents reviewed for hospitalizations (Resident #3). The facility also failed to provide a recapitulation of stay, to provide an appropriate plan of care for discharge to the community and failed to notify the long term care (LTC) Ombudsman before the discharge for 1 of 3 residents reviewed for transfer and discharge (Resident #40). The facility reported a census of 59 residents. Findings include:1. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] documented Resident #3 scored 14/15, which indicated intact cognition. Review of the electronic health record (EHR) revealed Resident #3 had the following hospitalizations: a. admitted to the hospital on [DATE], returned to the facility on [DATE]. b. admitted to the hospital on [DATE], returned to the facility on [DATE]. The EHR lacked documentation of a bed hold issued to Resident #3 for either hospitalization. During an interview on 3/15/26 at 3:47 PM, Resident #3 stated he did not remember anyone talking to him about the bed hold policy at admission or when he went to the hospital. On 03/18/2026 at 12:23 PM, the Administrator asked to provide documentation of a bed hold for Resident #3 hospitalizations. At 12:41 PM, the Administrator sent an email to the State Agency which stated there were no bed holds issued to the resident. Review of the facility policy, titled Transfer and Discharge (including AMA) reviewed/revised 07/14/2025 documented in section 10.g. the facility would provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as part of emergency transfers to acute care. 2. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #40 revealed a list of diagnoses which included diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking and the use of a manual wheelchair. The MDS indicated the use of opioid pain medication, antiplatelet, insulin and anticonvulsant. The BIMS score of 15 out of 15 indicated intact cognition. During an interview on 3/16/2026 at 10:09 AM, the Ombudsman stated Resident #40 left phone messages for her stating the facility was kicking him out because he pushed a pregnant staff member, he denied the action, and reported the police was notified. The Ombudsman stated the facility had not reported the incident, police action or a discharge. During an interview on 3/16/2026 at 2:34 pm, Staff B, Social Service Director stated she was hired in the fall of 2025 and began to find a facility in the community for Resident #40 to transfer and he was denied multiple times. Staff B stated Resident #40 had received discharge papers in February 2026 and she was attempting to locate safe housing for him. Staff B stated when she arrived to work on 3/13/26 at 8:34 am, police were talking to Resident #40. Staff B stated she was instructed to give Resident #40 discharge papers to the homeless shelter and attempted to give him the discharge papers to include the appeal paperwork but Resident #40 stated he did not want to be discharged and refused to sign the paperwork. Staff B stated the aggressive behavior was why he needed to be discharged and the physician was not notified. Staff B stated she did not notify the LTC Ombudsman. Review of a letter on facility letterhead, dated 2/17/26, addressed to Resident #40, revealed, in part: This notice is to serve as an immediate involuntary discharge pursuant to 42 C.F.R. 483.15(c)(1)(C) Iowa Administrative Code 481-58. A facility may involuntarily transfer or discharge a resident when: The safety of individuals in the facility is endangered .The effective date of this notice is February 17th, 2026. The expected date of transfer is March 17th, 2026. You will be discharged to: [name and address of homeless shelter redacted] . Right to appeal information. The discharge notice is unsigned. Notice sent to physician and Ombudsman. Review of a letter on facility letterhead, dated 3/13/26, addressed to Resident #40, revealed, in part: This notice is to serve as an immediate involuntary discharge pursuant to 42 C.F.R. 483.15(c)(1)(C) Iowa Administrative Code 481-58.The effective date of this notice is March 13, 2026. The expected date of transfer is March 13, 2026. You will be discharged to: [name and address of homeless shelter redacted (same shelter identified on the 2/17/26 discharge notice] . Right to appeal information. The discharge notice is unsigned. Notice sent to physician and Ombudsman. During an interview on 3/16/26 at 3:22 pm, the Administrator stated on 3/13/26 she discharged Resident #40 due to potential for violence and the aggressive behaviors toward staff and residents .In a later interview at 4:47 pm, the Administrator stated she gave the involuntary 30 days right to appeal in February 2026 and Resident #40 refused to sign it and that is why she didn't notify the Department of Inspection, Appeals and Licensing (DIAL) and the LTC Ombudsman, then on 3/13/26, it was an emergent discharge and she did not notify and did not know why. The Administrator stated her expectation was that nursing would notify the physician. The Administrator stated she was unsure what a recapitulation of stay entailed but stated there was an incident summary in the computer. Review of a policy titled Transfer and discharge date d 7/17/23 revealed, in part: a. It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. c. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; g. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge. h. The facility will maintain evidence that the notice was sent to the Ombudsman. i. In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding reason for the transfer or discharge will be provided by a physician, but not necessarily the resident's attending physician. j. Discharge to the Community: Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care. A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. ii. A final summary of the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure Care Plans are revised to reflect changes in the care needs and the monitoring needs for 3 of 18 residents (Resident #39, Resident #50, and Resident #65) reviewed. The facility reported a census of 59 residents.Findings include:1. The Minimum Data Set (MDS) assessment tool, dated 1/3/26, listed the following diagnoses for Resident #50 insomnia, obesity, and depression. The MDS listed a Brief Interview for Mental Status (BIMS) score of 14 out of15, which indicated intact cognition. A 2/1/26 Administration Note stated staff found a bottle of sleep aids on the resident's night stand that was open with pills on the nightstand, floor, and bedside table. The staff member educated the resident with regard to self-medicating and notified the provider. A 2/3/26 Physician Progress Notes stated the resident should not utilize OTC (over the counter) medications without approval of the provider. The note stated if staff located OTC sleep aids again, the provider would discontinue Resident #50's order for Ambien (a prescription sleep aid) because the resident should not take the OTC and Ambien at once. A 2/14/26 General Note stated staff found two bottles of aspirin (a non-narcotic pain medication which also prevented blood clot formation) and 2 bottles of a sleep aid. The resident had bright red clots in her stool and the facility sent her to the ER (emergency room). A 3/11/26 Physician Progress Note stated the resident had a gastrointestinal bleed from taking OTC medications. Staff also found the resident with sleep aids on more than one occasion. The resident's Care Plan did not address the resident's history of taking OTC medications and did not provide direction for staff to monitor this in the future. 2. The MDS assessment tool, dated 3/10/26, list of diagnoses for Resident #65 included malnutrition, weakness, and heart failure. The MDS listed a BIMS score of10 out of 15, which indicated a moderate cognitive impairment. A 3/7/26 Daily Skilled note stated the resident was nothing by mouth (NPO) status. A 3/9/26 Care Plan entry stated the resident was NPO. An Order Summary Report listed a 3/19/26 order for a regular diet with regular texture, nectar thick consistency with food cut up into bite sized pieces. A 3/20/26 General Note stated the resident reported he was confused because one person told him he could eat and another said that he couldn't and he didn't know what to believe. The facility failed to update the Care Plan to reflect the resident's current diet order. On 3/25/26 at 8:04 a.m., via phone, the Director of Clinical Services stated Care Plans should include a resident's correct diet and should also address if a resident had a history of taking unprescribed OTC medication. 3. The Minimum Data Set (MDS) dated [DATE] identified Resident #39 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and had the following diagnoses: multiple sclerosis, paraplegia (paralysis of half of the body) and renal insufficiency (kidney failure). The MDS also identified Resident #39 had an impairment to both legs, was totally dependent on staff for assistance with transfers, lower body dressing, putting on and removing footwear and required substantial/maximal assistance with showers and personal hygiene. The MDS identified Resident #39 utilized an indwelling catheter. Review of the electronic health record (EHR) revealed: a. On 3/10/26, Resident #39 diagnosed with a multi-drug-resistant infection (MRSA) only susceptible to intravenous (IV) antibiotics (ATB). b. On 3/11/26, Resident #39 is needing a PICC (peripherally inserted central catheter line, a type of IV that can be in place for several weeks to months) c. A 3/12/26 Physician Order for 7 days IV ATB for urinary tract infection, Meropenem 1 gram IV, 1st dose at infusion center. Review of the Care Plan, dated 11/17/23 revealed a Focus area to address the use of an indwelling foley catheter. The Care Plan lacked Interventions to address the UTI with a MRSA and the use of a IV antibiotic and associated care. The facility policy Care Plan Revisions Upon Status Change, dated 9/29/25, stated the facility would revise the comprehensive care plan when the resident experienced a status change.

Based on clinical record review, facility policy review, resident representative and staff interviews, the facility failed to ensure a resident had a private area to make telephone calls for 1 of 1 residents (Resident #57) reviewed. The facility reported a census of 59 residents. Findings include:The Minimum Data Set (MDS) assessment tool, dated 10/8/25, listed diagnoses for Resident #67 which included heart failure, depression, and anxiety. The MDS listed a Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating a severe cognitive impairment. On 3/16/26 at 10:35 a.m., via phone, the Resident's Representative (RR) stated she sent the resident a cell phone but it went missing after approximately a week. The RR stated the facility did not have a portable phone for residents to use so the cell phone was the only option. On 3/23/26 at 12:38 p.m., Staff F, Licensed Practical Nurse (LPN) stated residents could use the phone in the dining room or at the nursing station but it was not private. On 3/23/26 at 12:51 p.m., Staff A, LPN stated that there was a phone at the nursing station for residents to use but it was not private. She stated the facility's cordless phone was not connected. On 3/23/26 at 9:22 a.m., Staff V, Receptionist stated Resident #67 had a phone delivered that she used to speak with her daughter. Staff V stated she was not aware that the phone was missing. She stated if residents did not have a phone, they would bring them up to the nursing station to utilize the phone. She stated the facility did not have a cordless phone. On 3/25/26 at 8:29 a.m., the Administrator stated the facility had plans to get a new phone line in the conference room and residents would be able to come in and shut the door when they made calls. The facility policy Resident Right to Privacy in Communication, revised 3/7/25, stated the facility would provide residents with reasonable access to the use of a telephone in an area where calls were not overheard.

Based on observation of Video evidence, staff interview, clinical record review, and facility policy review, the facility failed to provide adequate supervision and assistance to 1 of 3 residents (Resident #1) reviewed for nursing supervision. Resident #1 had cognitive impairment, known to wander, and had multiple attempted elopements. The video evidence showed on 12/8/25 at 9:25 PM, the facility staff (Certified Nursing Assistant, CNA), responsible for Resident #1's care, entered the front door code and let them outside the building and then exited behind them. The CNA re-entered the facility at 9:27 PM without Resident #1 and didn't report to other staff that Resident #1 went outside. The staff at the facility became aware of Resident #1 missing on 12/9/25 at 6:12 AM, by a facility staff member, driving to work. The staff member found Resident #1 approximately 1.7 miles from the facility (approximately a 38-minute walk) near a busy road with 2 lanes of traffic in each direction, wearing a jacket and light weight shoes, no gloves or hat, with the weather reported as below freezing with snow on the ground and wind chill values ranging between 8-17 degrees Fahrenheit. The staff described Resident #1's hands as freezing cold. Upon their return to the facility, an assessment of Resident #1 found them with a decrease in oxygen saturation and wheezing. After an assessment by Resident #1's provider, they ordered to send her to the Emergency Department for a potential pulmonary embolism (blood clot in the lung).The State Agency informed the facility of the Immediate Jeopardy (IJ) situation on 12/11/25 at 11:35 AM. The IJ began on 12/8/25, and on 12/11/25 at 3:21 PM the SA confirmed the immediacy removed on 12/09/25 by the facility staff by implementing the following actions: The facility initiated an investigation of the elopement on 12/9/25 and placed Resident #1 on one-on-one supervision with staff until they had all systems for elopement risks place. The facility updated Resident #1's Care Plan and notified the physician and responsible party of the incident. The facility completed a visual head count of every resident to ensure all were present and safe. The Director of Nursing (DON)/Designee assessed every resident on 12/9/25 for wandering and elopement risk, then updated 3 of 3 elopement books. The facility educated all staff on the elopement policy and procedures, the elopement book, elopement response plans, and not allowing resident/visitors out of the front door until verified by a nurse or manager on 12/9/25. The facility implemented resident rounding sheets for frequent monitoring and rounding sheets to be reviewed on a daily basis. The facility completed a Performance Improvement Project (PIP) and discussed the incident in a Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director on 12/9/25. The scope was lowered from J to G at the time of the survey. The facility reported a census of 66 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 10/8/25, identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #1 had inattention, and disorganized thinking came and went, or fluctuated in severity. The MDS included diagnoses of non-Alzheimer's dementia, chronic obstructive pulmonary disease (COPD), asthma, and cognitive communication deficit. The MDS identified Resident #1 could transfer and ambulate more than 150 feet independently without the use of an assistive device. The Care Plan Focus, initiated 7/3/25, indicated Resident #1 had a high risk for an elopement due to wandering. The goal reflected Resident #1 would not leave the facility unattended. The Interventions dated 7/3/25 instructed the following: Assess Resident #1 for fall risk. Identify the pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. The Care Plan Focus, initiated 7/2/25, listed Resident #1 had a risk for falls related to wandering behavior. An intervention, initiated 10/20/25, instructed staff to be aware of their location and for signs of fatigue, increasing fall risk. Resident #1's Progress Notes from 7/2/25 and 12/8/25, reflected their attempted elopements. The entries included, in part: On 7/2/25 at 6:00 PM, as a visitor came in the front door, Resident #1 headed for the front door with her coat on and witnessed walking out the door. Resident #1 would not stop walking and stated she was going to a man's house. The note documented that redirection was ineffective, the nurse notified administration, the police, and emergency services. Resident #1 agreed to go back into the facility and staff members walked with her back to the facility. On 7/7/25 at 4:22 PM, Resident #1 attempted to leave the facility by trying to open exit doors. The note informed staff needed to de-escalate and redirect the resident. On 7/17/25 at 6:01 PM, a nurse witnessed Resident #1 push open the front door and walk out. The nurse remained with Resident #1 and attempted to redirect her. Resident #1 stated she didn't live at the facility and would not tell the nurse where she was going. The nurse noted Resident #1 rapidly walk through neighborhoods and across a busy street. She became angry when addressed by the nurse. The staff notified the Administrative Staff of the situation, police, and emergency services. The facility got Resident #1 into the ambulance and transported her to the hospital. At 8:25 PM Resident #1 found stable and returned to the facility from the hospital. On 7/20/25 at 3:26 PM, someone witnessed Resident #1 telling another resident, she'd see them tomorrow, as she walked towards the front door with a bag and drink cup in hand. Resident #1 had a pattern of waiting until a visitor left and opened the door. A Nurse and Certified Nurse Aide (CNA) blocked the door as Resident #1 became combative and hit the nurse. Resident #1 stated you better get out of my way right now and tried to push past the staff out the door. Resident #1 turned and walked away, yelling profanities. The nurse documented they advised the nursing staff to monitor Resident #1 for attempts to exit the facility. On 10/10/25 at 1:23 AM, someone observed Resident #1 wandering with episodes of restlessness and approaching the exit doors. Resident #1 had moderate exit seeking behavior. Resident #1's admission Record, dated 12/10/25, revealed she resided in room B8-2. The Daily Nursing Schedule dated 12/8/25, listed Staff A, CNA, as responsible for the residents on the B hallway from 2:00 PM until 10:00 PM. The schedule reflected Staff B, CNA, as responsible for the residents on B hallway from 10:00 PM on 12/8/25 until 6:00 AM on 12/9/25. Review of the facility provided Video evidence revealed the following timestamped camera observations: On 12/8/25 at 9:21 PM, Resident #1 walked out of a room and down the B hallway towards the dining room.On 12/8/25 at 9:24 PM, Resident #1 walked up the C hallway (connects the back of the facility to the front of the facility) towards the front door. One staff member observed walking out of a room on the C hallway, pushing a linen cart and going in the opposite direction of Resident #1. Resident #1 observed wearing a blue/purple colored jacket, legging-type pants, white socks, shoes, no gloves, no hat, hair up in a ponytail, and holding a black purse in her left hand. On 12/8/25 at 9:24:57 PM, Resident #1 walked to the front door, then touched the keypad on the wall, next to the front door. On 12/8/25 at 9:25:38 PM, Staff A walked to the front door. Staff A entered a code into the keypad and Resident #1 pushed open the front door. Staff A followed directly behind Resident #1 out the front door. On 12/8/25 at 9:25:55 PM, a staff member walked to the front door, looked out the window next to the front door, and at 9:26:55 PM, they walked away from the front door. On 12/8/25 at 9:27:38 PM, Staff A observed walking back into the facility through the front door. The video didn't include Resident #1 returning to the facility. On 12/8/25 at 9:28:06 PM, Staff A observed walking alone down C hallway towards the back of the facility.On 12/8/25 at 9:29:29 PM, Staff A observed walking down B hallway, past Resident #1's room. Review of nursing progress notes, dated 12/9/25, documented the following entries:On 12/9/25 at 5:30 AM: the facility received a phone call that morning of Resident #1 not in the building. Educated staff to call code silver and check the entire building, then proceed outside if Resident #1 is still not found. The staff notified the Director of Nursing (DON) notified immediately and Administrator. On 12/9/25 at 6:23 AM: The nurse completed a head-to-toe assessment Resident #1 following the incident. Resident #1's vitals assessed in normal range, except for pulse oximeter level of 89% on room air (RA) (normal oxygen level are 90% and above), pulse 68, blood pressure 120/76, 18 respirations, temperature 97.1 temporal (forehead scan). Resident #1's lung sounded abnormal with audible wheezing (loud high-pitched noise made when breathing). The nurse would request orders from provider for STAT (immediate) chest x-ray and albuterol nebulizer treatments as needed. When inquired if Resident #1 would like to go to the hospital, she declined and explained she was just tired now and didn't want to go now. The provider would be in facility at approximately 8:30 AM - 9:00 AM and would evaluate her at that time. The nurse completed Resident #1's skin assessment as normal, noting no discoloration at the time to her feet, toes, hands, fingers, lips, ears, or nose. She had a good capillary refill (measure of hydration status by pinching the skin looking at how quickly the skin returns to before it got pinched, the quicker the better). The nurse planned to monitor her as the day progressed. Resident #1 reported her feet didn't hurt and showed good sensation as well. Resident #1 reported no pain anywhere. The nurse provided a nebulizer treatment and portable x-ray company contacted for STAT chest x-ray 2 views. No other concerns at that time. On 12/9/25 at 11:45 AM: the nurse notified the hospital they sent Resident #1 over for possible PE (Pulmonary Embolism). Resident #1's x-ray returned with right lower lobe infiltrates (abnormal material in the lung) and diminished (hard to hear) lung sounds. The emergency room (ER) staff knew Resident #1 as a long-term resident at the facility and would need discharged back to the facility. On 12/10/25 at 3:50 AM: Resident #1 returned to the facility via ambulance following treatment for sarcoidosis (a buildup of cells in the body, noted in the lungs for Resident #1 that can affect breathing). Resident #1 had a follow-up appointment with pulmonology (physician who specializes in the lungs) in one week. In addition, Resident #1 had a follow-up appointment with her provider in 1 to 2 days. Review of an Incident Report, dated 12/9/25, completed by the Director of Nursing (DON), indicated on 12/9/25 at 5:30 AM, the staff called the DON to report Resident #1 not in the building. The Incident Report documented the immediate action taken included the DON educating the nurse to call a code silver (elopement protocol) and search the entire building. Then search for Resident #1 outside the building. The Incident Report indicated at approximately 6:10 AM the facility called reporting they found Resident #1. Upon return to the facility, the nurse conducted a head-to-toe assessment Resident #1 with no apparent injuries. The Incident Report listed Resident #1's oxygen saturation as 89%, temperature 96.9 degrees Fahrenheit (normal range 97.5 F- 99.5 F), Resident #1 had audible wheezing, and diminished lung sounds. The facility received an order from the provider to obtain a chest x-ray. Results of the chest x-ray showed infiltrates to the right (lung) lower lobe and the provider advised the facility to send Resident #1 to the hospital for possible pulmonary embolism (PE). The Incident Report noted upon return to the facility from the hospital, Resident #1 had no new orders, except to follow up with a Pulmonologist in one week. Review of the Emergency Department (ED) notes, dated 12/9/25, revealed Resident #1 presented for an abnormal x-ray. The hospital performed a Computed Tomography (CT) scan which showed an occlusion (blockage) of the left (lung) lower lobe segmental pulmonary artery (a blood vessel used to send blood to specific areas of the lungs) and left hilar adenopathy (swelling of lymph nodes located in the lungs where the bronchi and vessels enter/exit) related to Resident #1's history of sarcoidosis. The ED notes reflected the hospital cleared Resident #1 to discharge back to the facility on [DATE] and follow-up as an outpatient with her Pulmonologist. Review of a Global Positioning System (GPS), online mapping, revealed the location staff found Resident #1 as approximately 1.7 miles, or about a 38-minute walk from the facility. The GPS street view, for the location the staff reported they found Resident #1 noted to have one busy road with 2 lanes of traffic in each direction, perpendicular (two lines that meet) to a residential street. Review of a Climatology report, dated from 12/8/25 at 9:25 PM and 12/9/25 at 5:24 AM, indicated the temperatures ranged from 22 degrees Fahrenheit (F) to 28 degrees F with wind speeds reported between 7 miles per hour (mph) and 17 mph. The wind chill values ranged between 8 degrees F and 17 degrees F. Review of an Online Police Department Incident Report, dated 12/9/25 at 12:28 PM, revealed that the facility administrator reported they couldn't locate a resident in the building. The facility administrator received notification at 5:35 AM. They found Resident #1 at 6:09 AM by a facility employee. During an interview on 12/16/25 at 9:15 AM, Staff A, stated that she worked as a CNA for about 10 years and worked at the facility for approximately 2 weeks. Staff A reported not being familiar with the residents but worked on the B hallway before. She worked independently on B hallway 12/8/25 from 2:00 PM to 10:00 PM. Staff A stated she saw Resident #1 in the facility but didn't know she was a resident. Staff A reported on 12/8/25 around 9:25 PM, as she went outside to her car, she saw Resident #1 at the front door trying to enter the code. Staff A entered the code and let her out. Staff A reported that Resident #1 said she was going to visit her daughter and then started walking. Staff A stated that she didn't know who she was and didn't know she let out a resident. When queried about how Staff A found out which residents she was responsible for, Staff A reported she would learn the resident's faces. Staff A denied asking other staff about Resident #1 when she wasn't sure. She denied telling anyone about letting someone out of the front door when unsure who it was. Staff A denied having new hire training or education on residents with a risk for elopement. During an interview on 12/16/25 at 10:05 AM, Staff B reported they worked at the facility for almost 2 years, confirmed working the overnight shift from 10:00 PM on 12/8/25 until 6:00 AM on 12/9/25 on the B hallway. Staff B reported she didn't receive any report or communication from the previous shift when she took over the B hallway at 10:00 PM. Staff B stated during her first set of rounds, which included checking on residents and providing cares as needed, she saw Resident #1's bathroom door was shut with the bathroom light on. Staff B stated she assumed Resident #1 was in the bathroom at that time, because Resident #1 was able to take herself to the bathroom without staff assistance. Staff B recalled that at approximately 5:25 AM Resident #1's roommate called for assistance and Staff B identified that Resident #1 wasn't in her bed or the bathroom. When they asked the roommate if she saw Resident #1, the roommate told Staff B she hadn't seen Resident #1 all night. Staff B informed that she immediately notified the charge nurse about Resident #1 not being in her room and the staff began to search for Resident #1 throughout the facility and followed the search outside of the facility. During an interview on 12/15/25 at 1:00 PM, Staff C, CNA, worked at the facility since Sept. 2025. She confirmed she worked 12/9/25 at 6:00 AM and stated that during her drive to work she saw a woman walking on the sidewalk who appeared to be Resident #1. Staff C reported she called the facility and asked if Resident #1 was in her bed. The staff told Staff C about Resident #1 missing from the facility, so she drove around the block, parked on a busy road, put the car's hazard lights on, and approached Resident #1. Staff C stated she asked Resident #1 how long she walked and Resident #1 responded that she did not know. Staff C asked Resident #1 to get in her car, Resident #1 agreed and Staff C assisted her to step over a snowbank and sit in Staff C's car. Staff C recalled when she found Resident #1 the morning of 12/9/25, it was still dark outside with snow on the ground and an average amount of traffic on the street she walked next to. Staff C reported Resident #1 had on a jacket, didn't wear a hat or gloves, and had been shivering. Staff C reported when she helped Resident #1 over the snowbank, by holding her hands, Staff C noticed that the resident's hands were freezing cold. Staff C reported that when she assisted Resident #1 back into the facility from her car, Resident #1 could barely walk. Staff C said that Resident #1 had on mesh sneakers with a Velcro strap over top and stated Resident #1's socks were wet and freezing cold. The staff removed the socks and shoes right away. Staff C reported that Resident #1 recognized some peers and staff faces but was not oriented to time of day or surroundings and had been known to wander in the facility. During an interview on 12/15/25 at 11:45 AM, Staff D, Licensed Practical Nurse (LPN), confirmed she worked as Resident #1's nurse on the morning of 12/9/25. Staff D reported they completed a skin assessment on Resident #1 when she returned to the facility without discoloration or injury noted. Staff D stated they noted Resident #1's oxygen saturation level as low, between 84-89% on room air and a low body temperature, when they took her vitals. Staff D reported Resident #1 had a lot of expiratory wheezing and nasal drainage. Staff D stated she asked the DON about sending Resident #1 to the hospital when she returned to the facility but, the DON told her they would get a chest x-ray and start nebulizer treatments instead. Staff D recalled they obtained a chest x-ray at approximately 10:00 AM and the provider visited the facility at about 10:30 AM to assess Resident #1. Staff D reported due to the results from the chest x-ray the provider ordered to have Resident #1 seen in the ED. During an interview on 12/16/25 at 1:30 PM, the DON, explained they expected the staff to check the elopement book for residents at risk of elopement before letting any resident outside. In addition, they expected the staff to ask when they didn't know if someone was a resident or visitor. The DON stated Staff A worked at the facility for approximately 2 weeks, had worked on B hallway 3 or 4 times prior to 12/8/25 shift, and should have known that Resident #1 was not a visitor. The DON denied personally checking with Staff A to see how she performed as a new hire. Review of the facility policy, titled Elopements and Wandering Residents, revised 7/1/25, listed the policy purpose statement as to ensure residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents. In addition, they received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Section A.: Policy Explanation and Compliance Guidelines directed the following: The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.Monitoring and Managing Residents at Risk for Elopement or Unsafe WanderingResidents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan.Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.Adequate supervision will be provided to help prevent accidents or elopements.Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.Review of the facility policy, titled Walking Rounds Shift Report, implemented 12/9/25, defined the policy purpose statement as to use walking round shift reporting to promote successful transfer of information between nursing staff at shift change in an effort to prevent adverse events, medication errors, and medical mishaps. Section A. Policy Explanation and Compliance Guidelines directed the following:Walking rounds shift report will be used for a 24-hour period to ensure continuity of care. The night shift nurse will enter the necessary information on the shift report for the following day. The walking rounds shift report may only be altered by the DON if there are changes that need to be made. All staff will be in-serviced on the use of walking rounds shift report prior to implementation as well as upon hire and as needed.

Based on observations, clinical record review, facility policy review, resident and staff interviews the facility failed to identify and respond to an elopement in a timely manner for 1 of 1 residents (Resident #474). Resident #474 eloped from the facility on 6/8/24 at approximately 2:55 PM and was found 5.6 miles from the facility by a bystander at approximately 6:38 PM. Facility staff initially identified the resident was missing at 4:00 PM, notified management at 6:00 PM and called 911 at 6:03 PM. The facility failed to utilize equipment for resident safety for 2 of 2 residents (Resident #19 and Resident #48) during assistance with mobility/transfers. The facility reported a census of 60 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 6/12/24 at 5:47 PM. The IJ began on 6/8/24. Facility staff removed the Immediate Jeopardy on 6/14/24. The facility staff removed the Immediate Jeopardy by implementing the following actions: 1. Complete visual headcount of every resident at Ivy at [NAME] to ensure all were present and safe. 6/8/24 2. Residents residing in the community were re-evaluated for elopement 6/8/24. 3. 1:1 supervision placed on (Resident #474) 6/8/24 upon return to the facility until front door code can be changed and all systems for elopement in place 4. The weekend receptionist was given education on 6/9/24 when she returned to work. 5. An order was placed in Tels for the front door to be assessed for recording. 6. All staff education initiated on 6/8/24 on the facility protocol for elopement and the requirement to validate with Nurse or Management who an individual is, if unsure, before helping them exit the facility. Education will be ongoing until all staff have been educated. Facility staff, new hires, and contract staff will not be allowed to work until education is completed. 7. New Admissions will have wandering/elopement risk assessments completed and when/if identified at risk for elopement will be placed in the elopement risk binders. For admissions after normal business hours the admitting nurse will utilize the instant camera in R hallway medication cart to immediately place photo and demographic sheet in the binders accessible to staff at receptionist desk and other nursing elopement binders. The other two books will be updated next business day. The elopement books will contain a face sheet with photo of residents residing in the facility. The Admissions Director/Designee will provide communication to non-clinical staff of new admissions or anticipated new admission either during the week during normal business hours and during after -hour and weekends. 8. Staff education was completed in regard to after hours admission or weekends for residents identified at risk for elopement will have instant camera photo taken as well as the Resident identified book at the reception area to communicate non-clinical staff of current residents as well as any new admits and/or potential after hours of weekend admissions, Began on 6/13/24 with completion on 6/14/24. The scope was lowered from a J to a D at the time of the survey after ensuring the facility implemented education. Findings include: 1. A review of the Electronic Health Record (EHR) revealed Resident #474 admitted to the facility on [DATE] after a hospitalization . The diagnoses documented in the EHR included: Unspecified sequelae of cerebral infarction (stroke); unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; and type 2 diabetes mellitus. The Baseline Care Plan, dated 6/7/24, indicated the resident at risk for falls, cognitively impaired, required one person physical assistance for transfers and walking in room and corridor, and utilizes a manual wheelchair and walker. A Progress Note, dated 6/8/24 at 1:17 PM, documented the resident is A&Ox2 (alert and oriented times two - aware of who they are and where they are at), resident has been wandering throughout the day from her room to the dining room. Resident is pleasant and orient[ed] call light. Resident ate meals today in the dining room. Resident denies pain or discomfort at this time. BP (blood pressure) 120/81, P (pulse) 80, RR (resting respirations) 18, T (temperature) 98.0, O (oxygen saturation) 98%. A Progress Note, dated 6/8/24 at 9:40 PM, documented family notified of elopement, no concerns at this time and they are grateful and stated these things happen, she has run away before she was in a nursing home, and she's very quick and sneaky. family coming from [redacted] to meet resident at ER (emergency room ) and are bringing her back OT (Occupational Therapy) the facility after the evaluation. A document titled, Initial Federal Report, dated 6/8/24, revealed on 6/8/24 at approximately 5:50 PM the Administrator and ADON (Assistant Director of Nursing) were notified by Nurse [redacted] who reports that resident [name redacted (Resident #474)] could not be found in the facility. Facility Nursing Staff report searching the entire facility and not able to find her. The Director of Clinical Services was notified. The Administrator was notified and immediately called 911 to report the facility had been unable to find this resident. The Initial Federal Report revealed when the ADON notified the family of the incident, the family member said she was not surprised and reported that she [the resident] ran away before while living in her apartment. When asked if the family had mentioned anything about her [the resident] running away prior to admission when they completed her admission documentation, the Social Services Director stated they did not say anything. The Initial Federal Report continued, stating the resident was found by local police at/near the police station on [NAME] Street at approximately 6:45 PM. The Initial Federal Report documented after being found the resident transferred to a local emergency room for evaluation. Then transported back to the facility following treatment for UTI (urinary tract infection), minor scarp to her upper lip and chin. Hospital ED (emergency department) records show she didn ' t ' need sutures and scans were negative for major injury including fractures. Upon return, the resident was placed on 1:1 supervision by staff. During an interview on 6/12/24 at 12:53 PM, the Administrator stated the front door of the facility is armed with an alarm. The Administrator demonstrated the alarm will sound if a code is not entered. The door is equipped with a two inch 15 second delayed egress. Meaning the door will open approximately two inches and stop. The alarm will sound, building in intensity, until a staff answers the alarm. The system also announces the location of the open door. The door will remain stopped at two inches unless the alarm is not answered after 15 seconds, when it will open all of the way. An observation on 6/12/24 at 1:01 PM, found Resident #474 in her room, in bed with the covers over her head. Staff Q, Certified Nursing Assistant (CNA) sat outside in the hallway outside of the residents room During an interview on 6/12/24 at 1:02 PM, Staff Q stated Resident #474 is receiving 1:1 supervision after having eloped on 6/8/24. Staff Q stated she is covering the 10:00 AM to 2:00 PM shift. Staff Q stated she did not know when the 1:1 supervision started. During an interview on 6/12/24 at 1:15 PM, Staff M stated she worked the morning of 6/8/24. She stated someone entered the code to the front door, and Resident #474 left the facility. Staff M stated she did not know who entered the alarm. Staff M stated she Resident #474 was found at a local park, approximately a mile from the facility. During an interview on 6/12/24 at 1:44 PM, Staff O, Receptionist stated there have been a lot of discharges and new admissions lately. Staff O stated there is an Elopement book at the front desk. Staff O stated the book includes residents who need supervision. A sheet for each resident includes their name and a picture. A description of height, weight and color of hair is also listed. Staff O stated the book was last a few days ago. Staff O stated she did not know if Resident #474 had been added to the book prior to 6/8/24. An observation on 6/12/24 at 2:15 PM, found Resident #474 in her room, in bed sleeping. The resident noted to have abrasions on her upper lip, and the left side of her chin. During an interview on 6/12/24 at 3:08 PM, Staff N, LPN stated on 6/8/24 at approximately 4:15 PM a staff informed her Resident #474 could not be found. Staff N stated she checked her assigned hallway and after not being able to find the resident called a Code Silver. Staff N explained a Code Silver means everyone needs to stop doing what they are doing and do a headcount of the residents on each hallway. Staff N stated she did not know the last time the resident had been seen. Staff N stated after the headcount, all nurses met in the center hallway and reported the headcount results. Staff N stated only Resident #474 could not be accounted for. The team decided to check all empty rooms and connected bathrooms and meet again in the center hall. Staff N stated after the nurses reconvened and confirmed they could not find Resident #474, she called the ADON. Staff N stated she was unsure of the time. But knows she text the height and weight of Resident #474 to the ADON at 4:51 PM During an interview on 6/12/24 at 3:34 PM, when queried about reviewing the facility investigation notes, the Administrator stated all notes are found in the EHR. The Administrator stated he did not complete staff interviews. The Administrator added during his investigation he reviewed camera footage of the front door area of the facility. He stated the footage revealed on 6/8/24 at 2:55 PM Resident #474 walked to the front door, wearing a red and black fleece coat, carrying a white plastic shopping bag. The Administrator stated the weekend receptionist, entered the alarm code to the front door, and Resident #474 exited the building. The Administrator stated staff started looking for the resident at 5:30 PM, and he called 911 at 6:03 PM upon being informed the resident could not be found. The Administrator stated he was notified at 7:31 PM, the resident was found by local police. When queried as to where the resident had been found the Administrator stated he believed the resident to have been found at the police station on [NAME] Street, approximately 2.2 miles from the facility. During an interview on 6/13/24 at 8:55 AM, a local police department officer stated they received a call on 6/8/24 at 6:03 PM from the facility regarding a missing resident. When queried on the location the resident was found, the police officer stated the missing persons report remains open as the department had not found the resident, or been informed the resident has been found. During an interview on 6/13/24 at 9:06 AM, a local emergency department confirmed Resident #474 was brought to the hospital on 6/8/24 at approximately 7:38 PM. The ED staff stated they have no information as to where the resident had been found. The staff stated the resident came to the hospital by ambulance. The local hospital document, titled ED Provider notes, dated 6/8/24, revealed Resident #474 presented to the ED by ambulance for AMS (altered mental status). Initial patient evaluation time 7:38 PM. Patient found on the side of the road by EMS (Emergency Medical Services). She has abrasions to her face likely from a fall today. Clinical Impressions included: At high risk for elopement; abrasion of chin; abrasion of lip, fall, and cystitis (urinary tract infection). During an interview on 6/13/24 at 9:13 AM, a dispatch staff from the local EMS provider stated Resident #474 was found at the side of the road at the intersection of [NAME] and [NAME] Drive. The dispatch stated a bystander saw Resident #474 on the side of the road, became concerned, pulled over help her and called 911. The bystander assisted the resident into their car until the ambulance arrived. The Emergency Medical Service provider report titled, A Patient Care Report - Final, dated 6/8/24 revealed: a. A call received at 6:38 PM b. Dispatched at 6:39 PM c. At scene at 6:49 PM d. At destination (local emergency room ) at 7:29 PM. Per a global positioning system, the [NAME] and [NAME] Drive intersection, depending on the route taken, is 5.5 to 5.8 miles from the facility. During an interview on 6/13/24 at 12:50 PM, Staff P, Receptionist stated on 6/8/24 she worked from 8:00 AM to 3:00 PM. She stated she did not know she had opened the door for Resident #474 until 6/9/24, when the Administrator showed her the video. Staff P stated she opened the door for the resident and let her out before the end of her shift. Staff P stated she thought that was around 2:50 PM. Staff P stated she was trained by the full time receptionist. She stated she was trained to ask people who they are before letting them in or out of the facility. Staff P stated she had never met Resident #474 prior to the incident. Staff P stated after watching the video she remembered the resident, and assumed she was a family member visiting a resident. Staff P stated she finds out who is a new resident by word of mouth, or from the full time receptionist. She stated there was an Elopement book at the front desk, but it has not been updated with Resident #474 picture/information. Staff P stated the book is now updated. During an interview on 6/13/24 at 4:20 PM, the Director of Clinical Services stated the facility waited too long to contact 911 after realizing Resident #474 was not in the building. She stated after the initial headcount, and the resident identified as missing administration should have been notified and 911 called immediately. When queried as to where the resident was found, the Director of Clinical Services stated she did not know the exact location where the police found Resident #474. On 6/13/24 at 5:00 PM, a drive from the facility to the intersection of [NAME] and [NAME] Drive revealed: a. [NAME] to [NAME] Street is heavily trafficked with cars and semi-trucks. b. The speed limit varies between 25 to 35 miles per hour depending on school zones. c. The pedestrian sidewalk ends at the intersection of [NAME] and Wisconsin Avenue. d. The intersection of [NAME] and Wisconsin Avenue is 0.6 miles from the [NAME] Drive intersection. e. The speed limit at Wisconsin Avenue increases to 45 miles per hour. f. After Wisconsin Avenue, the side of the road is paved with gravel. A facility policy, revised date of 3/2024, titled Elopements and Wandering Residents documented the facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Guidelines included: 5. Procedure for Locating Missing Resident a. Any staff members becoming aware of a missing resident will alert personnel using facility approved protocol b. The designed facility will look for the resident. c. If the resident is not located in the building or on the grounds, administrator or designee will notify the police department and serve as the designated liaison between the facility and the policy department. The administrator or designee should also notify the company ' s corporate office. d. DON (Director of Nursing) or designee shall notify the physician and family member or legal representative. e. Policy will be given a description and information about the resident; include any photos. f. All parties will be notified of the outcome once the resident is located. g. Appropriate reporting requirements to the State Survey agency will be conducted. 34821 4. The MDS for Resident #19 dated 5/24/24, listed diagnoses of cerebrovascular accident (CVA), hypertension (high blood pressure) and diabetes mellitus (DM). The BIMS reflected a score of 4 out of 15, indicating severely impaired cognition. The MDS assessed Resident #19 required substantial staff assist for transfers. The Care Plan for Resident #19 dated 12/4/23, directed he required assist of 1 and gait belt for all transfers. The Care Area Assessment (CAA) dated 5/24/24, revealed Resident #19's needed max to dependent assist of staff with most activities of daily (ADL's) for task completion due to impaired mobility and weakness. Resident is at risk for falls due to impaired mobility and weakness. He required max to dependent assist of staff with transfers. During an observation on 06/17/24 at 10:54 AM, Staff C, CNA took Resident#19 from under his arm as he stood on the one leg and turned him (stand pivot transfer) from his bed to his scooter. Staff C failed to use a gait belt with the transfer. During an interview on 06/20/24 at 9:58 AM Staff G, CNA described her transfer of Resident # 19, she sat him up on the side of the bed applied a gait belt, made sure his foot is on the pivot disk before she helped him stand and turned him to the scooter. During an interview on on 6/20/24 at 1:05 PM, Staff F Licensed Practical Nurse (LPN) reported R#19 required assist of 1, and a gait belt for a transfer out of bed. The policy titled Safe Resident Handling/Transfers revised 10/4/23 identified, it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Guidelines of the policy included: a. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. b. Handling aids may include gait belts, transfer boards, and other devices. c. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. d. Resident lifting and transferring will be performed according to the resident's individual plan of care. 48888 5. The MDS dated [DATE], revealed a BIMS score of 5 out of 15, indicating severely impaired cognition. Resident #48 utilized wheelchair for mobility and dependent on staff assistance to transfer to and from chair. Once sat in wheelchair, Resident #48 able to self propel wheelchair 150 feet independently. Diagnoses included encephalopathy and difficulty in walking. Resident #48 had 2 or more falls without injury since prior assessment. The Care Plan, initiated 02/27/24, revealed Resident #48 had an impaired ability to independently move or navigate wheelchair. An intervention, initiated 02/27/24, instructed staff that Resident #48 does some of the work to move or navigate the wheelchair, but usually required assistance of a helper to provide more than half the effort in moving the wheelchair from one place to another. During an observation on 06/18/24 at 12:32 PM, Staff M, Certified Nursing Assistant (CNA), pushed Resident #48 from the main C hallway into north dining room, no foot pedals in place on wheelchair, Resident #48 held his feet up approximately 1 to 2 inches from the floor during transportation. During an interview on 06/20/24 at 01:17 PM, Staff M, CNA, revealed that foot pedals must always be used when a resident is pushed in wheelchair and stated if she saw a resident pushed in wheelchair without pedals, she would stop. Staff M indicated transportation of residents in wheelchair without foot pedals may result in fall or injury to the resident. During an interview on 06/20/24 at 01:17 PM, Director of Nursing (DON) stated she would expect foot pedals are applied to wheelchairs before staff assist a resident with wheelchair transportation. The DON confirmed Resident #48 required occasional staff assistance with wheelchair transportation. During an interview on 06/20/24 at 01:20 PM, the Director of Clinical Services, revealed that many residents who self propel in wheelchair had pedal bags added to the back for foot pedal storage.

Based on record review, staff interview and policy review the facility failed to provide adequate assessment and intervention to prevent deterioration of a pressure wound for 1 out of 4 residents reviewed with a pressure sore. (Resident # 153). The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #153 as mildly cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 11 out of 15. The MDS listed the following diagnoses anemia, coronary artery disease, peripheral vascular disease, renal insufficiency and diabetes. It also identified Resident #153 required extensive staff assistance to total dependence of staff with bed mobility, transfers and toileting. The MDS indicated the resident received dialysis. The MDS indicated resident had a Stage 2 and a Stage 3 pressure ulcer. The Care Plan dated 1/23/24 indicated Resident #153 had a pressure ulcer upon admission. The Care Plan directed staff to provide wound cares as ordered by physician and treatment record. Staff to monitor dressing every shift to ensure it is intact and adhering. Report lose dressing to the treatment nurse. Staff to complete weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The nurse is to assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Report declines and/or signs and symptoms of infection to MD Review of the Nursing Admission assessment dated [DATE] revealed Resident #153 had a Stage 3 pressure ulcer on the sacrum measured 6 centimeter(cm) length by 4 cm width with a 4 cm depth. The Braden Scale for Predicting Pressure Ulcer Risk dated 1/22/24 revealed a score of 12 which indicates Resident #153 was high risk. The Nursing Admission assessment dated [DATE] revealed Resident #153 had a wound on his coccyx measured 7 cm length by 7 cm width. There was no depth documented and the documentation failed to reveal a Stage of the pressure ulcer. The Braden Scale for Predicting Pressure Ulcer Risk dated 1/22/24 revealed a score of 14 which indicates Resident #153 was moderate risk. The Weekly Skin Observation tool dated 3/20/24 noted a wound on the sacrum but failed to reveal measurements or the stage of the wound. The record revealed it was non pressure. The Braden Scale for Predicting Pressure Ulcer Risk dated 3/20/24 revealed a score of 07 which indicates Resident #153 was very high risk. The Wound Evaluation document dated 3/27/24 revealed a pressure type wound on the sacrum with a length of 12 cm. The evaluation lacked documentation of the width or depth of the wound. Review of January 2024 Order Summary Report revealed the following order with a start date of 1/23/24: Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) Apply to coccyx topically two times a day for wound cleanse with saline, pack with quarter strength dakins moistened 4 x 4's or kerlix, cover with aquacel sacral, change BID (twice daily) & as needed if loose or soiled. Review of February 2024 Order Summary Report revaled the following order with a start date of 2/7/24: Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) Apply to coccyx topically two times a day for wound cleanse with saline, pack with Dakins moisten kerlix - being sure to pack into undermining from 12 o'clock to 12 o'clock, cover with silicone foam, change BID. Review of the January 2024 and February 2024 Treatment Administration Records lacked documentation of treatments completed for Resident #153 sacrum pressure sore. Review of the facility Progress Notes revealed a lack of documentation on any descriptions of the wound or condition report to physician to notify of the decline in the wound. The Physician Notes from an emergency department document on 4/12/24 at 9:41 AM revealed Resident #153 there with worsening hip/low back pain in addition to concerns for worsening sacral decubitus ulcer. Wound VAC found not to be working so was removed and replaced with wet-to-dry dressing. Patient not meeting septic criteria on presentation but his work-up showed significantly elevated inflammatory markers. Computed Topography scan (CT) concerning for new osteomyelitis (bone infection). Resident started on broad-spectrum antibiotics and admitted to hospital with infectious disease for consult. Results of CT from hospital on 4/12/24 revealed new osseous (relating to bone) findings and increased soft tissue loss overlying the sacrum compatible with infection and osteomyelitis. Chronic changes seen in both hips and lower lumbar spine. Wound care nursing note from hospital admitted d 4/12/24 revealed pressure wound to sacrum Stage 4 measured 11.5 cm length by 10.5 cm width, The depth of the wound 4 cm with undermining at 6-10 o'clock with max of 4 cm depth. On 06/20/24 at 12:19 PM Staff H, Licensed Practical Nurse (LPN) stated when there is a pressure ulcer the nurse should provide treatments per the physician order. The wound measurements are done by the wound physician if there was something new I would do the measurement myself. The wound physician does a measurement every week. If someone had a wound vac the nurse should be checking every shift to make sure there is no beeping and there is a good seal and if the canister is full. I also would provide the dressing change for it as ordered. If there was an issue I would reach out to supervisors and let them know. There has been issues getting supplies for wound vac in the past. It has taken about a week to get the proper supplies. On 06/20/24 01:00 PM Staff D, Registered Nurse (RN) stated the nurse should measure wounds on admission and then every time you change the dressing. Follow the physician order for treatment and if no treatment contact the physician to get an order. If there is a wound vac the nurse should be change the dressing every 3 days and if the canister is full it will alarm. The nurse should be looking at them in between time to make sure still intact. I remember Resident #153 he had a wound on his coccyx it would come up often we would change it 2-3 x day due to the spot it was in. I believe he had the wound vac but he also at times had a wet to dry dressing. We document the dressing changes on the treatment administration record. On 06/20/24 at 3:41 PM the Assistant Director of Nursing (ADON) stated the expectation is for pressure wounds to be documented and measured weekly and they are dressing changes done weekly. There were wound treatment orders for Resident # 153. On 6/20/24 at 3:41 PM the Director of Clinical Services stated if their is a change in condition with a wound they should be notify the family and the physician and if needed their is appropriate referral made to the wound clinic to be seen by a physician. The end goal is for the wound to heal. On 06/20/24 04:05 PM reviewed the wound sheets with the ADON and she stated there was no documentation for the wound after the initial admission documentation. She states the expectation is to have wound measurements completed on admission, readmission and then weekly. The nurse completing the readmission should have measured the wound and notified the physician of changes in the wound. The facility provided a policy titled Pressure Injury Prevention and Management with revision date of December 2022 which stated the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. The policy directed licensed nurses to conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. The policy revealed assessments of pressure injuries will be performed by a licensed nurse and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. Nursing assistants will inspect skin during bath and will report any concerns to the resident ' s nurse immediately after the task. Training in the completion of the pressure injury risk assessment, full body skin assessment, and pressure injury assessment will be provided as needed.

Based on observation, clinical record review, and staff interviews, the facility failed to provide appropriate precautions and care to prevent resident injury, and caused a resident's bone fracture with associated pain and swelling, when they pushed the resident in a wheelchair without footrests applied, for 1 of 8 resident's reviewed (Resident #1). The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 7/27/23 revealed Resident #1 had diagnoses that included diabetes, seizure disorder, anxiety, schizophrenia and delirium, and scored 11 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment. The MDS documented the resident required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed or chair, toileting, bathing and personal hygiene. The assessment revealed the resident had not experienced pain in the 5 days that preceded the assessment. The Care Plan dated 10/31/22 documented Resident #1 has a self care performance deficit related to impaired mobility. The care plan directed staff that the resident uses a wheelchair for locomotion/mobility, is able to propel independently often but may require limited assistance at times. The care plan listed an intervention dated 7/3/23 directing staff that a specialty shoe is to be worn on her left foot when up in her wheelchair. It also documented the resident prefers to propel with her left foot and to encourage her to place her foot on the foot rest. The Medication Administration Record (MAR) dated September 2023 documented an order for stat portable 2 view x-ray of left ankle and left foot dated 9/7/23 at 2:30 p.m. The X-ray report dated 9/7/23 at 5:19 p.m. revealed findings and impression as an oblique acute fracture through the neck of the 3rd metatarsal bone on the left foot, and was a new development when compared to a previous X-ray that was completed on 7/26/23. The Physician Orders included the following orders dated 9/8/23: -Norco (Hydrocodone-Acetaminophen) 5-325 milligrams (mg) 1 tablet every 6 hours as needed for foot/ankle pain. -Apply ice to affected area, 15 minutes on and 15 minutes off. -Refer to ortho for evaluation of large calcaneal spur. Pain assessments documented on the resident's September and October MAR's revealed pain levels of 0 from 9/1/23 through 9/6/23, a 0 to 10 pain scale used, with 10 assigned to the worst pain possible. Staff recorded the following pain levels after 9/6/23: Day Shift Night Shift 9/7/23 4 0 9/8/23 0 0 9/9/23 0 0 9/10/23 0 0 9/11/23 0 0 9/12/23 0 8 9/13/23 0 0 9/14/23 0 4 9/15/23 5 6 9/16/23 0 6 9/17/23 0 0 9/18/23 3 0 9/19/23 0 0 9/20/23 0 0 9/21/23 0 0 9/22/23 0 0 9/23/23 5 0 9/24/23 5 7 9/25/23 0 0 9/26/23 0 2 9/27/23 0 0 9/28/23 6 0 9/29/23 0 0 9/30/23 0 0 10/1/23 0 0 10/2/23 0 0 10/3/23 0 0 10/4/23 0 0 10/5/23 0 0 10/6/23 0 6 10/7/23 0 0 10/8/23 0 0 10/9/23 0 0 10/10/23 0 0 10/11/23 4 0 The resident's September, 2023 and October, 2023 MAR's, and narcotic inventory control records revealed staff administered Hydroco/APAP tablets to the resident as follows: 9/10/23 2 times 9/11/23 2 times 9/12/23 1 time 9/15/23 3 times 9/16/23 1 time 9/17/23 1 time 9/19/23 2 times 9/20/23 1 time 9/21/23 1 time 9/22/23 2 times 9/23/23 2 times 9/24/23 1 time 9/25/23 3 times 9/27/23 1 time 9/28/23 1 time 9/29/23 1 time 9/30/23 1 time 10/1/23 1 time 10/6/23 1 time 10/9/23 1 time 10/10/23 1 time 10/11/23 2 times During an observations on 9/20/23 at 10:04 a.m. observed the resident seated in a wheelchair, gripper socks on bilateral feet, both feet on footrests of the wheelchair, and the resident's left foot appeared swollen and considerably larger from the ankle area to the toe area, in comparison to the right foot that appeared normal in size. Staff interviews revealed the following: On 9/21/23 at 11:22 a.m., Staff A, Certified Nursing Assistant (CNA), stated she worked on 9/7/23, assisted Staff B, CNA, and got the resident up, dressed, and transferred to her wheelchair. The resident wanted to be pushed and Staff Bed pushed her out of the room and into the hall. Shortly after that everyone was around the resident near the Administrators office. On 9/21/23 at 11:39 a.m., Staff B, CNA, stated on 9/7/23 the resident was assigned to her 1 to 1 that day. She stated she got the resident dressed, and put her hiking boots on, due to they were the only shoes she could find in her closet. She stated the resident told her the left shoe was tight after she put them on. Staff A, CNA helped her transfer the resident to her wheelchair with a mechanical lift, positioned her normally so her feet didn't touch the floor. The resident could self-propel in the wheelchair with her feet if she moved herself forward on the seat and she left the footrests off the wheelchair to enable the resident to do that. That morning the resident refused to self-propel, wanted to be pushed by the staff, so she pushed her out of the room and into the hallway. Staff B stated when they got about 50 feet down the hall the resident stated ouch, ouch. Staff D, Registered Nurse (RN) nearby, checked the resident, they removed her boot and could see the imprint from the boot on the resident's skin. After the incident, Staff C, CNA instructed Staff B the resident wasn't supposed to wear those shoes. On 9/21/23 at 11:53 a.m., Staff E, RN, MDS Nurse, stated she was in her office on 9/7/23 when she heard the resident scream. She ran out of her office and saw the resident in her wheelchair, her left foot was sort of turned to the left and behind the little wheel of the wheelchair, and she had boots on. On 9/21/23 at 12:05 p.m. Staff C, CNA, stated on 9/7/23, she looked down the hall after the resident screamed, saw the resident seated in the wheelchair by the Administrator's office. She stated staff from the nearby offices came out to the hall, Staff D, RN and Staff B, CNA were there and the resident had hiking boots on. She stated the resident had an open wound on her left heel before, the Assistant Director of Nursing (ADON) instructed staff to put a sandal on her left foot, and the resident could wear her hiking boot on her right foot. Staff put the left hiking boot up on the shelf in her closet and the left sandal and right boot were placed on the floor in her closet. Staff C responded to the incident, removed the boot as directed by the nurse, and the resident fussed because it hurt. Staff D looked at it, her foot wasn't swollen then. Staff C put the resident in bed after lunch, about 1 and 1/2 to 2 hours after the incident, noticed her foot was swollen, the resident complained of pain when she touched her foot and she told Staff D, the nurse. On 9/21/23 at 2:42 p.m., Staff D, RN, stated on 9/7/23 Staff B, CNA, pushed the resident in her wheelchair, without footrests, towards her while she was in the hallway. She stated the resident yelled ouch, she saw the resident's left foot was on the floor, kind of bent, turned a little and behind the small wheel of the wheelchair but not lodged, the small wheel was also turned a little, and the resident had hiking boots on. She stated they took her shoes and socks off, saw lines from the shoe on her skin, her foot/ankle did not look swollen, and the resident complained of pain. Staff D stated she thought it was because the boot was too tight, or maybe her ankle was sprained because of how her foot was turned. A couple hours later the resident was in bed, the CNA told her the resident's foot was swollen. She assessed her left foot/ankle, it was swollen, she didn't see any redness or bruising, and the resident complained of pain when her foot was touched. She notified the medical provider and received an order to get an X-ray. Staff D stated staff shouldn't push a resident in a wheelchair unless the resident's feet are positioned on footrests on the wheelchair. On 9/21/23 at 4:02 p.m., the Administrator, stated they didn't save a copy of the hallway security camera video from 9/7/23 that captured the incident. She stated she watched the video at the time and could tell Staff B pushed the resident in her wheelchair, without footrests. She stated the resident's feet were on the floor and her left foot ended up behind the wheel of the wheelchair as Staff B pushed her.

Based on observations, staff interviews and record review, the facility failed to store, prepare and serve residents ' food under sanitary conditions that met professional standards of food service, for 5 of 5 observed resident meals. The failures led to an immediate jeopardy situation for the health and safety of residents. The facility reported a census of 69 residents. The State Agency notified the facility of the IJ on 5/28/23 at 11:00 a.m. The IJ began on 4/11/23 upon the first initial kitchen tour. The facility abated the IJ on 6/5/23 by adding cleaning of the ceiling air return vents to the maintenance staff's routine schedule, cleaning the AC vents added to the routine cleaning dietary duties, and all dietary employees completed components of Safe Serve food safety education, and following the planned menu education through Relias, a computer based education program utilized by the facility. The facility did not have documentation of the dietary staffs completion of the required education prior to 6/1/23, all training completed by 6/5/23. The facility staff's actions lowered the scope and severity from a L to a F at the time of the survey, after the State Survey Agency verified the facility staff had implemented the education and additional corrective actions. Findings include: The initial kitchen observations for the Main Kitchen on 4/11/23 with the Dietary Manager (DM) at 9:00 AM, revealed the following: a. Plate warmer located inside the door did not work according to the DM. b. Plate warmer contained visible dry food debris of chips and cereal on the bottom shelf; the middle shelf contained a dried-on, pink colored substance on the surface and outside edge; and the top shelf contained a dried pink substance sporadically across the surface. c. The middle shelf was noted to have a tray of clean drinking glasses and a banana lying on them. d . Inside the main kitchen South entry door was a fire extinguisher. Beside the extinguisher was noted brown buildup substance on the wall. e. All walls inside of the microwave contained a dried brown substance. f. The bottom of the toaster had approximately a quarter inch thick buildup of brown substance. g. A visible brown substance present on the bottom of the Glove brand mixer and the clear plastic attachment sticky to touch. h. A white wheeled container approximately 3 feet by 3 feet by 2 feet in size contained a dried light brown substance and a couple of buildup nickel size darker brown spots of a sticky consistency. i. Above the food prep stainless steel table a cluttered shelf observed with stickers hanging down at various lengths, a personal cell phone, an opened partially drank plastic water bottle with no date or name, and a a slightly wet linen cloth approximately 6 inches by 6 inches in size. j. The milk cooler contained a visible dried yellow substance across the front, lower half of the cooler. k. The six gas burners of the gas range with a build-up of black substance with an adjacent griddle that contained a dried black substance on the griddle and across the back. l. To the left of the Southbend range, the ceiling contained a circular heating, ventilation, air conditioner (HVAC) vent that had been approximately two feet in diameter. Adjacent to the vent the ceiling white paint had been visible for approximately two inches and then noted a dark ring approximately 19-24 inches in diameter where air blows out of the vent. m. A Motak freezer located against the left wall of the kitchen contained a dried dark substance across the bottom of the horizontal vents and the wheeled casters; the inside contained a sticky pink substance across the bottom shelf and dried food contents. n. The refrigerator labeled number 1 contained a dried dark gray and black substance on the horizontal vents at the bottom. o. Freezer #1 contained dried contents around the handles and the wheeled casters had a gray substance. The top left outside of the freezer had a gray visible substance that included a one-inch length piece dangling vertically. p. Freezer #2; and noted across the bottom horizontal vent and the bottom of the right shelf had been pieces to include freezer burnt french fry and cardboard box pieces. q. Adjacent to the second Freezer #2 was a small porcelain white handwashing sink that had a buildup of brown substance around both water faucets, and noted beside the sink was a plastic trash can with visible soiling on the top of lid and several items stuck to the outside of lid. r. On the wall above the clean dishes' storage, a Garrisons brand portable air conditioner had visible gray substance built up on all horizontal vents. The top of the [NAME] brand air condition had a buildup of gray substance. s. Below the air conditioner, on the same wall, an Ecolab dishwasher machine noted on the floor area with discarded disposable plastic cups, pieces of paper, visible debris, and polyvinyl chloride (pvc) pipe had a buildup of a gray substance. t. Clean dishes rack with clear acrylic drinking glasses with white residue on the inside of several glasses. u. The separate dry goods storage room noted with dry uncooked noodles on the floor, storage wood shelves with peeling white paint and a gritty substance to touch. A large can storage rack noted to have a visible brown dust substance on the unused shelves. On 4/11/23 at 11:25 AM, an initial observation took place of the North Dining Room Kitchenette with the following noted: a. On the left wall, brown stains dried vertically beside on the wall. b. A Haier brand refrigerator with a sign, for residents and staff, full of to-go containers, drinks, and sacks with few names or dates. Outside surface of the refrigerator door had a dried brown substance splattered across the front. c. On top was a gray color silverware container and the front of the container noted to have dried brown substance in streaks. d. A small Hiscense brand refrigerator with a buildup of a gray substance. e. Inside of the microwave, dried bright yellow substance on the clear rotating tray and all walls inside the microwave, observed a brown color substance buildup f. The steamer noted to have a brown dried substance on the outside right and noted on the lower shelf was dried material and food content. The wall surface between the steam table and serving window was noted to have a brown dried substance. g. On the kitchenette back wall noted a stainless-steel sink with a buildup of brown substance around the water faucets and the sink itself had dried brown stains. The cold-water faucet was not working, as no water flowed when the faucet was turned on. Noted below the sink was a cabinet floor with visible brown and loose gray substance, and noted storage of [NAME] brand paint cans, Ecolab brand lime-a-way, and Ecolab cleaning gel. Paint cans had apparent rust on lids. When opening the left side door, a few small winged insects had flown out. h. A large area of liquid brown color substance drying and dry coffee grounds across the counter by the Keurig small coffee pot. i. A commercial Warine brand coffee pot was noted to be on as a green light was noted. The outside of the coffee pot contained brown streaks down the left side. Observations on 4/11/23 at 9:00 AM and on 4/12/23 at 7:44 AM revealed Staff P, Dietary, wore a hair net that did not cover all scalp hair while in the main kitchen. On the right and left side of Staff P's face there was approximately one to two inches of thick hair hanging past facial [NAME]. Observation on 4/12/23 at 11:00 A.M. revealed two plastic oscillating fans approximately two feet in height present on the prep counter in the main kitchen. Observation revealed both fans contained a visible gray substance on the fan blades and the blade cover; both fans positioned to produce air flow over the prep table and gas range area. Observation on 4/12/23 at 11:20 AM, revealed Staff P, Cook did not wash her hands nor don gloves prior to preparing resident lunch food. Staff P touched her face cheek area, then facial [NAME] and then touched silverware to assemble for residents' lunch. Staff P continued in this manner touching her bare skin on arms, clothing and then took plated food from the cook and put a plastic lid over the plate. On 4/12/23 at 12:06 PM, observed a male Dietary Staff enter the kitchen and not wash his hands. The male staff touched his facial skin and arms and then pulled aluminum foil sheets with bare hands and Staff P picked up the foil to cover a resident's plated food. The male staff transferred cooked steam table container pans of resident food items to a plastic cart for transport to the North Dining room kitchenette. On 4/12/23 at 12:30 PM, the Dietary Manager (DM) observed in the North Dining Room kitchenette did not wash her hands, touching resident coffee cups to fill and putting vegetables in the microwave that had not temped on the steam table. On 4/12/23 at 4:03 PM, in an interview with the DM, she showed a Daily Cleaning Checklist instituted in the last month. When asked who would be responsible to follow-up on the check sheets and verify the cleaning completed, the DM stated that was her responsibility. During the interview an opened 5-pound bag of shredded cheddar cheese was noted left out on the stainless-steel counter, with the bottom contents noted to be melting. No Dietary Staff present. The floor dirty with a discarded disposable glove and a piece of bread. Staff T, Cook entered the kitchen and the DM asked Staff T about the cheese and then requested the oscillating fans be put away. Staff T responded using profanity. The DM observed shaking her head. On 4/13/23 at 7:55 AM, observation of the North Dining Room kitchenette showed Staff P enter the kitchen and noted there was no handwashing, Staff P touched her skin and then was observed making coffee in the Warine coffee pot. An observation on 4/13/23 at 8:16 AM, showed Staff U transport breakfast food to the North Dining Room kitchenette. Staff U touched her bare skin arms, face and then put gloves on without washing hands. Staff U observed using a personal cell phone, placed the phone in a pocket and then continued to plate resident food. At 8:18 AM, Staff U asked if the kitchenette sink had working water faucets and Staff U stated unaware if the water worked. Noted no paper towels on the kitchenette counter. On 4/18/23 at 12:15 PM, an observation of the main kitchen had shown Staff V, Dietary Aide was working at the food prep table area with no hairnet worn. Staff V wore white framed plastic sunglasses on top of her head. When Staff V asked about wearing a hairnet, she stated that her mind had just been going while taking items out of a refrigerator. On 4/20/23 at 11:00 A.M. an observation of the North Dining room kitchenette had taken place and the following noted: a. The black plastic trash can lid was off with trash overflowing to the floor. b. A black dried and partially wet circle of liquid noted on the trash can and on the linoleum floor around the garbage can. c. Winged insects noted flying around the garbage can. e. The floor noted with empty cardboard boxes, silver aluminum piece, food, and white condiment packets. f. The toaster on the counter observed with winged insects on the tray and the tray stained with a dark brown substance. 26529 2. Observation in the facility kitchen on 5/31/23 at 11:03 a.m. revealed: a. Water temperature at the handwashing sink was cool, and did not warm when the faucet was left on for over a minute. b. The low-temp dishwasher in operation, the exit surface/counter from the dishwasher approximately 7 feet long, clean dishes in dishwasher racks were on the exit counter and a window type of Air Conditioning (AC) unit positioned on the wall, at the end and approximately 24 inches above the counter surface, and blew down over the dishes on the counter. The grates on the lower 1/2 of the AC unit, through which the cold air blew, were covered with a gray dusty substance approximately 2 to 3 millimeters (mm) thick, that looked similar to lint from a clothes dryer. c. An opened box with 24 Chocolate Mighty Shakes (a dairy-based 4 ounce nutritional supplement shipped and stored in a frozen state, served after thawed) and an unopened box of 50 Mighty Shakes that were not dated when the containers were removed from frozen storage. The product expires 3 days after removed from frozen storage. d. A scoop positioned in a bin container of dry oats used for oatmeal. e. Broken thermometers located in a 3 door refrigerator located next to the 3 compartment sink, and in the milk cooler where various 8 ounce cartons of milk were stored, at least 200 cartons in milk crates inside the cooler. Observation in the facility kitchen on 5/31/23 at 12:50 p.m. revealed: a. Water temperature at the handwashing sink remained cool, did not warm when faucet was left on for over 3 minutes. b. The wall AC unit continued to have dust that covered the grate on the lower half of the unit and blew down on cleaned dishes in dishwasher racks positioned on the dishwasher exit counter. c. Two air return vent grates located in the ceiling above food preparation counters, approximately 24 inches square, that were covered with gray colored dusty substance approximately 2 to 3 mm thick. d. The daily cleaning assignments and schedule did not list the ceiling vents or wall AC unit. During an interview 5/31/23 at 12:56 p.m., Staff RR, the interim Dietary Manager was informed that the window AC and ceiling air return grates were covered with what appeared to be dust, the scoop in the oats bin and broken thermometers found in the refrigerators. Staff RR stated she cleaned the wall AC grate and ceiling air return grates on 5/28/23, a contracted company came on 5/19/23 and cleaned the Kitchen floor, she cleaned the other Kitchen issues on that date and after that were identified as concerns on the initial annual survey exit on 5/1/23. During an interview 5/31/23 at 1:03 p.m., the facility Administrator was informed there was no hot water at the handwashing sink in the Kitchen. During an interview 5/31/23 at 2:55 p.m., the facility Administrator stated the handwashing sink water temperature was fixed, it was a mixing valve issue that Staff TT, the Maintenance Director had taken care of, and had not been reported as a problem by any of the dietary staff. Observation on 5/31/23 at 4:10 p.m. in the North Kitchenette revealed: a. A strong odor of coffee that came from an approximate 20 inch by 5 to 6 inch puddle of coffee that dripped on the counter from the Coffee dispenser that was turned on and in use above the area. b. A microwave unit with 6 to 7 dried brown spots that varied in size from 2 - 3 mm to 6 - 10 mm located inside on the bottom of the unit, located between the door and the edge of the glass turntable plate. There were no staff in the area and the microwave was not in use. c. Four chocolate Mighty Shake containers in the refrigerator, fully thawed, undated when pulled from frozen storage. Observation on 5/31/23 at 4:20 p.m. in the facility Kitchen revealed: a. Hot water from the handwashing sink faucet. b. The wall AC unit grate and ceiling air return grates unchanged in appearance, remained covered in dust-like substance. c. Staff RR, interim Dietary Manager, observed the open box with undated and thawed Mighty Shakes, and the unopened box of 50 Mighty Shakes in the refrigerator. Staff RR stated she did not know when the opened box was pulled from the freezer, would throw the cartons away, the unopened box was pulled from the freezer that day and she wrote 5/31/23 with a marker on the outside of the unopened box of Might Shakes. On 5/31/23 at 4:33 p.m., the Surveyor requested to speak to Staff TT, maintenance Director, in reference to the ceiling air return vents in the Kitchen, and informed Staff TT had left for the day but could return. On 5/31/23 at 5:14 p.m., the facility Administrator stated staff TT returned, the window AC grate and ceiling air return grates had a greasy-residue substance under the dust, they ran them through the dishwasher, they were cleaned and the ceiling air return vents were added to Staff TT's duties to clean/inspect. Observations on 5/31/23 between 6:18 p.m. and 6:37 p.m. revealed Staff R, Cook, plated the evening meal from the steam table in the North Kitchenette and wore the same gloves throughout the process. At 6:29 p.m., Staff R grabbed 4 chicken nugget pieces with the same gloves worn throughout the plating process and did not use serving utensils, or remove his gloves and apply new gloves. On 6/1/23 at 9:50 a.m., the Surveyor requested a report from the facility's computer based staff education program that listed the dietary staff's completion of food sanitation and safety education, and education on following the planned menu, both mandated upon initial employment for dietary duties. On 6/1/23 at 2:18 p.m., the facility's Chief Clinical Officer stated the facility could not provide documentation the dietary employees had received the required education upon hire, he ensured all the dietary staff on duty would receive the education that afternoon, and if a dietary employee wasn't on duty, they would receive the education prior to work on their next day assigned in the Kitchen. On 6/1/23 at 3:44 p.m., the facility's Chief Clinical Officer stated they had provided education to the dietary staff and wanted the Immediate Jeopardy status to be abated as of that time because they provided the required education. As of that time, there were 9 employees listed on the dietary employee roster, their position and hire date listed below: Staff Q, Cook, hired 1/2/23 Staff R, Cook, hired 12/15/22 Staff S, Cook, hired 10/19/21 Staff T, Cook, hired 12/27/21 Staff V, Dietary Aide, hired 8/6/21 Staff W, Dietary Aide, hired 6/8/22 Staff RR, interim Dietary Manager, hired 11/26/21 Staff UU, Cook, hired 1/17/22 During an interview 6/5/23 at 7:19 a.m., Staff Q, Cook, in the facility Kitchen and in process of breakfast meal preparation, stated she had not received education related to food safety or following the planned menu on 6/1/23, she didn't work that day, she had received education on the cleaning schedule at a staff meeting that she thought occurred on 5/30/23. Staff S, Cook, also present in the Kitchen at the time, stated Staff Q didn't work on 6/1/23 and wasn't there when they went over that education. Staff Q was unaware that she required the training before she worked again. Observation on 6/5/23 at 11:25 a.m. revealed Staff Q in the administrator's office with education in process. Observation on 6/5/23 at 12:23 p.m. revealed 19 residents seated in the Dining Room for the noon meal, resident room trays for the North A and B Halls and food for the steamtable in the Kitchenette had not been distributed by the dietary department. During an interview on 5/31/23 at 9:39 a.m., a dietary employee stated room trays for the noon meal went out to the North A and B Halls at approximately 12:00 noon, with meal service to the Dining Room immediately after that. Observation on 6/5/23 at 12:25 p.m., through the glass window of the Kitchen door, revealed Staff RR, interim Dietary Manager and 2 dietary employees, 1 that appeared texting on a cell phone, all positioned by the prep counter. Staff RR responded to the knock at the door, emerged from the Kitchen with the cart used for the A Hall room trays, said they would be going out now and transported the cart to the A Hall. Observation on 6/5/23 at 12:34 p.m. revealed the B hall room trays and food for the Kitchenette not dispensed from the dietary department, 21 residents were seated in the Dining Room. On 6/5/23 at 12:34 p.m., the facility RDLD was informed of the meal status for B Hall room trays and Dining Room residents, and concern for the number of insulin dependent diabetic residents who had not received their noon meal as of that time. The RDLD went into the Kitchen immediately, returned from the Kitchen at 12:40 p.m. and stated dietary staff were finishing up on some things for the front/skilled hall, would take the food to the North Kitchenette after that for the meal service, and they were running behind due to the required education for Staff Q. Observation on 6/5/23 at 12:50 p.m. revealed the dietary department had not delivered food for the North Kitchenette/Dining Room residents, 22 residents seated there, 1 of the residents asked when they could have their food, stated they were hungry and had waited for a long time for their lunch, then stated don ' t you work for the State, can ' t you make them serve our food? Observation on 6/5/23 at 12:57 p.m. revealed dietary staff delivered food for the North Kitchenette steamtable and meal service commenced. Observation on 6/5/23 at 1:08 p.m. through the service window at the North Kitchenette revealed Staff S, Cook, wore gloves throughout meal plating, grabbed a handful of French Fries and served to a resident without changing gloves, and did not have a utensil present to serve with. The RDLD was informed of that at that time, went to the Kitchenette, observed Staff S did not have a utensil for the French Fries and addressed the matter with the employee. During an interview 6/5/23 at 1:11 p.m., the RDLD stated staff should always use serving utensils, should not touch or handle food, and if unavoidable, staff should apply clean, single use gloves if they had to handle resident food.

Based on observation, clinical record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure the functioning of a door alarm in order to prevent an elopement for 1 of 1 cognitively impaired residents reviewed for an elopement (Resident #71), failed to ensure residents could safely store and administer medications for 2 of 2 residents reviewed for self-administration of medications (Resident #36, #24), failed to ensure 2 of 2 treatment carts and 1 of 2 medication carts locked or secured when staff not present, and failed to secure the kitchen steam table in a manner to prevent unsafe access by cognitively impaired residents with 5 residents nearby during 1 of 1 observations. The facility identified 26 residents as cognitively impaired and self-mobile. These failures resulted in possible endangerment for the residents, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the residents. The facility reported a census of 69 residents. On April 19, 2023 at 12:45 p.m., the State Survey Agency informed the facility of the staff's failure to ensure a cognitively impaired resident would not elope from the facility creating an Immediate Jeopardy situation, which began on September 19, 2022. The SA informed the facility they removed the immediacy on September 19, 2022, when the facility staff implemented the following Corrective Actions: a. Turned the door annunciators back on. b. Supervised the egress doors until the Maintenance Director assessed the 15 second delayed egress annunciators for functionality. c. Initiated an immediate investigation, including staff and resident interviews. d. Completed a visual head count of every resident to ensure all were present and safe. e. Evaluated Resident #71 by a nurse, with no signs of trauma, harm or injuries, or further psychological impairment. f. Re-evaluated all facility residents for elopement risk and updated care plans and elopement books. g. Conducted staff education on elopement risk and procedures; elopement triggers; elopement response plans; monitoring of doors and ensured no one worked without education prior to the start of shift. h. Conducted simulated elopement drills. i. Completed a root cause analysis of the event. j. Placed the resident on 1:1 supervision until door mechanics could be assessed. After CMS review, the State Agency informed the facility on 5/28/23 at 11:00 a.m. that based on the identification of additional failures to provide adequate supervision, a current IJ situation existed related to the unsecured medications and access to the steam table. Therefore, another IJ template presented to the facility on [DATE]. The facility removed the IJ on 5/31/23 after taking the following actions: a. lock/latch on the door to the kitchenette changed to ensure the door locked when it closed b. locks on all medication and treatment carts changed on 5/31/23 c. no observations of the hazards or unsecured medications in rooms on 5/31/23. The facility staff's actions lowered the scope and severity from a K to an E at the time of the survey, after the State Survey Agency verified the facility staff had implemented the education and additional corrective actions. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 8/29/22, listed diagnoses for Resident #71 which included non-Alzheimer's dementia, unspecified dementia with behavioral disturbance, and anxiety disorder. The MDS documented the resident independent with transfers, and required supervision for walking and eating, extensive assistance of 1 staff for dressing, extensive assistance of 2 staff for toilet use and personal hygiene, and depended completely on 2 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 1 out of 15, indicating severely impaired cognition and identified he had wandering behaviors 4-6 days out of the 7-day review period and stated his behaviors placed the resident at significant risk of getting to a potentially dangerous place. An 8/23/22 Elopement Risk Evaluation stated the resident was currently actively exit seeking and was a high risk to elope. A 9/6/22 Social Service Note documented facility staff called the resident's sister to discuss possibly having to find a different placement for the resident due to exit seeking behaviors. A 9/12/22 Physician Note established the Nursing Staff reported on 8/23/22 that the resident stated he wanted to leave and be with his brother and that the resident tried to go out the doors twice last night. The note stated staff discussed the possible risk for elopement and they would keep an eye on him. A 9/19/22 1:45 p.m., a General Note indicated the resident sat quietly eating lunch and denied pain or the need for analgesia (pain medication) at this time. A 9/19/22 4:44 p.m., a General Note reported the resident got out of the facility and the Police were contacted. The note revealed the resident was found shortly after by a Certified Nursing Assistant (CNA) outside of the facility. A 9/21/22 Physician Note documented the resident had an elopement on 9/19/22 and was found a few blocks away from the facility. Care Plan entries, dated 9/19/22, stated the resident was an elopement risk and wanderer related to disorientation to place. The resident had a history of attempts to leave the facility unattended and had impaired safety awareness and wandered aimlessly. Further 9/19/22 entries stated the resident's safety would be maintained through the review date and directed staff to: a. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. b. Monitor for fatigue and weight loss. c. Provide structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes. d. Identify a pattern of wandering. The Care Plan lacked documentation of the resident's risk/history of eloping or interventions directed at the prevention of elopement prior to the 9/19/22 incident. The National Weather Service Climatological Data retrieved from https://www.weather.gov/wrh/Climate?wfo=dvn on 4/19/23 listed the high and low temperatures on 9/19/22 as 83 degrees Fahrenheit and 63 degrees Fahrenheit. During a phone interview on 4/18/23 at 4:11 p.m., Staff I, CNA stated she remembered the resident leaving the facility. She stated while staff were in a meeting, the resident got out and they looked for him. Staff I stated she found him on [NAME] and [NAME] streets near the facility. She stated the resident was walking on the sidewalk and it was about an hour from the time they realized he was missing to the time they located him. Staff I stated they found him about a 5-minute walk away. During a phone interview on 4/18/23 at 4:33 p.m., Staff J, former Director of Nursing (DON) stated when the resident eloped the door alarm was not engaged. She stated staff observed the door opened and immediately did a head count and noticed the resident was not there. She stated the B Hall door alarm was broken and had been intermittently problematic when she worked there. She stated because of Resident #71's past history, when the door was open, they immediately thought of him. The former DON stated the resident had exit seeking behaviors was constantly walking and he eloped from the Group Home he was at previously. She stated it was 30 minutes by the time they found him. She explained some interventions they utilized to address his wandering were redirection and maintaining a visual on the resident. The former DON reported the resident was in the Elopement Book which had his picture and basic information. She stated the Elopement Book was a tool used if someone eloped but would not prevent an elopement. She stated the doors were supposed to be locked and reported the facility staff requested a Wanderguard (a device which alerted when residents were near exits) multiple times because the resident should absolutely have one. During an observation on 4/19/23 at 9:49 a.m., the Administrator demonstrated the door alarm mechanisms on the left hall door, right hall door, front dining room door, back dining room door, B Hall door, and A Hall door. The Administrator pushed on the door for 15 seconds and the door alarmed and the light turned red. In order to rearm the doors, the Administrator utilized a key. A receptionist sat next to the front door so the door was unarmed. She stated the door was armed when the receptionist was not present and required a code to be silenced. During an interview on 4/19/23 at 7:45 a.m., Staff F Certified Medication Aide (CMA) stated prior to the resident's elopement he kept getting out and they brought him back in. She stated on the day of the elopement, she did not hear the alarm. During an interview on 4/19/23 at 8:22 a.m., the Assistant Director of Nursing (ADON) stated if one pushed on the B hall door, the light would turn red and the alarm would be disabled. She stated staff did not rearm the door after the resident touched the door. The ADON reported prior to the elopement, the resident touched the door and they removed him and disabled the door but did not re-arm the door. She stated if the door was green, that indicated the door alarm was armed. She stated it was her practice to look at the doors and after the elopement, the facility completed education related to the door locks. During an interview 4/19/23 at 10:05 a.m., the Administrator stated prior to the elopement, the resident was agitated and staff had disarmed the door but not rearmed it. She remarked it was staff error. During an observation on 4/20/23 at 7:20 a.m., when the facility front door was pushed, it was locked and would not open. During an interview on 4/20/23 at 9:13 a.m., Staff N, CNA stated she did not know how the resident got out of the facility but she heard a Code Silver. She stated staff were trying to figure out who eloped but she knew it was him because of his history of wandering. During a phone interview on 4/20/23 at 9:44 a.m., Staff O, former Administrator stated the biggest concern he had with the resident was that he would pace. He explained the day before the elopement, the facility shut off the door annunciator due to complaints but stated the doors also had local alarms staff could still hear. He stated the resident left the facility and they completed a search and found the resident within the hour near a park sitting on some bleachers. The former Administrator stated if the door opened, the light at the top would turn red to indicate the door was not engaged. He stated a key was needed in order to re-arm the door and stated more than likely, the door opened prior to the elopement and staff failed to re-arm the door. After the elopement, he stated the facility turned the annunciators back on and completed staff education regarding elopement and door locks. The undated facility document Cognitively Impaired and Independently Mobile, provided on 4/25/23 listed 26 cognitively impaired and independently mobile residents. During an interview on 4/26/23 at 2:04 p.m., the Director of Nursing (DON) stated a resident's history of elopement and related interventions should be included on the Care Plan. The facility policy Elopements and Wandering Residents reviewed 1/2023, stated the facility ensured that residents who exhibited wandering behavior and were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 2. The MDS assessment dated [DATE] listed diagnoses for Resident #36 which included psychotic disorder, schizophrenia, and paranoid schizophrenia. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 10/6/21 Care Plan entry stated the resident had delusions and hallucinations. During an observation on 4/13/23 at 10:39 a.m., Resident #36 sat in her wheelchair next to a small dresser. In the top dresser drawer, the resident had 2 medication cups containing approximately 5 pills each. The resident reached into one of the cups and consumed a blue pill. The resident stated that pill was for blood pressure and stated the other pills were mostly vitamins but pointed to other pills in the cups and stated one was for gout (a type of arthritis) and the others included metformin (used to treat diabetes), magnesium, and potassium. She stated one of the cups was from yesterday. On 4/13/23 at 10:50 a.m., the Administrator was aware that the resident had 2 pill cups in her drawer. A 4/13/23 3:48 p.m., a General Note stated the resident requested for her vitamins to be left at bedside and stated the resident was alert and oriented and able to make her own decisions. A 4/13/23 Medication Self-Administration Evaluation stated the resident was deemed able to safely self-administer medications. The resident's clinical record lacked an evaluation completed prior to 4/13/23. A Care Plan entry, dated 4/14/23, directed staff to complete a self-administration of medication assessment. The Care Plan lacked prior documentation regarding the self-administration of medications. The facility policy Resident Self-Administration of Medication, reviewed January 2023, stated the facility would evaluate residents to determine if they could self-administer safety. During an interview on 4/25/23 at 1:00 p.m., the Director of Nursing (DON) stated the resident could only have her vitamins at bedside and stated she observed the resident's 2 cups containing other medications. 47336 3. The MDS assessment dated [DATE] revealed Resident #24 scored 15 out of 15 on a BIMS exam, which indicated cognitively intact. During an observation on 4/18/23 at 1:01 PM, medications found in a pill cup on Resident #24's bedside table. The medication cup had 1 brown capsule, 1 oval tablet and 3 small round tablets in it. Resident #24 stated he was getting ready to take them. Resident #24 queried if staff left medications on his table often and he stated 99% of the time they brought them and left them on the table. Resident #24 asked if he knew what the medications in the cup were and he stated he knew one pill was gabapentin (nerve pain med) and wasn't sure about the other pills. Resident #24 stated he waited for his milk to take the pills. Resident #24 proceeded to open his milk carton and took the pills in the medication cup. Resident #24 had a Self-Administration of Medications Assessment completed on 9/16/21 and 2/4/22 and both assessments indicated Resident #24 not capable of storing medications in a secured area and not capable of opening or closing medication containers. The Care Plan dated 3/24/23 failed to reveal any documentation on Self-Administration of medications. The April MAR (Medication Administration Record) included the following medications: a. Acetaminophen (Tylenol) 325 mg tablet b. Buspirone (antianxiety med) 7.5 mg tablet c. Furosemide (diuretic med) 20 mg tablet d. Gabapentin 400 mg tablet e. Magnesium oxide tablet 400 mg tablet f. Spironolactone (diuretic med) 25 mg tablet g. Tamsulosin (treats urinary symptoms) 0.4 mg capsule During an interview on 4/18/23 at 1:26 PM, Staff AA, Certified Medication Aide (CMA) queried if the facility had any residents who Self-Administered their medications and she stated no, that is why the facility had Medication Aides and Nurses. Staff AA asked if she watched the residents take their medications and she stated yes, we watch them. Informed Staff AA medications were found on Resident #24 bedside table and Staff AA stated he supposed to take them with milk and she put them on the table to get him milk and planned on coming back and forgot because she doing something for another resident. Staff AA informed Resident #24 had milk and she queried if she watched Resident #24 take his pills and Staff AA stated no, she didn't watch him, she forgot to and she knew they were supposed to watch the residents take their medications. During an interview on 4/24/23 at 4:01 PM, the DON queried if anyone in the facility Self-Administered medications and she stated Resident #15 could Self-Administer her lactase and Resident #36 issued a locked box for her vitamins and self administered her vitamins. The DON asked what the expectations of medication administration for the nurses and CMA's and she stated don't pre-pop the medications, watch the residents take their medications, take vitals when indicated, and medications not be left at the bedside. The Facility Policy titled Medication Administration dated 3/2023 indicated the following: a. Observe resident consumption of medication. 4. During an observation on 4/12/23 at 2:48 PM, a Medication Cart left unlocked in the dining hall when staff delivered medication to resident in the dining hall. Observed a resident pass in a wheelchair by the unlocked cart. During an observation on 4/13/23 at 7:51 AM, Staff BB, Registered Nurse (RN) walked down Hall B with the Treatment Cart unlocked and stated he needed to get a computer and walked away from the Treatment Cart and left it unlocked. During an observation on 4/13/23 at 7:53 AM, Staff BB returned to the cart and looked for blood glucose paperwork and stated he grabbed the wrong paper and walked away from the unlocked cart and walked into the dining room and retrieved the papers and returned to the cart. Staff BB prepared the insulin for the resident and went into the resident's room and left the insulin vial and insulin pen on top of the treatment cart and left the cart unlocked in the hallway. Staff CC, Licensed Practical Nurse (LPN) observed in the hallway with her back turned to the Treatment Cart and residents in the hallway in their wheelchairs. During an observation on 4/13/23 at 8:09 AM, Staff BB prepped insulin for another resident and left the insulin vial and insulin pen on top of the Treatment Cart and left the cart unlocked when he went into the resident's room to ask the resident if he wanted his fast-acting insulin. The cart observed sitting in the hallway 2 doors down from the resident's room. During an interview on 4/13/23 at 8:13 AM, Staff BB queried if the Treatment Carts expected to be locked and he stated yes, the carts are supposed to be locked. Staff BB stated he guessed he had left it unlocked. He stated they had a lack of keys. Staff BB asked if medications were supposed to be secured in the carts and he stated yes, and he walked back to the cart to check. Staff BB informed he had left the insulin vials and pens on top of the cart when he administered the medications and Staff BB did not respond. During an observation on 4/13/23 at 8:16 AM in Hall B, Staff BB drew up insulin and went into a resident's room and left the insulin vial on top of the cart and left the cart unlocked. During an interview on 4/13/23 at 8:25 AM, Staff CC, LPN queried if medication carts are supposed to be locked and she stated yes, unless you are pulling or popping pills. Staff CC asked if the facility was short on keys and she stated she didn't know, she just started, maybe so. During an observation on 4/13/23 at 9:52 AM in Hall A, Treatment Cart #1 left unlocked between rooms A 5 and A 7. Observed Staff DD, Certified Medication Aide (CMA), down the hall two doors looking at the computer on her Medication Cart. The following observations made with the unlocked Treatment Cart: a. At 9:55 AM, staff walked by the cart and didn't lock the cart. A resident in an electric wheelchair circled around the cart. b. At 10:04 AM, staff walked by the cart and asked Staff DD where to locate Staff BB and looked at the treatment cart and walked away. c. At 10:16 AM, resident wheeled by the unlocked treatment cart. d. At 10:17 AM, Staff DD wheeled her Medication Cart past the treatment cart and didn't lock it. e. At 10:21 AM, resident wheeled by the treatment cart in their wheelchair. f. At 10:22 AM, surveyor opened the cart and observed insulin and syringes found in the drawers. g. At 10:46 AM, Staff BB, approached the Treatment Cart and moved it next to the Medication Cart by room A 3 and opened the drawers and pulled up medication into a syringe. h. At 10:48 AM, Staff BB went into a resident's room with syringe and left the cart unlocked and the 3rd drawer slightly opened on the cart. During an observation on 4/13/23 10:50 AM, found a set of keys left on the Treatment Cart in B Hall. At 10:51 AM. Staff DD, CMA picked up the keys off the cart. During an interview on 4/13/23 at 10:52 AM, Staff DD queried who the keys belonged to that she picked up and she stated she believed the keys belonged to one of the nurses and not supposed to be left on the cart so she snatched them up. Staff DD asked what the keys unlocked and she stated she didn't know, but thought the Treatment Carts and something else. During an interview on 4/13/23 at 2:11 PM, Staff BB queried if he had keys in his pocket and he stated yeah. Staff BB informed a pair of keys found on the Treatment Cart and he pulled out the keys from his pocket and stated his keys went to the utility room. Staff BB asked if the keys unlocked the Medication or Treatment Carts and he stated no, he didn't even know what most of the keys on the chain went to. He stated he was the A and B Hall Nurse and when he needed to do treatments he went to someone else to get the keys for the carts because they were short on keys. Staff BB queried why they were short on keys and he stated the Medication and Treatment keys are on the same key chain and if he needed something he would need to go to the Nurse or the Medication Aide for their keys. During an observation on 4/18/23 at 2:51 PM, the Medication Cart left unlocked in the dining hall. Staff EE, Activity Director with her back to the cart sat at a table with 9 residents and another staff member. Three other residents observed at tables in the dining area. During an observation on 4/18/23 at 2:53 PM, Resident #70 wheeled by the Medication Cart and spoke to a staff member right next to the cart. During an observation on 4/18/23 at 2:55 PM, Staff EE walked out of the dining area, another staff member walked into the dining area and sat behind the Nurse's Station with a computer monitor and counter between the staff member and unlocked Medication Cart. During an observation on 4/18/23 at 2:56 PM, the DON walked by the cart and then turned around and stood in front of the cart and locked the Medication Cart. During an interview on 4/24/23 at 4:01 PM, the DON queried about the expectations of medication and treatment carts being locked and she stated they should be locked at all times. The DON asked about the expectations of key control and she stated the Medication Aides had their own set of keys and the nurses had their own keys. The DON queried if the facility was short on keys and she stated she knew that one set of keys for A Hall had the Medication Cart and Treatment Cart keys and at one time the Assistant Director of Nursing (ADON) requested more keys for the carts. The DON stated she had the master keys for the carts. The undated document named Cognitively impaired and independently mobile provided by the Administrator revealed 26 residents cognitively impaired and independently mobile. The Facility Policy titled Medication Storage dated March 2022 revealed the following: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel accessed to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 46874 5. Observation on 4/12/23 at 11:50 AM, revealed the North kitchenette keypad door had been open. The door was noted to be left open 4-6 inches and the commercial steam table was left on. No facility Dietary or Nursing Staff observed in the North Dining room area. Noted approximately five residents, both ambulatory and able to propel a wheelchair within five to ten feet of the open door.

Based on observations, staff interviews, clinical record review, and policy review, the facility failed to address a resident's significant weight loss of 41 pounds or a 13.59% weight loss in 35 days (Resident #61). Resident #61 received 51% or more of his calories and 501 cc (cubic centimeters) per day or more of fluid intake via tube feeding. The facility also failed to notify the physician of residents' significant weight loss, seek orders to address the weight loss, and follow physician ordered interventions that addressed the loss for 2 residents (Resident #25, #45). The failure resulted for 3 of 7 residents reviewed for significant weight change and this situation resulted in an immediate jeopardy to health and safety of the residents. The facility reported a census of 69 residents. The State Agency notified the facility of the IJ on 5/28/23 at 11:00 a.m. The IJ began on 3/3/23 with the first failure to notify the physician of Resident #45's significant weight loss. The facility abated the IJ on 6/5/23 by assessing all resident ' s current weights, reviewing weight histories and identifying residents with significant weight loss or at risk for significant weight loss, reviewing and revising physician orders related to diet and interventions specific to residents at risk for weight loss, and education to dietary staff to follow orders as directed and specified on each resident ' s meal ticket at every meal. The facility staff's actions lowered the scope and severity from a J to a D at the time of the survey, after the State Survey Agency verified the facility staff had implemented the education and additional corrective actions. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 3/15/23, listed diagnoses for Resident #61 which included malnutrition, morbid obesity, and weakness. The MDS documented the resident required supervision assistance with eating and listed the resident's cognition as moderately impaired. The MDS listed the resident's weigh as 312 pounds (lbs). A 3/2/23 Hospital History and Physical listed the resident's weight as 142 kilograms (kg) or 313 lbs. A 3/28/23 Hospital Discharge Summary listed the resident's weight as 156.2 kg or 344 lbs. The resident's Weights Summary listed the following weights: a. On 3/1/23: 303.2 lbs. b. On 3/10/23: 312.4 lbs. c. On 4/5/23: 262.0 lbs (crossed out on 4/19/23 and reweighed). d. On 4/19/23: 287.2 lbs. The resident's weight loss during the period of 3/1/23-4/5/23 calculated as a 13.59% loss. The facility lacked documentation of Physician Notification or additional interventions related to the resident's significant weight loss from the resident's weight on 4/5/23 and 4/19/23. Care Plan entries, dated 3/30/23, documented the resident was at risk for malnutrition related to recent critical illness and stated the resident would maintain adequate nutritional status as evidenced by maintaining weight within 5% current body weight. The entries documented the resident received nothing by mouth (NPO) and directed staff to provide the ordered enteral (referring to via the stomach/intestinal tract) feeding of Jevity 1.5 cal (a nutritional feeding) 360 milliliters (ml) with 50 ml water before and after three times daily. A 3/30/23 Nutrition Evaluation listed the most recent weight as 312.4 lbs on 3/10/23 and stated the resident was at risk for malnutrition with the goal to maintain current body weight. The Evaluation recommended increasing the tube feeding order to better meet estimated needs: Jevity 1.5 cal, 360 ml 5 times per day. A 4/3/23 order directed staff to weigh the resident weekly every Thursday. The facility lacked documentation of a weight obtained between 4/5/23-4/19/23. During an observation on 4/18/23 at 10:36 a.m., Staff BB Registered Nurse (RN) administered a bolus (single dose) of Jevity 1.5 360 ml per the resident's G-tube (gastrostomy tube-a type of feeding tube). During an interview on 4/18/23 at 10:01 a.m., Staff G, Nurse Practitioner (NP) stated she was not aware of the resident's weight loss. She stated he needed a re-weight and would like to know about such losses. She stated in the past, the facility did not complete weights in a timely manner. During an interview on 4/25/23 at 1:00 p.m., the Director of Nursing (DON) stated from now on staff should provide her the list of weights for review. She stated if someone had a weight loss, the facility would speak to the Registered Dietician and possibly talk to psychiatric services. She stated they would reweigh the resident. She stated she would review Resident #61's weight and look at adjusting his caloric intake. In an interview on 4/26/23 at 2:04 p.m. the DON stated she thought the resident's weight was an error so they completed a reweigh. The facility policy Weight Monitoring revised March 2023, documented the facility would ensure all residents maintained acceptable parameters of nutritional status such as usual body weight. The policy defined a significant change in weight as 5% in 30 days, 7.5 % in 90 days, or 10% in 180 days. 26529 2. The 5/24/23 Minimum Data Set (MDS) Assessment revealed Resident #25 had diagnoses that included congestive heart failure, hypertension (high blood pressure), cerebrovascular accident (a stroke) with hemiplegia (paralysis on 1 side of the body) and malnutrition, required extensive assistance from at least 1 staff for transfers to and from bed or chair, dressing and toileting, non-ambulatory and set-up assistance required for eating. The assessment reported the weight 181 pounds and not identified as a significant change in the last month, described as a change of 5 percent body weight, or a 10 percent change of body weight in the last 6 months. The resident's weights, recorded in pounds, revealed: 9/3/22 193.7 10/1/22 194.9 11/4/22 192.6 12/2/22 198.8 1/2/23 199.5 2/14/23 197.2 3/7/23 193.1 4/3/23 187.5 5/4/23 180.5 6/1/23 175.9 The 6/1/23 weight indicated a 11.52 percent weight loss for 6 months and a significant weight loss. , Physician orders directed staff: 2/21/23 Provide Ensure Plus twice daily for risk of malnutrition. 3/9/23 Provide a regular diet, soft and bite sized texture, add gravy/sauce on meats. Needs assist with all meals. A Swallowing Deficit related to Dysphagia (difficulty or inability to swallow) problem initiated 10/29/22 on the nursing care plan directed staff: Follow prescribed diet, initiated 10/29/22. Monitor for shortness of breath choking, labored respirations or lung congestion, initiated 10/29/22. Monitor/document/report any signs or symptoms of dysphagia that included pocketing food, choking, coughing, drooling, several attempts at swallowing, refusing to eat or appears concerned during meals, initiated 10/29/22. A Progress Note transcribed by the facility's Registered and Licensed Dietician (RDLD) on 4/13/12 at 2:35 p.m. stated significant weight change note, Albumin 2.7, a low value, on 2/23/23 (a measurement of serum protein level), resident received regular diet, soft and bite sized texture (consistent with mechanical soft texture), Ensure Plus (liquid supplement) provided twice daily, extra nourishments provided through snacks and activity attendance. Meal intake variable from 25 to 100 percent, feeding ability ranged from independent to limited assistance. Significant weight loss for 30 days, unplanned/undesired with etiology likely related to possible need for feeding assistance at meals. Observed at lunch and half of meal was eaten with food found on his shirt. When asked if he needed help with eating he said yes. Spoke with nursing about administration of supplement. Education provided to offer and encourage this drink twice daily and not to be given at meals. It is my belief that either this has not been given as ordered or was refused by the resident. Will trial this and see if albumin improves. The RDLD's recommendations described in the Progress Note included continue the current diet order, please elaborate to have gravy/sauce on meats and starch, request order for assistance at meals, request order for protein snacks, request Speech Therapy (ST) to evaluate and treat, request vitamin D, folate and vitamin B12 lab levels, request multiple vitamin with mineral supplement administered oral daily. The RDLD summarized the information transcribed in the Progress Note in an email transcribed at 7:24 p.m. on 4/13/23 and send to the Administrator, Director of Nursing (DON) and Certified Dietary Manager (CDM). Progress Notes transcribed by the Advanced Practice Registered Nurse Practitioner (ARNP) on 4/14/23, 4/19/23, 4/21/23, all that describe a physical assessment of the resident, made no mention of the resident's significant weight loss or notification of such. The planned Soft & Bite Sized menu for the 5/31/23 evening meal included: 6 ounces Vegetable Soup 3 ounces Barbequed Chicken 4 ounces Baked Beans 4 ounces Mashed Potatoes Observations on 5/31/23 between 6:18 p.m. and 6:37 p.m. revealed Staff R, Cook, plated the evening meal from the steam table in the North Kitchenette, and did not utilize resident tray tickets or resident information diet cards for reference to plate the meals Observations 5/31/23 at 6:29 p.m. revealed the resident received 4 breaded Chicken Nuggets (not Barbequed), French Fries, Baked Beans, ketchup used for the French Fries, no other gravy or sauces observed and feeding assistance not provided. During an interview 6/1/23 at 12:42 p.m., the facility's RDLD stated she observed the resident during a meal without feeding assistance, the resident had spilled food on his chest area, she asked him if he needed assistance with eating and he stated that he did. The RDLD stated she communicated her findings and recommendations to key facility staff via email for documentation purposes, and dietary staff should follow physician orders and directives for resident diet and nutrition orders. On 6/5/23 at 9:09 a.m., the facility was asked to provide documentation that the physician was notified of the identified weight loss and the RDLD's recommendations, and could not provide the documentation as of the survey exit on 6/5/23. Other staff interviews related to weight loss: On 6/2/23, administrative staff at the Iowa Department of Inspections & Appeals notified the facility Administrator that she had to provide an updated list of resident weights, completed between 6/1/23 and 6/4/23, to the Nurse Surveyor assigned on the morning of 6/5/23. During an interview 6/5/23 at 9:58 a.m., the facility RDLD provided a list of June, 2023 weights for 49 residents, and stated she thought there were 15 residents without an updated weight at that time. During an interview 6/5/23 at 2:53 p.m., the facility Administrator and interim Director of Nursing provided an updated June, 2023 weight list for 63 residents and stated they had just obtained the last resident weight. 3. The 3/15/23 MDS Assessment revealed Resident #45 had diagnoses that included hypertension (high blood pressure), a cerebrovascular accident (a stroke), Parkinson ' s disease, diabetes and dysphagia (difficulty or inability to swallow), required extensive assistance of at least 1 staff for transfers to and from bed and chair, dressing and toileting, non-ambulatory, and supervision with 1 staff assist required for eating. The MDS Assessment revealed the resident ' s weight 178 pounds and a significant weight loss of 10 percent or more in 6 months. The resident's weights, recorded in pounds, revealed: 9/3/22 209.8 10/1/22 181.8 11/4/22 186.4 12/6/22 184.4 1/9/23 181.9 2/14/23 179.4 3/3/23 177.7 4/13/23 178.4 5/3/23 179.4 6/5/23 179.8 The 3/3/23 weight represented a 15.3 percent loss in 6 months and a significant weight loss. Physician orders directed staff: 3/9/23 Serve a Controlled Carbohydrate Diet (CCD), No Added Salt (NAS), regular texture, large portion diet. 11/15/22 Serve 4 ounces of House Supplement (Mighty Shakes) 3 times daily with meals. Resident #45's record revealed the last assessment and note transcribed by the facility's RDLD was on 1/19/23, the former RDLD prior to 4/1/23. Resident #45's record lacked documentation the physician was notified of the significant weight loss in March, 2023, or any additional interventions implemented as a result of the documented weight loss. A Nutritional Problem related to Diabetes, Parkinson's disease and need for therapeutic diet and supplementation problem initiated 8/18/21 on the Nursing Care Plan directed staff: Weigh per physician orders, initiated 3/20/23. Monitor/document/report any signs or symptoms of dysphagia that included pocketing food, choking, coughing, drooling, several attempts at swallowing, refusing to eat or appears concerned during meals initiated, initiated 8/18/21. Provide and serve diet as ordered, initiated 8/18/21. Provide and serve supplements as ordered: Sugar Free Might Shakes times a day, initiated 11/14/22. RDLD to evaluate and make diet change recommendations as needed, initiated 11/14/22. Report to physician signs or symptoms of malnutrition that include muscle wasting, significant weight loss of 5 percent or more in 1 month, or 10 percent or more in 6 months, initiated 8/18/21. The facility's planned CCD menu for the 5/31/23 evening meal included: 6 ounces Vegetable Soup 3 ounces Barbequed Chicken 4 ounces Baked Beans 4 ounces French Fries Observation on 5/31/23 at 6:10 p.m. revealed Resident #45 seated in the Dining Room, received 4 ounces of Baked Beans, plate approximately 1/2 covered with French Fries and 3 pieced of Barbequed Chicken, each approximately 3 inches in length, 1 inch in width, with heavy breading/coating and bone inside each piece. Observation in the kitchen on 5/31/23 at 6:50 p.m. with the facility's Chief Clinical Officer revealed 2 pieces of Barbequed Chicken, that included the breading and bone, weighed 2.5 ounces. During an interview 5/31/23 at 6:31 p.m., Staff R, Cook, stated 4 pieces was the regular serving size of Barbequed Chicken.

Based on observation, staff interviews and clinical record review, the facility failed to provide wound care in a manner to reduce the risk of wound infections and failed to implement offloading devices to decrease pressure for 2 of 4 residents observed with pressure ulcers (Residents #4, #49). This failure led to harm when Resident #4 developed a facility acquired Stage 3 pressure ulcer. The facility reported a census of 69 residents. Findings include: Minimum Data Set (MDS) Definitions of Pressure Ulcers Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 1. The MDS assessment dated [DATE] for Resident #4 identified an original admitted [DATE]. The MDS documented no pressure ulcers present upon assessment. The wound physician Initial Wound Evaluation & Management Summary notes dated 1/16/23 documented under History of Present Illness that the resident had a Stage 3 pressure wound of the left, posterior heel for at least 2 days duration. The summary included the following: a. Focused Wound Exam (Site 1) - Stage 3 pressure wound of the left, posterior heel full thickness Wound Size: 6.0 cm (centimeters) by 4.0 cm by 0.2 cm with surface area 24.00 cm 2 (square centimeters) Duration: greater than 2 days Recommendations: float heels in bed, offload wound, reposition per facility protocol, turn side to side and front to back in bed every 1 to 2 hours if able, sponge boot. Coordination of Care: offloading is the resident's main issue and her compliance would be difficult due to her behavioral issues, severe schizophrenia/bipolar issues, and having her comply had been difficult. they would get her a sponge boot but unsure if she would be able to keep it on but discussed with RN (Registered Nurse) staff and resident and they would try. The MDS assessment dated [DATE] documented the resident discharged to the hospital with return not anticipated. The MDS assessment dated [DATE] documented an entry tracking when the resident returned from the hospital. The MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS revealed the resident used a manual wheelchair and with partial assistance could wheel approximately 50 feet and make two turns. The MDS recorded the resident dependent on staff for toileting, picking up dropped objects from the floor, needed substantial assistance rolling side to side while lying in bed, and dependent on staff for taking off and putting on footwear. The MDS documented diagnoses that included sleep apnea, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and type two diabetes. The MDS recorded the presence of an unstageable pressure ulcer upon admit to the facility. The Care Plan focus area initiated 1/30/23 identified on 1/16/23 the resident had an in-house (facility) acquired Stage 3 pressure ulcer develop on her left heel. The care plan interventions directed staff to avoid positioning the resident with heels touching bed or chair. The care plan lacked documentation regarding a sponge boot or directions to raise wheelchair legs to offload pressure to the heel. The Progress Notes dated 3/21/23 at 12:20 PM documented a late entry physician progress note. The entry recorded on 3/8/23 the wound MD (doctor) continued to follow the resident and the resident to continue to try to offload the heel with the help of NS (nursing staff). The entry documented the wound continued to improve and the resident did have the PRAFO boots as well. The wound physician Wound Evaluation & Management Summary notes dated 4/3/23 documented the following: a. Focused Wound Exam (Site 1) - Stage 3 pressure wound of the left, posterior heel full thickness Wound Size: 1.5 cm by 3.0 cm by 0.1 cm with surface area 4.50 cm 2 (square centimeters) Duration: greater than 75 days Wound Progress: improved Recommendations: offload wound, turn side to side and front to back in bed every 1 to 2 hours if able, float heels in bed, sponge boot, reposition per facility protocol, antibiotic choice Bactrim DS 1 tab orally twice a day for 14 days. Observation on 4/11/23 at 11:30 AM revealed the resident used her left heel to propel her wheelchair in Hallway B. Observation on 4/12/23 at 1:00 PM revealed the resident used her left heel to propel her wheelchair in the North Dining Room. Observation on 4/13/23 at 2:00 PM revealed the resident used her left foot to propel her wheelchair in the South entry of the facility. The wound physician Wound Evaluation & Management Summary notes dated 4/14/23 documented the following: a. Focused Wound Exam (Site 1) - Stage 3 pressure wound of the left, posterior heel full thickness Wound Size: 1.7 cm by 3.0 cm by 0.1 cm with surface area 5.10 cm 2 (square centimeters) Duration: greater than 86 days Wound Progress: no change Recommendations: offload wound, turn side to side and front to back in bed every 1 to 2 hours if able, float heels in bed, sponge boot, reposition per facility protocol, antibiotic choice Bactrim DS 1 tab orally twice a day for 14 days. Observation on 4/17/23 at 9:00 AM revealed the resident used her left foot to propel her wheelchair in the South hallway outside of conference room area. In an interview on 4/19/23 at 7:55 AM, Staff LL, LPN, stated the resident had a PRAFO (sponge) boot however the resident used her left foot to propel her wheelchair throughout the day. At 8:04 AM, Staff LL commented the resident's sponge boot had not been on all night due to the boot being on the floor. Observation on 4/19/23 at 8:04 AM revealed Staff LL, LPN, completed the daily wound care as provider ordered for the left heel Stage 3 pressure ulcer. Staff LL elevated the lower left leg and left foot on a pillow. Staff LL washed hands, donned gloves, removed the old dressing. Staff LL proceeded to cleanse wounds and apply the ordered treatment. Staff LL used scissors to cut a new medicated dressing then applied another dressing as ordered. Staff LL never washed hands or changed gloves during the wound care when removing dirty dressings, cleaning the wound, and then applying new dressings. In an interview on 4/19/23 at 8:40 AM, Staff LL responded she should have changed her gloves when going from a dirty field to a clean field. In an interview on 4/19/23 at 10:02 AM, the Advanced Registered Nurse Practitioner (ARNP) responded when asked about the resident's wounds and expectations that the resident was to have a PRAFO boot on her left foot for offloading. The ARNP stated the resident had a blister that opened and the resident to offload when sitting in the wheelchair with leg rest in the up position. After being informed that observations from 4/11/23 through 4/19/23 revealed the resident's wheelchair not observed in the up position, the ARNP responded the leg rest was to be in the up position whenever the resident was up. In an interview on 4/19/23 at 4:05 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they expected nursing staff to follow the policy to wash hands and change gloves when going from a dirty to a clean wound field. The facility policy revised March 2023 titled Clean Dressing Change included the following documentation: 7. Wash hands and put on clean gloves. 9. Loosen the tape and remove the existing dressing (old dressing). 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse wound. 13. Remove gloves. 14. Wash hands and put on clean gloves 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. 25855 2. The MDS assessment dated [DATE] for Resident #49 identified the resident admitted from the hospital originally on 2/16/23. The MDS recorded a BIMS score of 14 which indicated intact cognition. The MDS documented diagnoses included Multiple Sclerosis (MS), paraplegia (paralysis of the legs and lower body), osteomyelitis (inflammation of the bone) of sacral region, bacterial infection unspecified, neurogenic bladder, pressure ulcer of sacral region Stage 4, and pressure ulcer of right buttock Stage 4. The MDS coded the presence of an indwelling catheter as well as 1 Stage 3 pressure ulcer and 2 Stage 4 pressure ulcers present upon admit to the facility. The MDS revealed the resident required extensive physical assistance of 1 person for bed mobility, extensive physical assistance of 2 persons for transfers, and totally dependent upon staff for bathing. The hospital discharge summary dated 2/16/23 documented discharge diagnoses that included osteomyelitis, Stage 4 decubitus ulcer, wound infection, chronic kidney disease stage 2, multiple sclerosis, paraplegia, and neurogenic bladder. The summary recorded the resident wheelchair-bound with chronic sacral decubitus ulcers with ulcer present on the coccyx, right ischial buttock, and left lateral ankle. The Care Plan focus area initiated 2/17/23 identified the resident had infection of the wounds of the coccyx and directed staff to administer antibiotics as per doctor orders and to maintain universal precautions when providing resident care. The Care Plan focus area initiated 2/20/23 identified the presence of a Stage 3 pressure ulcer on the left ankle and Stage 4 on the sacrum and right ischium related to a history of ulcers and immobility. The Care Plan interventions included notification to staff the resident needed to turn/reposition at least every 2 hours, more often as needed or requested. The Progress Notes dated 2/20/23 at 1:39 PM recorded a nutrition/dietary note which documented the resident seen by the wound MD (doctor) that day. The skin measurements recorded as: a. Stage 3 to left lateral ankle 7.0 cm (centimeters) by 3.0 cm by 0.2 cm surface area 21.00 cm 2 (square centimeters) b. Stage 4 to right ischium 8.0 cm by 5.0 cm by 2.5 cm surface area 40.00 cm 2 c. Stage 4 to sacrum 8.0 cm by 8.0 cm by 20 cm surface area 64.00 cm 2. The Progress Notes dated 2/22/23 at 2:44 PM recorded a Physician Note. The assessment portion documented the resident had a Stage 4 decubitus ulcer complicated with osteomyelitis and treated with IV (intravenous) antibiotics for 2 weeks after wound debridement performed 1/31/23 prior to admission to the facility. The Progress Notes dated 3/27/23 at 1:19 PM documented a change in condition summary that recorded the resident seen by the wound care provider due to increased drainage and foul odor and exposed necrotic bone exposed. The resident sent to the ER (Emergency Department) for evaluation. The Progress Notes dated 4/4/23 at 3:00 PM recorded the resident readmitted to the facility. The wound physician Wound Evaluation & Management Summary notes dated 3/6/23 documented the following: a. Focused Wound Exam (Site 1) - Stage 3 pressure wound of the left, lateral ankle full thickness Wound Size: 5.0 cm (centimeters) by 3.0 cm by 0.2 cm with surface area 15.00 cm 2 (square centimeters) Duration: greater than 44 days Wound Progress: Improved Recommendations: offload wound, reposition per facility protocol, turn side to side in bed every 1 to 2 hours if able b. Focused Wound Exam (Site 2) - Stage 4 pressure wound of the right ischium full thickness Wound Size - 8.0 cm by 5.0 cm by 2.5 cm, surface area 40.00 cm 2 Duration: greater than 164 days Wound Progress: no change Recommendations: Limit sitting to 60 minutes, offload wound, reposition per facility protocol, turn side to side in bed every 1 to 2 hours if able, upgrade offloading chair cushion, low air loss mattress c. Focused Wound Exam (Site 3) - Stage 4 pressure wound sacrum full thickness Wound Size - 8.0 cm by 8.0 cm by 20 cm, surface area 64.00 cm 2 Duration: greater than 164 days Wound Progress: no change Recommendations: Limit sitting to 60 minutes, offload wound, reposition per facility protocol, turn side to side in bed every 1 to 2 hours if able, Group 2 mattress, upgrade offloading chair cushion The Care Plan focus area lacked documentation to reflect the recommendations made by the wound physician to offload the wound, limit sitting to 60 minutes, upgrade the offloading chair cushion, low air loss mattress, and Group 2 mattress. The wound physician Wound Evaluation & Management Summary notes dated 4/3/23 documented the resident was not seen due to a wound-related hospitalization since the previous visit. The wound physician Wound Evaluation & Management Summary notes dated 4/14/23 documented the following: a. Focused Wound Exam (Site 2) - Stage 4 pressure wound of the right ischium full thickness Wound Size - 3.1 cm by 4.4 cm by 0.3 cm, surface area 13.64 cm 2 Duration: greater than 202 days Wound Progress: improved Primary Dressing: negative pressure wound therapy (wound vac) apply three times per week for 30 days Recommendations: upgrade offloading chair cushion, offload wound, limit sitting to 60 minutes, low air loss mattress, reposition per facility protocol, turn side to side in bed every 1 to 2 hours if able, low air loss mattress b. Focused Wound Exam (Site 3) - Stage 4 pressure wound sacrum full thickness Wound Size - 3.0 cm by 2.2 cm by 1.0 cm, surface area 6.60 cm 2 Duration: greater than 202 days Wound Progress: improved Primary Dressing: negative pressure wound therapy (wound vac) apply three times per week for 30 days Recommendations: Group 2 mattress, upgrade offloading chair cushion, reposition per facility protocol, turn side to side in bed every 1 to 2 hours if able, limit sitting to 60 minutes, offload wound, low air loss mattress Observations of wound care on 4/12/23 revealed the following: a. At 3:33 PM, Staff D, Licensed Practical Nurse (LPN), and Staff E, LPN, both entered room, washed their hands and donned gloves. b. At 3:53 PM, after Staff D had placed new foam into the wounds for the wound vac, she picked up the Foley (indwelling catheter) bag, handed it to Staff HH, LPN, and proceeded to finish the dressing change to the pressure ulcers without changing her gloves after she handled the Foley bag. In an interview on 4/25/23 at 9:43 AM, Staff D, LPN, reported during wound care nurses should change gloves after picking up dirty dressings and before putting on new dressings. She also admitted she should have changed her gloves after picking up the resident's Foley bag during wound care. In an interview on 4/25/23 at 9:53 AM, Staff K, Registered Nurse (RN), reported during wound care nurses should change gloves after touching anything soiled, wash hands, and put on new gloves. In an interview on 4/25/23 3:12 PM, the Director of Nursing (DON) reported during wound care she would expect nurses to change gloves before and after removing soiled dressings or if the gloves become visibly soiled. She would also expect nurses to change gloves after picking up a Foley bag before resuming the wound care. A review of the facility policy titled: Clean Dressing Change dated as last reviewed March 2023 had documentation of the following: 1. When multiple wounds are being dressed, the dressings will be changed in order of least contaminated to most contaminated (i.e. change extremity wounds before wounds contaminated with stool). Dressings of infected wounds should be changed last. 2. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape). d. If performing photo documentation, label measuring guide with patient identifier and date. e. Use no-touch techniques to remove ointments and creams from their containers (i.e. use tongue blade or applicator). Liquid solutions should be poured directly onto gauze sponges. 3. Establish area for soiled products to be placed (Chux or plastic bag). 4. Wash hands and put on clean gloves. 5. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 6. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 7. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 8. Wash hands and put on clean gloves. 9. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze. 10. Measure wound using disposable measuring guide. (Note: If performing photo documentation, remove gloves and wash hands. Photograph wound being careful to avoid any contamination of the camera equipment). 11. Wash hands and put on clean gloves. 12. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 13. Secure dressing. [NAME] with initials and date. (Add time if dressing is more than once daily.) 14. Discard disposable items and gloves into appropriate trash receptacle and wash hands.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide medications as ordered to 1 out of 15 resident reviewed by giving the wrong medications to a resident causing the resident to be transported to the emergency room for medication overdose (Resident #19). The facility reported a census of 69 residents. Findings Include: The Minimum Data Set Assessment (MDS) for Resident #19 dated 5/18/22, revealed the diagnosis of Coronary artery disease (CAD), and hypertension (HTN). Resident #19's Brief Interview for Mental Status (BIMS) score reflected 14 out of 15 indicating intact cognition. The medications utilized in the past 7 days reflect antidepressant daily. The MDS medication utilized over the 7 day lookback failed to include antipsychotic medication, and opioids. The Care Plan for Resident # 19 dated 1/13/2022, directed Nursing Staff to administer medications as ordered and monitor/document for side effects and effectiveness. The Situation, Background, Assessment and Recommendation (SBAR) on 7/10/22 reflected Resident #19 lethargic, decreased consciousness, slurred speech. Transferred to the hospital. The General Note 7/10/2022 at 7:15 PM, included Resident #19 sat at table in Min Dining Room asleep. Resident easily aroused but returned to sleep quickly. Staff FF, Certified Medication Aide (CMA) reported she made a medication error. Staff FF stated she gave Resident #19 another resident's medications. The note continued Resident #19 sat at the Main Dining Room table unresponsive. Vitals assessed. B/P. 69/52. Respirations 12 and shallow. Multiple attempts to arouse Resident #19 ineffective. Call placed on call provider and order received to send to emergency room (ER). The facility provided a document titled #931 Medication dated 7/10/22, the report revealed the CMA reported to the Nurse she gave another residents medication to Resident #19. Resident #19 unresponsive at the time. Vital signs included blood pressure 69/52, respiration 12 and shallow. Staff attempted multiple times to arouse resident unsuccessfully. Called Staff H, Nurse Practitioner and ordered to send Resident #19 to the ER for evaluation and treatment. The report reflected potential medication side effect. The Physician Progress Note dated 7/11/2022 at 4:01 PM, reflected the chief complaint medication overdose. The note identified a medication overdose on 7/10/22 per Nursing Service, when an accident on medication administration occurred. Resident # 19 sent to ER and received intravenous (IV) fluids. Resident #19 evaluated at the bedside. Nursing Services reported yesterday Resident #19 received the wrong resident's medications. Resident #19 took 2 milligrams (mg) Risperidone (anti-psychotic), 300 mg trazodone (antidepressant), 0,4 mg tamsulosin (alpha blockers), Docusate Senna (stimulant laxatives), 10 mg buspirone (anxiolytics), 500 mg Keppra and 300 mg gabapentin (anticonvulsants). On 4/11/23 at 1:28 PM, Resident #19 denied concerns or problems with the facility administering his medications. On 4/17/23 at 1:40 PM, Staff DD, CMA, stated the facility does monthly mandatory education. Staff DD reported if medication errors happened in the facility she would expect some education. On 4/18/23 at 5:22 PM, Staff FF, CMA confirmed she administered the wrong medication to Resident # 19 on 7/10/22. She stated the nurse sent him to the hospital because he seemed very sleepy. Staff FF said she just started at the facility the two residents looked alike. Staff FF stated the facility provided her educated to pay attention, if unsure who the residents are, ask another staff. On 4/18/23 at 2:04 PM, the Assist Director of Nursing (ADON), reported the Medication Aide administered Resident #19 the wrong medication on 7/10/22. She reported the nurse called her and reported the medication error. The ADON stated the Medication Aide completed a return demonstration on medication administrations. The ADON reported she failed to document the education provided to the CMA. On 4/18/23 at 2:15 PM, the Director of Nursing DON stated she expected medications administered per the Physician's Order. On 4/19/23 at 10:21 AM, Staff H, Advanced Registered Nurse Practitioner (ARNP) stated she knew staff administered Resident #19 medications that belonged to another resident. Staff H stated the nurses sent Resident # 19 to the ER related a lethargic condition. Staff H stated the Hospital administered intravenous (IV) fluids and sent the resident back to the facility for staff to monitor. The facility policy titled Medication Administration dated 3/23, directed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: point #3 directed; Identify resident by photo in the Medication Administration R (MAR) Record.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to create and/or carry out interventions and/or follow orders in order to prevent the development and/or worsening of a pressure ulcer for 3 of 5 residents reviewed for pressure ulcers (Resident #56, #174, and #271). The facility reported a census of 61 residents. Findings Include: 1. The MDS(Minimum Data Set) Assessment Tool dated 10/1/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance of 1 staff for dressing, extensive assistance of 1 staff for bed mobility, toilet use, personal hygiene, and bathing, and extensive assistance of 2 staff for transfers. The MDS stated the resident had no unhealed pressure ulcers and was at risk for developing pressure ulcers. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS stated the resident admitted to the facility on [DATE]. A 9/24/21 Progress Note regarding the resident's skin stated the resident had excoriation to the groin and scrotal area. The note failed to state the resident had skin concerns to the heels. The Braden Scale for Predicting Pressure Ulcer Risk, dated 9/24/21, stated the resident was at risk for the development of pressure ulcers. A 9/24/21 order directed staff to apply skin prep to the bilateral heels for 2 weeks. The September and October 2021 Medication Administration Records (MAR's) displayed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The entries for the treatment were blank and lacked staff initials to indicate the completion of the treatment. A 10/18/21 Progress Note stated staff noticed a new pressure injury to the left heel and the wound was not open but black and boggy and measured 8 centimeters (cm) x 6 cm (length x width). A 10/19/21 order stated the resident with left bottom heal necrosis (dead tissue) 5 cm x 5 cm and directed staff to have a Wound Consult as needed. A 10/21/21 order directed staff to make an appointment for an outside Wound Consult by end of business Friday (10/22/21). A 10/23/21 Progress Note stated the resident had a wound to the second toe 1.7 cm x 1.9 cm. An 11/3/21 order directed staff to apply [MEDICATION(S)] (an iodine based cleanser) to the left heel daily and as needed (PRN). The facility lacked documentation the resident had a Wound Clinic appointment prior to 11/9/21 and lacked documentation staff made the appointment until 11/3/21. An 11/9/21 Wound Clinic Note stated the resident had an unstageable left great toe pressure ulcer 1 cm x 1.5 cm x 0.1 cm (length x width x depth) with full-thickness skin and tissue loss and a left heel pressure ulcer 4.3 cm x 5.2 cm x 0.1 cm with full-thickness skin and tissue loss. The photos on the Wound Clinic Note showed dark areas to the left great toe and left heel. An 11/9/21 order directed staff to cleanse the left heel with normal saline and apply [MEDICATION(S)] and dress with [MEDICATION(S)] (a type of dressing) and roll gauze. Care Plan entries, dated 10/19/21, stated the resident had a pressure ulcer to the left heel and directed staff to float the resident's heels. The care plan lacked documentation of an intervention to prevent heel breakdown prior to this date. During a phone interview on 1/27/22 at 8:50 a.m., Staff Z, Wound Clinic Department Secretary stated her clinic set up an appointment for Resident #271 on 11/3/21. She stated it was the clinic's policy to call and schedule an appointment within 24 hours of receiving a referral. She stated it was not typical for a patient to have to wait 20 days for an appointment. During a phone interview on 1/27/22 at 11:35 a.m., Staff D, Licensed Practical Nurse stated Resident #271 spent a lot of time in bed. She stated he wore Prafo boots after the breakdown started. She stated when she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on 1/31/22 at 2:06 p.m., Staff A stated she scheduled appointments at the facility. She stated nursing placed it in the Communication Section of the Electronic Health Record (EHR). Staff A stated a staff member placed it in communications on 11/3/21 but she did not know who made the appointment. During a phone interview on 2/1/22 at 4:31 p.m., Staff FF, Registered Nurse (RN) stated she discovered dark spots on Resident #271's heels. She stated prior to that he did not have anything on his heels that she knew of but she did not complete his admission. She stated after they discovered the areas, they floated the heels and started a treatment. She stated the resident did not have a skin treatment prior to this. She stated the resident did not like being out of bed. During a phone interview on 2/2/22 at 4:00 p.m., the Director of Nursing (DON) stated staff should create and implement Care Plan interventions right away and carry out orders right away. She stated staff referred and sent residents to the Wound Clinic right away. During a phone interview on 2/3/22 at 11:42 a.m., Staff MM, LPN stated she was the facility Wound Nurse. She stated she first saw the resident's heels when he first arrived at the facility and he had no breakdown but it seemed like he may have had an area there before. Staff MM stated she did not know what happened with the resident's Wound Clinic appointment. She stated possibly it was miscommunication and they didn't get the order to her. She stated she did not know who made the appointment. 2. The MDS dated [DATE], did not list any diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the resident's BIMS score as 13 out of 15, indicating intact cognition. The MDS stated the resident had 2 Stage III pressure ulcers (defined as full thickness tissue loss). The MDS stated the resident admitted to the facility on [DATE]. During an observation on 1.20.22 at 10:35 a.m., Staff D, LPN measured the following areas: a red, open area on the resident's right great toe as 1 cm x 1 cm, a black area on the left first toe as 1 cm x 1.5 cm, and a open red area to the second left toe as 0.8 cm x 1.0 cm. Staff D cleansed the wounds on the left toes with wound cleanser and covered with Xeroform gauze (a type of non-adherent wound dressing). A 12/6/21 Skin Only Evaluation stated the resident had excoriation to the left great toe. The evaluation lacked further documentation of the resident's skin concerns. A 12/8/21 Advanced Registered Nurse Practitioner (ARNP) note stated the resident had bone exposed on the left great toe and had a scab on the second left toe. The note stated the resident had his left great toe amputated as a child but in the last 3 months it became gangrenous and the tip of the great toe fell off. The note stated the facility would send the resident to the Wound Clinic. A 12/16/2021 progress note stated the resident had a Stage III pressure ulcer on left, distal, great toe measuring 1.5 cm x 1 cm x 0.1 cm with a moderate amount of serosanguineous (bloody/watery) drainage and a Stage III pressure ulcer on left, second toe measuring 7 cm x 6 cm with scant amount of serosanquinous drainage. The facility lacked documentation of a Wound Assessment of the areas completed prior to 12/16/21. A 12/16/21 Wound Clinic Note stated the resident had a left great toe Stage III pressure ulcer 1.5 cm x 1.1 cm x 0.1 cm and a left second toe Stage III pressure ulcer 0.7 cm x 0.6 cm x 0.1 cm. A 12/30/21 Wound Clinic Note stated the resident's great toe wound was 1.1 cm x 0.9 cm x 0.1 cm and the resident's second toe was 0.6 cm x 0.5 cm x 0.1 cm. The facility lacked documentation of a wound assessment from 12/30/21 until the resident's Wound Clinic appointment on 1/13/22. A 1/13/22 Wound Clinic note stated the resident had a left great toe Stage 3 Pressure Injury to the left great toe 1.4 cm x 0.9 cm x 0.1 cm and a left second toe Stage III Pressure Injury 0.7 cm x 0.8 cm x 0.1 cm. The note stated both wounds were deteriorating. A 12/6/21 Care Plan entry stated the resident had pain related to wounds on the left toes. The Care Plan lacked interventions related to the skin impairment until 1/12/22 entries. 1/12/22 Care Plan entries directed staff to assess the area weekly and include measurements of each skin area. The 2020 facility policy Wound Treatment Management directed staff to carry out wound treatment orders. The policy did not contain direction as to how often staff should carry out wound assessments. 3. Resident #174's Face sheet identifies an initial admitted [DATE]. The Face Sheet diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive deficit. The Resident's Care Plan documented a focus of Stage IV pressure ulcers to right lower extremity and wounds to left lower extremity. The Care Plan included a goal of improved skin integrity. The interventions included monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. Review of Resident #174's Progress Notes revealed the facility did not measure the resident's wounds at all in March 2021 and showed the days measured for subsequent months as follows: a. The wounds were measured on April 6, 13, 14, 16, and 23, 2021. b. The wounds were measured on May 20 and 25, 2021. c. The wounds were measured on June 3 and 30, 2021. d. The wounds were measured on July 7, 2021 e. The wounds were measured on August 1, 9, and 25, 2021. f. The wounds were measured on September 29, 2021. The resident was seen by the Wound Clinic of the following days: a. For March on 12, 25 and 26, 2021 b. For April on 9, 16, and 23, 2021. c. For May on 28, 2021. d. For July on 2, 2021. e. For August 6 and 21, 2021. Records shown the resident hospitalized on the following days: a. On March 31-April 6, 2021. b. On May 10-17, 2021. c. On June 3-18, 2021. d. On July 18-27, 2021. e. On August 30-September 20, 2021. f. On October 3, 2021. The facility's undated policy titled Wound Treatment Management stated treatment decisions will be made based on etiology of the wound, characteristics of the wound including pressure injury stage, size, exudate, pain, infection, wound bed condition and peri wound skin condition. The policy stated the effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modification include lack of progress through healing, change in characteristics of the wound and changes in the resident's goals and preferences. The policy does not state any interventions related to prevention. During an interview on 2/1/21 at approximately 10:30 AM, the Director of Nursing stated her goal was to have a Weekly Wound Assessment in the Progress Notes, but that is not being done at this time.

Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to create and/or implement interventions in order to prevent falls for 4 of 6 residents reviewed for falls (Residents #47, #56, #61, #272), failed to ensure safe transfers when a staff member utilized a folding wheeled walker as a wheelchair for transport for 1 of 3 residents observed during a room to room transfer (Resident #70), failed to utilize a gait belt for 1 of 3 residents reviewed for gait belt transfers (Resident #47), failed to ensure staff properly secured a resident for 1 of 1 residents reviewed for a van transport (Resident #121), and failed to secure an oxygen concentrator during a general facility observation. The facility reported a census of 61 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool dated 12/2/21, listed diagnoses for Resident #47 included [CONDITION(S)] (stroke), muscle wasting, and the need for assistance with personal care. The MDS documented the resident required extensive assistance of 1 staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The MDS listed the resident's BIMS score as 13 out of 15, indicating intact cognition. An 8/22/19 Care Plan entry stated the resident required the assistance of 2 staff and a gait belt to transfer between surfaces. During an observation on 1/20/22 at 9:49 a.m., Staff B, CNA assisted the resident to sit up on the side of the bed. Staff B then put each of her arms under the resident's arms while standing in front of him and assisted him to stand and sit in the wheelchair. Staff B did not utilize a gait belt. Staff X, Transporter was also present in the room but did not assist with the transfer. A 6/1/21 Incident Audit Report stated the resident fell during a transfer with another staff member and complained of pain in his upper left rib and pain in his left arm. A 7/19/21 Incident Audit Report stated a CNA called for the nurse and the resident laid on the floor next to the bed. The resident had a skin tear to the left elbow and a small amount of blood. The resident stated he rolled out of bed. During an interview on 1/19/22 at 8:10 a.m., Resident #47 stated staff had dropped him 4 times and once they hurt his shoulder. During a phone interview on 1/31/22 at 10:43 a.m., Staff AA, Dietary Aide stated she started at the facility as a CNA. She stated she once had a fall with Resident #47. She stated she transferred the resident by herself because someone told her he required the assistance of 1 staff member. The resident slipped and after the fall, the nurse informed her that he required the assistance of 2 staff members. She stated the fall caused a scrape on his elbow and he was bleeding. During a phone interview on 1/31/22 at 11:28 a.m., Staff BB, Occupational Therapist (OT) stated Resident #47 required the assistance of 2 staff for transfers. During a telephone interview on 2/22/22 at 4:00 p.m., the DON stated she expected staff to follow the Care Plan and utilize 2 staff to assist Resident #47 with transfers. She stated the Kardex (a document reference for CNA's) should be up-to-to date. 2. The MDS dated [DATE], did not list any diagnoses for Resident #56 and stated the resident required extensive assistance of 1 staff for personal hygiene and bathing, and extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use. The MDS listed the resident's BIMS score as 13 out of 15, indicating intact cognition. A 12/23/21 Incident Audit Report stated the resident fell out of his wheelchair in the dining room and hit his face on the floor and was bleeding. The resident transferred to the ER. A 12/23/2021 Progress Note stated the resident transferred to the hospital due to a head injury. The resident's nose was bleeding and resident had an episode of emesis (vomiting). A 12/23/21 Care Plan entry listed the intervention of a low bed. The Care Plan lacked an intervention related to the resident's fall in the dining room A 1/16/22 Incident Audit Report stated staff heard a thud and found the resident on the floor of his room. A 1/16/22 Progress Note stated the resident had fall while he attempted to self-transfer and he had 2 areas where blood was raised to skin but not open. A 1/18/22 Incident Audit Report stated the resident laid in his room on his back and had skin tears to his left elbow and left knee. During an interview on 2/2/22, the DON stated the facility should have a different fall intervention for the resident's fall in the dining room because the low bed as an intervention did not make sense. 3. The MDS dated [DATE], listed diagnoses for Resident #61 include heart failure, [CONDITION(S)] and non-Alzheimer's dementia. The MDS documented the resident required limited assistance of 1 staff for eating, extensive assistance of 1 staff for bed mobility, dressing, toilet use, and personal hygiene, extensive assistance of 2 staff for transfers, and depended completely on 1 staff for bathing. The MDS identified the resident's BIMS score as 11 out of 15, indicating moderately impaired cognition. Observations on 1/18/22 at 2:30 p.m., 3:14 p.m., and 3:21 p.m. revealed the resident in his room alone. During an observation on 1/24/22 at 4:08 p.m. and 1/25/22 at 7:30 a.m. the resident was in bed with no mat on the floor near the bed. A 10/20/21 Care Plan entry stated the resident had a fall mat beside his bed. An 11/1/21 Incident Audit Report stated the resident laid on the left side of his body on the floor in front of his bed in his room. An 11/1/21 Care Plan entry instructed staff to not leave the resident alone in his room unless he was in bed. An 11/13/21 Incident Audit Report stated staff found the resident lying on the floor of his room. An 11/15/21 Care Plan entry listed reeducation of staff on the need to check on frequently and not leave alone in room. A 12/26/21 4:53 p.m. Incident Audit Report stated the resident's door was closed and the nurse entered the room and found the resident on his back. The Care Plan lacked an intervention after the resident's 12/26/21 fall. A 1/22/21 Incident Audit Report stated the resident was on the floor in his room. During a phone interview on 2/1/21 at 11:30 a.m. Staff EE, LPN stated when Resident #61 fell (on 12/26/21), it was between 4:00 p.m.-5:00 p.m. in the evening and the door was closed and she walked in and he was on the floor. She stated he had not been in bed yet and pushed himself to his room. During a phone interview on 2/22/22 at 4:00 p.m., the DON stated she thought the intervention for staff not to leave Resident #61 alone in his room was possibly not realistic. She stated another intervention may be more appropriate. 4. The MDS, dated [DATE], listed diagnoses for Resident #272 included heart failure, diabetes, and non-Alzheimer's dementia. The MDS documented the resident required limited assistance of 1 staff with walking, limited assistance of 2 staff for transfers, toileting, personal hygiene, and dressing, extensive assistance of 1 staff for bathing, and extensive assistance of 2 staff for bed mobility. The MDS identified the resident's cognition was severely impaired. The MDS dated [DATE], listed diagnoses for Resident #272 included fracture, heart failure, and diabetes. The MDS documented the resident required limited assistance of 1 staff for eating and transfers, extensive assistance of 1 staff for walking and personal hygiene, extensive assistance of 2 staff for bed mobility, and toilet use, and depended completely on 1 staff for bathing. The MDS identified the resident not steady and only able to stabilize with staff assistance when moving from seated to standing, walking, turning around, moving on and off the toilet, and transferring between the bed and chair. The MDS documented the resident's cognition was severely impaired and the resident had 2 falls without injury, 1 fall with a non-major injury, and 1 fall with a major injury in the review period. The Morse Fall Scale, dated 11/20/20, stated the resident was at high risk for falling. A 12/11/20 Incident Audit Report stated the resident fell and complained of left hip pain. The facility obtained an order for an x-ray. A 12/11/20 Progress Note stated the resident had increased pain to the left hip area and was unable to bare weight and walk this morning. A 12/11/20 Radiology Report stated the resident had an acute minimally displaced fracture of the left inferior pubic ramus (hip bones). The facility lacked documentation of a Care Plan intervention following the 12/11/20 fall. A 12/14/20 Progress Note stated the resident was in bed due to her fracture. A 12/19/20 Incident Audit Report stated the resident laid in the middle of the floor. A 12/20/20 Progress Note stated the resident had facial grimacing and could not grip as with previous neurological checks and staff would request an x-ray. A 12/20/20 Radiology Report stated a nondisplaced fracture at the base of the fourth metacarpal (wrist bone) could not be excluded. 12/21/20 Care Plan entries stated the resident was at risk for falls and directed staff to always maintain sight of the resident. A 1/1/21 Progress Note stated the resident had a right wrist cast. A 1/7/21 Physical Therapy Discharge Summary stated the resident was a 1:1 assist with a walker. A 2/18/21 Incident Audit Report stated staff found the resident lying on the floor next to her bed. The resident cried and screamed in pain and transferred to the emergency room ( ER). An untitled, undated document, provided to the survey team during the week of 1/24/22 by the Director of Nursing (DON) listed Resident #272's fall incidents and a plan for each incident. The document directed staff to implement a low bed as a plan for the 2/18/21 fall however the care plan listed this as a previous intervention initiated 12/21/20. A 2/25/21 Incident Audit Report stated a Certified Nursing Assistant (CNA) reported the resident was flat on her back and scooting all over the floor. The resident transferred to the ER. The facility investigation of the 2/25/21 fall stated the resident was supposed to have one on one supervision due to an extreme high fall risk. The CNA who was in charge of this resident (Staff NN) neglected her duty and per interview with the aide failed to watch the resident for some time leading up to the fall and when she returned to the room she found the resident on the floor. Management issued disciplinary action and terminated the CNA. A 3/6/21 Progress Note stated the resident readmitted to the facility. A 3/8/21 hospital Discharge Summary stated the resident had a subacute fracture of the left pubic ramus determined by a CT (Computerized Tomography-a type of scan) of the pelvis on 2/25/21. A 3/21/21 Incident Audit Report stated the resident laid on the floor near her bed. An untitled, undated document, provided to the survey team during the week of 1/24/22 by the DON listed Resident #272's fall incidents and plan for each incident. The document stated the plan for the resident's 3/21/21 fall was on antibiotics. The document contained no further interventions. A 6/3/21 10:05 a.m. Incident Audit Report stated the resident laid in a fetal position on the floor and the facility placed a fall mat for safety. An untitled, undated document, provided to the survey team during the week of 1/24/22 by the DON listed Resident #272's fall incidents and plans for each incident. The document directed staff to implement a mat. A 6/3/21 2:10 p.m. Incident Audit Report stated the resident laid on the floor next to the fall mat and complained of pain in her lower back, buttocks, and right arm/elbow and the facility obtained an order for an x-ray. A 7/15/21 Incident Audit Report stated another resident pushed the resident and she fell to the floor on her back. A 7/31/21 Incident Audit Report stated the resident laid on her back in her room. An 8/13/21 Incident Audit Report stated staff found the resident sitting on the floor in her room. The resident had a red mark to the center of the forehead and complained of a headache. An 8/15/21 Incident Audit Report stated the nurse heard the resident cry and observed her lying on the floor on her buttocks. The resident turned to another resident and asked her why did you do that?. An 8/20/21 Physical Therapy Discharge note stated the resident required 24 hour supervision and supervision with gait. A 9/23/21 Incident Audit Report stated staff found the resident on the floor next to her bed. A 9/23/21 Progress Note stated the resident appeared to slip off the bed. An untitled, undated document, provided to the survey team during the week of 1/24/22 by the DON listed Resident #272's fall incidents and plan for each incident. The document directed staff to implement a scoop mattress after the resident's 9/23/21 fall however this intervention was not listed on the resident's care plan. A 9/27/21 Incident Audit Report stated staff found the resident sitting on the floor of her room. An untitled, undated document, provided to the survey team during the week of 1/24/22 by the DON listed Resident #272's fall incidents and plan for each incident. The document stated the facility would conduct a conference with the family to discuss Memory Care as a plan related to the resident's 9/27/21 fall. The document contained no further fall prevention interventions related to this fall. A 9/28/21 Incident Audit Report stated the resident started screaming and 2 nurses observed the resident on the floor in front of her bed holding her head. The resident had a hematoma (bruise) to the right of her eye and complained of right shoulder pain. The resident transferred to the ER. A 9/28/21 Emergency Department report stated the resident had a scalp contusion and a shoulder sprain. An 11/3/21 Incident Audit Report stated staff found the resident sitting on the floor in front of the bathroom door and the resident was very confused. An untitled, undated document, provided to the survey team during the week of 1/24/22 by the DON listed Resident #272's fall incidents and plan for each incident. The document directed staff to implement non-skid strips by the resident's bed however the resident's fall occurred near the bathroom door. An 11/11/21 Incident Audit Report stated staff found the resident in the middle of her room sitting upright and confused. The note stated it appeared she may have slipped out of the wheelchair. An 11/14/21 COMS-Post Fall Evaluation stated staff observed the resident lying on the floor under her bed in her room with her head bleeding and range of motion to her lower left extremity not within normal limits (WNL). The resident transferred to the hospital for evaluation and treatment and the resident sustained a left humerus fracture, hematoma (a bruise), and laceration. The note stated the resident did not have a floor mat on the floor at the time of the fall. An 11/14/21 Emergency Department Final Report stated the resident fell and sustained a left sided abrasion to her forehead, a hematoma on the left temporal region, and a left humerus (arm bone) fracture. During a phone interview on 1/31/22 at 11:28 a.m., Staff BB, Occupational Therapist (OT) stated Resident #272 required the assistance of 1 person and staff should utilize a gait belt. During a phone interview on 2/1/22 at 5:00 p.m., Staff G, Licensed Practical Nurse (LPN) stated regarding Resident #272's fall on 11/14/21, she was just in the room prior to the resident's fall and the resident was sitting on the edge of the bed. She stated when she fell she was near the bed and was directly on the floor. Staff G at first stated she did not think there was a fall mat but later stated maybe there was a fall mat. During a follow-up phone interview on 2/2/22 at 10:05 a.m., Staff G stated she was not sure about the fall mat. She stated she saw the resident 5-6 minutes prior to the fall. During a telephone interview on 2/2/22 at 4:00 p.m., the DON stated she expected staff to complete a root cause analysis of falls and create fall prevention interventions based on this. She stated she expected staff to follow the care plan. During an interview on 2/7/22 at 9:58 p.m., the DON stated with regard to the resident's 2/25/21 fall, Staff NN, CNA was supposed to be 1:1 with the resident but the resident was on the floor and the staff member did not alert the nurse. She stated the facility terminated Staff NN. She stated with regard to Resident #272's 11/14/21 fall, a mat should have been in place. She stated if staff charted there was no mat in place, they had to go with what staff charted. 5. During an observation on 1/19/22 at 12:31 p.m., an unsecured oxygen canister sat on the floor of Room A4 Bed 1. The canister sat freely on the floor and was not contained by any sort of holder. Immediately after the observation the surveyor informed Staff L, LPN and she stated she would take care of it. The undated facility policy Oxygen Storage stated the facility secured oxygen tanks in an oxygen carriage of oxygen tank holder. During an interview on 2/2/22 at 4:00 p.m., the DON stated staff should secure oxygen cylinders. The undated facility policy Safe Lifting and Movement of Residents directed staff to utilize gait belts. The undated facility policy Falls and Fall Interventions stated fall interventions provided staff with individualized, person-centered care after a fall to prevent recurrence of a fall and directed staff to immediately put a fall intervention in place after a fall. 6. The MDS dated [DATE], documented Resident #70 with long and short term memory loss and moderately impaired decision making abilities. The resident required limited assistance of one resident for transfer and extensive assistance with walking. The MDS documented the resident as not steady, only able to stabilize with staff assistance when moving from a seated to a standing position, walking and turning around facing the opposite direction while walking, and surface to surface transfers (transfer between bed and chair or wheelchair). The resident had impairment on one side of the upper and lower body that interfered with daily functioning which required the use of a walker and wheelchair. The MDS listed a diagnosis of [CONDITION(S)] following cerebral infarct, right side dominant side, Alzheimer's Dementia, [CONDITION(S)] and urinary tract infection in the past 30 days. The Care Plan, dated 6/17/21, documented the resident at a high risk of falls related to decreased mobility and with a activities of daily living (ADL) self-care performance deficit related to a history of stroke. The ADL Care Plan, under transfers, directed the resident required limited assistance by 1 staff member to move between surfaces. The Physical Mobility Care Plan, dated 7/12/21, documented Resident #70 with limited physical mobility related to stroke and directed the staff to provide limited assistance of 1 staff member for locomotion using a gait belt and four wheeled walker. During an observation on 1/20/22 at 8:03 a.m., Staff N, Patient Care Aide, (PCA), brought resident #70 out of his room seated on the seat of the four wheeled walker dragging the resident backward with his feet dragging on the floor from his room to the foyer area approximately 56 feet on the seated four wheeled walker. Staff N then turned the walker around and wheeled the resident in the walker 20 feet into the dining room with his feet in his slippers sliding on the floor. The four wheeled walk did not have wheelchair pedals to be utilized as a wheelchair. During an observation on 1/20/22 at 9:15 a.m. Staff N told Resident #70 stand from the dining room table and move behind the four wheeled walker without placing a gait belt on the resident. Staff N ambulated the resident approximately 20 feet out of the dining room without the use of a gait belt. Once in the foyer Staff N stood over 10 feet in front of the resident's walker, no gait belt or hand contact with the resident stating to the resident, come on let's go. The resident stated he did not want to walk, still standing behind his walker with no gait belt on and Staff N over 10 feet away. Staff N came back to the resident's side and stood by the resident. Staff N started to sit the resident back down on his seated walker, when Staff BB, Occupational Therapist (OT) came and stated the seated walker should not be used to take the resident back to his room. Staff BB placed a gait belt on the resident and assisted Staff N with seating the resident into a wheelchair to take him back to his room. During an interview on 2/7/22 at approximately 2:08 p.m. the DON reported the seated four wheeled walkers should not be used as a wheel chair. The resident's should not be wheeled backwards in the seated walkers and acknowledged the seated walker did not have foot pedals. She stated if a resident requires staff assistance for ambulation and transfer, a gait belt should be used for safety. A review of the Physical Therapy Discharge Summary documented the resident discharged from therapy on 07/28/21 able to ambulate in facility with supervision. During an interview on 2/08/22 at 11:35 a.m. Staff BB, OT, reported she had also worked with Resident #70 and he has had a huge decline since his therapy discharge on 07/28/21. She stated he definitely would have needed one assist and use of a gait belt for ambulation. The Care Plan would have been correct. She stated all resident that need assistance for ambulation and transfer, staff should use a gait belt for. The undated Safe Lifting and Movement of Residents Policy, version 1.2 (H5MAPL0970, provided by the facility documented a Policy Statement in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The Policy Interpretation and Implementation documented: a. Resident safety, dignity and comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. b. Manual lifting of residents shall be eliminated when feasible. - Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance the care plan will reflect transferring needs considering: - Resident's preferences for assistance; - Resident's mobility; - Weight-bearing ability; - Cognitive status; - Whether the resident is usually cooperative with staff; and - The resident's goals for rehabilitation, including restoring or maintaining functional abilities. c. Staff responsible for direct resident care may employ use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 7. The MDS dated [DATE] for Resident #121 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnoses for Resident #121 included spinal stenosis of the cervical region and cerebral infarction. The Self Report document provided by the facility revealed an incident had occurred on 3/31/21 at 4:30 PM in a motor vehicle. The Incident Summary documented, Resident on his way back from doctor's appointment, transport driver used brakes to slow down van and resident reportedly fell due to not being buckled securely. Transport driver statement indicated that she rolled the resident in a wheel chair into vehicle handed the resident his seatbelt and asked him to buckle it up then proceeded to secure the front and back of the wheelchair prior to departing the appointment. Driver stated a car pulled out in front of her causing her to slam the brakes. When she noticed the resident, she immediately addressed the situation by pulling in to parking lot and securing the resident driving back to facility and presenting him immediately to the Director and Assistant Director of Nursing. The Resident Statement indicated that after the driver slammed on the brakes he flew out of his wheel chair with wheelchair falling on top of him. He stated that neither he nor the wheelchair were strapped down. He stated that he did not get help off the floor and did it himself furthermore stated that he was not strapped in for the rest of the way back to the facility. The resident stated that his left wrist, neck, and right ankle were in pain and the Medical Doctor (MD) notified and sent resident to Hospital emergency room (ER) where no injuries were found. The Resident Statement dated 3/31/21 documented, I was coming back from an appointment in the van. The driver quickly slammed on the brakes. I then flew out of my wheelchair and hit the floor. The wheelchair fell on top of me. I was not strapped in nor was my wheelchair strapped down. On the way down I saw rusty bolts on the floor, but I did not hit them. I tried to brace my fall and hurt my left wrist. Also, my neck hurts and my right ankle where I have had surgery on. My right leg has scratches on it caused by my fall. I did not get help off the floor, instead I did it myself. I was not strapped in for the rest of the way back to here (facility). The written statement by Staff A, Restorative Aide (RA), provided by the facility documented, in part, Resident #121 and I left his Dr. appointment I put him in the van put the seat belt around him and told him to buckle. I hooked the strap to the back of wheel chair put the ramp up, locked it, closed the hatch back and went around to the side door hooked the straps to front of chair then got in and left. We were on [Name Redacted] Road by [Business] and the car in front of me stopped so I pushed had to stop hard and Resident #121's chair moved forward and he fell out of his chair and he hit his right knee on the bolts that are sticking up. I pulled into [Business] helped him back in his chair checked his leg, and noted 3 scrapes on his knee. I made sure everything was hooked up. I made sure his seat Belt was fastened, then picked up another Resident and Returned to the facility and went straight to Director of Nursing's office told her and showed her the resident's leg. Then took the resident to the nurse to clean his knee. The Disciplinary Action form dated 3/31/21 for Staff A, RA, documented, Description of events leading to personnel action: Transport vehicle incident leading to injury of resident. The Inservice/Education Record dated 3/31/21 documented, in part, Staff designated to utilize the vehicle for transportation of the residents must ensure that all appropriate straps and belts are connected securely. Staff must ensure proper engagement of wheelchair tie downs (Q'Straint) and that the resident is safely buckled in using the lap belt. On 1/27/22 at 8:38 AM, Staff A, RA, was queried about the incident involving Resident #121. Staff A explained she had picked up the resident from their doctor, locked the back of the wheelchair in and gave the resident the seatbelt. Per Staff A, she asked the resident if he could buckle it, and went to the front and secured the front of the chair. Staff A acknowledged she had not checked if the resident had secured the seatbelt and assumed the resident had done so. As she was driving down the road, someone pulled in front of her and she had to stop. Staff A explained the resident had come out of the chair onto their knees. Staff A pulled into a parking lot, assisted Resident #121 back into the chair, and explained the chair was still secured down. Staff A explained they assisted the resident into the chair, and explained she had seen the resident falling as they were stopping. Per Staff A, Resident #121 had scrapes to their knees. Staff A acknowledged fault and said they had not checked to make sure they the resident had buckled themselves in. On 2/3/22 at 12:10 PM, the Facility Administrator explained that the resident had not been seriously injured, Staff A was suspended after the incident, Staff A no longer drove the van, and further explained another staff member now drove. The undated Facility Policy documented, It is the facility policy to provide transportation free of charge to residents to appointments and medically necessary meetings. It is also the policy to provide transportation within reasonable accommodations and if guidelines allow for personal outings such as resident shopping or pleasure outings.

Based on observation, resident, family and staff interviews and record review, the facility failed to prevent facility acquired pressure ulcers forming and failed to document assessments/measurements weekly on two of two residents reviewed with pressure ulcers. (Residents #10 and #14) The facility reported a census of 56 residents. Findings Include: 1. Resident #10's Minimum Data Set (MDS) Admission Assessment completed 11/21/20 documented the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 and required limited staff assistance with most activities of daily living and identified the resident at risk for developing pressure ulcers. The Care Plan with the target date of 12/23/20 identified the resident with potential impairment to skin integrity and actual pressure area related to decreased mobility and directed staff to provide weekly treatment documentation to include the measurement of each area of skin breakdown to include there width, length, depth, type of tissue and exudate and any other notable changes or observations. A review of the daily skin assessment completed 11/18/20 at 2:47 p.m. revealed the resident's skin intact with no pressure ulcers, only with bruising to the skin. A review of the Nurse's Notes revealed the following entry on 12/12/20 at 3:35 p.m. patient complained of burning to the sacral/coccyx area, the nurse assessed the area and found an open pressure sore measuring 4 by 3 by ¾ stage 1 (dimensions had not been labeled as to which were length, width or depth) New order from the Nurse Practitioner to apply [MEDICATION NAME] to the area and for wound care to see. A review of the Weekly Pressure Wound Observation Tool completed 12/12/20 at 3:49 p.m. revealed the following: a. Documented as Stage 1 which tool identified as Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. b. Measurements of Length: 4 cm Width: 3 and ¾ cm Depth: 0.1 cm. c. Description - [MEDICATION NAME] tissue present, granulation tissue present, no drainage, skin surrounding wound pink and intact, well defined skin edges No further documentation of assessments or measurements of the wound found. During an observation of wound care/dressing change revealed the following beginning 12/15/20 at 9:29 a.m. with Staff K, Personal Care Aide (PCA) and Staff F, Licensed Practical Nurse (LPN) providing incontinence care. Staff F removed the dressing and cleansed rectal crease using correct technique, one wipe per swipe. An open area noted to the coccyx missing a top layer of skin, wound bed appears pink, no drainage, covered with white cream which Staff F reported had been barrier cream and the only treatment had been a [MEDICATION NAME] dressing. Staff F then applied Phytophex barrier cream using the same gloves that she cleansed the resident's rectal crease and wound with, applied from outward edges of wound inward to middle of wound and did not change gloves before applying Mepliex dressing to wound. Staff F did not change gloves before she began cleansing the resident's peri area, before removing a tube of Triad ointment from drawer and applied to peri area or before repositioning the resident in bed using the soaker pad. In an interview on 12/15/20 12:49 p.m., Staff K, PCA reported the resident did not have a pressure relieving mattress on her bed or cushion in her recliner or wheelchair. She had been off a few days and when she returned, the resident had an open area which she did not know what caused it. The only intervention she had been aware of had been to remind the resident to turn from side to side. During an interview on 12/15/20 at 1:17 p.m., Staff F, LPN reported when she had first been informed by the aide of the pressure sore, she measured it, cleaned it up. Prior to the wound opening, the intervention she had was barrier cream and the area had been caused by pressure as the resident is non-compliant with repositioning. Staff F reported she assessed the wound every shift she worked and that the nurse is responsible for documenting measurements and assessments on the Weekly Wound Care Assessment Form and she also documented in the Progress Notes. When asked how she would perform wound care on Resident #10, she reported she would clean the wound with the wipes, reapply the barrier then apply the [MEDICATION NAME] dressing, should change gloves when finished and admitted she should have removed her gloves, washed her hands and put new gloves on before she applied the barrier and dressing. In an interview on 12/28/20 9:12 a.m., the Director of Nursing (DON) reported the Assistant DON (ADON) is responsible for documenting on wounds. She expected nurses to address each time the wound is observed and document on the Weekly Skin Assessment Forms. They should be documenting anything pertinent to the wound, measurements - the form pretty much drives what needs to be documented. There is also a spot they can add any additional Progress Notes. While completing wound care, she would expect the nurse to change gloves any time from dirty to clean areas or from one part of the body to the next, or after cleaning the wound and before putting on any new treatments or dressings. A review of the undated facility policy titled: Prevention of Pressure ulcers/injuries had documentation of the following: Risk assessment a. Assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. b. Conduct a comprehensive skin assessment upon admission including: Skin integrity - any evidence of existing or developing pressure ulcers or injuries. Tissue tolerance - the ability of the skin (and supporting structures to endure the effects of pressure and Areas of impaired circulation due to pressure from positioning or medical devices. c. Use a screening tool to determine if a resident is at risk for under-nutrition or malnutrition. d. Inspect the skin on a daily basis when performing or assisting with personal cares or Activites of Daily Living (ADL's). Identify any signs of developing pressure injuries (ie: non-blanchable [DIAGNOSES REDACTED]) For darkly pigmented skin, inspect for changes in skin tone, temperature and consistency. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Wash the skin after an episodes of incontinence, using pH balanced skin cleanser. Moisturize dry skin daily. Reposition resident as indicated on the Care Plan. Mobility/Repositioning: a. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance and the resident's stated preferences. b. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. c. At least every 2 hours, reposition residents who are reclining and dependent on staff for repositioning. d. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. e. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Support surfaces and pressure redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight and overall risk factors Monitoring: a. Evaluate, report and document potential changes in the skin. b. Review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility policy with the last revision date of July 2017 titled: Pressure Ulcers/Injuries Overview had documentation of the following: Avoidable: Avoidable means that the resident developed a pressure ulcer/injury and that the one or more of the following was not completed: a. Evaluation of the resident's clinical condition and risk factors. b. Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice. c. Monitoring or evaluation of the impact of the interventions: or d. Revision of the interventions as appropriate. Stage 2 Pressure Ulcer: partial-thickness skin loss with exposed dermis: a. The Stage 2 pressure ulcer appears as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. b. The wound bed is viable, pink or red, moist and may also present as an intact or open/ruptured blister c. Adipose (fat) tissue is not visible and deeper tissues are not visible d. Granulation tissue, slough and eschar are not present e. This stage should not be used to describe moisture associated skin damage including incontinence associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness skin loss a. The Stage 3 pressure ulcer appears as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. b. Slough and/or eschar may be visible but does not obscure the depth of tissue loss c. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. d. Undermining and tunneling may occur. e. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. f. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/pressure injury A review of the facility policy with the last revision date of September 2013 and titled: Dressings, Dry/Clean had documentation of the following procedure: a. Clean bedside stand. Establish a clean field. b. Wash and dry your hands thoroughly. c. Put on clean gloves. Loosen tape and remove soiled dressing. d. Pull glove over dressing and discard into plastic or biohazard bag. e. Wash and dry your hands thoroughly. f. Open dry, clean dressings(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. g. Label tape or dressing with date, time and initials. Place on clean field. h. Using clean technique, open other products. i. Wash and dry your hands thoroughly. Put on clean gloves. j. Assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stage. k. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke from the least contaminated area to the most contaminated area (usually from the center outward). l. Use dry gauze to pat the wound dry. m. Apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initials to top of dressing. n. Discard disposable items into the designated container. o. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. p. Reposition the bed covers. Make the resident comfortable. q. Place the call light within easy reach of the resident. r. Clean the bedside stand. s. Wash and dry your hands thoroughly. 2. The MDS assessment dated [DATE] for Resident #14 shown [DIAGNOSES REDACTED]. The MDS indicated Resident #14 scored a 5 out of 15 on the BIMS, indicating the resident with severe cognitive impairment. The MDS indicated the resident needed extensive assist to total dependence of 1-2 staff with transfers, bed mobility, dressing and personal hygiene. The MDS indicated the resident is high risk for skin damage and has moisture associated skin damage. During an observation on 12/15/20 Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA were providing incontinent cares to Resident #14 during which 2 open areas approximately dime sized with red wound base were noticed to right gluteal fold. Staff A, CNA stated she had notified the nurse of this over the weekend. They told Staff E, Personal Care Assistant (PCA) to go get the nurse. Staff D, Licensed Practical Nurse (LPN) came into the room and then left again, she returned with a [MEDICATION NAME] dressing and applied this to the wound, She did not measure the area or cleanse. Staff D, LPN stated they have standing orders for the dressing. Staff B, CNA and Staff C, CNA transferred resident into her wheelchair and the wheelchair had no cushion in the seat. During an observation on 12/16/20 at 10:30 a.m. the resident is sitting in wheelchair at table in the main dining room hoyer sling underneath resident and no cushion in wheelchair. During an observation on 12/16/20 at 12:30 p.m. the resident remains in wheelchair in the main dining room with no cushion in the wheelchair and sitting on the hoyer sling. Review of the residents Braden scale dated 11/10/20 revealed a score of 14 which indicates the resident is at moderate risk for skin breakdown. Review of the standing orders for the facility dated 11/30/20 failed to reveal an order for [REDACTED].) Clean, dress, and off load per facility protocol 3.) Start weekly wound observation tool 4.) Implement pressure relief measures 5.) Reposition per facility protocol (every 2 hours in bed or every 1 hour in chair) 6.) Notify nursing supervisor and provider. Review of the Treatment Administration Record (TAR) and Resident #14 Physician Orders failed to reveal a treatment for [REDACTED]. Review of Resident #14's Care Plan dated 12/3/20 directed staff to provide pressure relieving/reducing pad to protect the skin while up in chair. Provide weekly documentation to include areas of skin breakdown, redness and any other notable changes or observations. The Administrator provided a sheet titled Admission Skin Review dated 12/11/20 which stated resident #14 had a blister at site 39 which is the right popliteal area which measured 1 centimeter by 0.2 centimeter. The Progress Notes for Resident #14 dated 12/13/20 states resident noted with multiple pressure areas on the inside of the right thigh. No complaint of pain noted to the area, and cleaned with normal saline and [MEDICATION NAME] cream applied to the area. Resident was placed in wheelchair after crawling out of bed onto the floor on her fall matt and unable to measure at this time. All areas open and the DON, ADON and Administrator aware of wounds. The Weekly Wound Documentation Tool in the Electronic Health Record (EHR) dated 12/13/20 was initiated but incomplete. Review of the resident's medical record failed to reveal any further documentation on the wound until the surveyor asked the Administrator for further information. Interview with Interim Administrator on 12/21/20 at 12:30 p.m. states typically they would complete a Risk Management Tool for Skin and do weekly measurements. The nurse should notify the Medical Doctor and the Power of Attorney (POA) when the pressure ulcer is discovered. During an interview with the DON on 12/21/20 at 3:15 p.m., stated she would expect the CNA to notify the nurse if an open area is noted. The nurse should clean, dress, position off the area and notify the Medical Doctor on the same day to obtain orders for treatment. During an interview on 12/21/20 at 4:00 p.m., Staff F, LPN stated the wound sheet was not filled out originally after initiated on 12/13/20 because it was change of shift and she asked the next shift to complete and it was never done. She was unable to obtain measurements today either because Resident #14 has been up in her wheelchair all day. Staff F, LPN did speak to the Nurse Practitioner today and she did not recall being notified of the pressure ulcer either.

Based on observation, family and staff interviews and record review, the facility failed to prevent falls resulting in fractures for two residents (Residents #4 and #12) and failed to prevent a fall out of the wheelchair for one (Resident #14) of six residents reviewed in the standard sample. The facility reported a census of 56 residents. Findings Include: 1. Resident #4's Minimum Data Set (MDS) Significant Change assessment completed 11/28/20 documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, required extensive staff assistance with most activities of daily living. The Care Plan dated with the target date of 11/15/20 identified the resident with the problem of an Activities of Daily Living (ADL) self-care performance deficit related to Disease Process , Impaired balance, limited range of motion related to history of bilateral fractured humerus. Interventions included to transfer: resident requires limited assistance by staff to move between surfaces and as necessary. A review of the Risk Management Report identified the resident fell on [DATE] at 12:00 p.m. and had documentation of the following: This nurse was informed by staff resident had fallen, entered the room, observed resident sitting on buttock bilateral lower extremities extended straight out, resident had gown on and non-skid slipper socks. Certified Nurse Aide (CNA) stated she assisted the resident to get changed,the resident stood up, the CNA pulled up the resident's incontinent brief when resident lost her balance and the resident fell back. No injuries observed at time of incident. The report did not include documentation to show the Personal Care Aide (PCA a non-certified Nurse Aide) did not place a gait belt on the resident which she had reported to this nurse and to the surveyor. A review of the Nurse Practitioner (NP) Notes revealed on 11/21/20 at 3:30 p.m., the NP asked to see the resident to evaluate after falling and possible injury to the left leg. The NP asked to assess patient after a fall on the left side of the body, NP assessed patient via webcam and patient is complaining of new onset of left hip pain. X-ray of the left femur status [REDACTED]. NP explained to patient if the x-ray shows a fracture she will be sent to the hospital. A review of the facility nurse's notes revealed the following: a. On 11/21/2020 at 5:00 p.m., X-Ray tech stated 2 views of front, unable to turn the resident as she had too much pain. View does show a [MEDICAL CONDITION] formal neck. Called on call physician and received orders to send to the emergency room to evaluate and treat. b. On 11/21/20 5:20 p.m. Medic here to transport the resident to the emergency room , appropriate paperwork given to medics. c. On 11/22/20 10:53 a.m. called hospital to follow up on resident, nurse reported resident had surgery this morning for fractured femur d. On 11/26/20 9:09 p.m. per report at shift change, resident [MEDICATION NAME] order requires prescription in order to be filled by pharmacy A review of the timeline provided by the Director of Nursing (DON) revealed the resident returned from the hospital post-surgical repair of a [MEDICAL CONDITION] on 11/26/20. In an interview on 12/14/20 at 10:20 a.m., Staff S, LPN reported she did not work the day the resident fell and had been informed of the resident's fall the day after when she returned to work. Staff E reported to her that she did not put a gait belt on the resident before she fell . The resident was not independent prior to this fall, she had to have the assist of one using a gait belt. During an interview on 12/14/20 at 2:24 p.m., Staff D, Licensed Practical Nurse (LPN) reported on the day the resident fell and fractured her femur, Staff E, PCA (non-certified nurse aide) had helped the resident who had already been standing without a walker, when Staff E attempted to change the resident's incontinent brief, the room was so cluttered, the resident lost her balance and fell on her bottom. After the aides informed her, Staff D went to the resident's room and found her sitting on the floor with Staff E beside her. Staff E did report that she did not place a gait belt on the resident before the resident fell . The resident did not have any outward rotation of either leg. She did complain of pain to the left leg. The aides used a gait belt to assist the resident up to the chair. After she notified the Nurse Practitioner and physician of the fractured femoral head, she received orders to send her to the hospital. In an interview on 12/14/20 at 3:18 p.m., Staff H, Certified Medication Aide (CMA), reported prior to the fall on 11/21/20, the resident had been Care Planned to pivot transfer with assist of two using a gait belt. The resident was not independent prior to this fall, she had to have the assist of two to transfer. During an interview on 12/15/20 at 11:37 a.m., Staff E, PCA, reported she had been informed that the resident had been independent. She was kneeling on the floor helping the resident pull up her incontinent briefs, the resident decided to stand up then fell sideways. She did not place a gait belt on her. The resident fell on her left side, no bleeding and she complained of left hip pain. Staff E pulled the emergency call light then Staff D, LPN entered the room and helped Staff E transfer the resident back to the wheelchair. In an interview on 12/15/20 at 11:53 a.m., Staff I, PCA, reported Resident #4 should have a gait belt around her and use a walker when the aides transfer her. She did not always cooperate and would try to get up on her own. During an interview on 12/15/20 at 12:29 p.m., Staff J, PCA reported the resident should not get up by herself and that staff should use the gait belt to help her up. In an interview on 12/28/20 at 9:12 a.m., the DON reported if the aide had not been sure of how the resident had been care planned to transfer, she would expect the aide to place a gait belt around the resident before transfer. 2. Resident #12's MDS 5 Day Assessment completed 11/27/20 documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively impaired with a BIMS score of 6 out of 15 and required limited staff assistance with most activities of daily living. The Care Plan with the last revision date of 12/22/20 identified the resident with the problem of an alteration in musculoskeletal status related to [MEDICAL CONDITION] and hand and directed staff to monitor/document/report as needed the signs/symptoms or complications related to arthritis. A review of the nurse's notes revealed the following: a. On 12/11/20 at 10:14 a.m., post fall on 12/10/20 and increased complaint of pain to the left hip/femur area, unable to bear weight or walk this morning. Noted anatomical difference from the left to the right. b. On 12/11/20 at 10:43 a.m., resident sent out to the emergency room for further evaluation and treatment post fall on 12/10/20. The notes did not have documentation of an assessment of the fall on 12/10/20. c. On 12/20/20 at 5:32 p.m., resident fell on [DATE], x-ray ordered for right hand. Results called to the doctor. The notes did not have documentation of whether or not the resident sustained [REDACTED]. An observation on 12/15/20 beginning at 9:53 a.m. revealed Staff K, PCA and Staff F, LPN entered the resident's room as the resident had been standing in the middle of the room, both assisted the resident to ambulate to the bathroom, holding her under each arm and did not place the gait belt (which was observed in the resident's closet) around the resident. Staff F reported the resident had a fall last week which resulted in a pelvic fracture. After both assisted the resident to sit on the toilet, Staff K then placed a gait belt around the resident's waist. In an interview on 12/22/20 at 9:59 a.m., Staff F, LPN reported she had not been working when the resident fell on [DATE]. She repeatedly informed the CNAs that there always needs to be someone in the hallway to keep an eye on the resident as she constantly got up on her own and did not understand to call for help. The resident had a fracture to her right hand, and prior to that fall had not been independent, she should have had assist of one staff with the gait belt. She also reported there should be documentation in the Nurse's Notes if a fracture had been identified. During an interview on 12/28/20 9:12 a.m., the DON reported she would expect the nurses to document after a resident fell on the Incident Report which guides them what to document. The nurse should document on the Progress Notes and document the head to toe assessment, anything new, describe what happened, should be assessed at least every 15 minutes four times, every 30 minutes twice and hourly four times then once a shift for 72 hours. She also reported she would expect the nurse to report to the physician whether or not the x-rays showed a fracture. She then reported if the staff had any doubts on how to transfer the resident, would expect them to use a gait belt. A review of the undated facility policy titled: Fall Prevention Program had documentation of the following: High Risk Protocols a. The resident will be placed on the facility's Fall Prevention Program. b. Indicate fall risk on the care plan. c. Place Fall Prevention Indicator on the name plate to the resident's room. d. Place Fall Prevention indicator on resident's wheelchair. e. Implement interventions from low/moderate risk protocols. f. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status or recent change in functional status. g. Provide additional interventions as directed by the resident's assessment. h. When any resident experiences a fall, the facility will: 1. Assess the resident. 2. Complete a post-fall assessment. 3. Complete an incident report. 4. Notify physician and family. 5. Review the resident's care plan and update as indicated. 6. Document all assessments and actions. 7. Obtain witness statements in the case of injury. A review of the policy with the last revision date of March 2018 and titled: Falls and Fall Risk, Managing had documentation of the following: - Resident-Centered Approaches to Managing Falls and Fall Risk a. The staff with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. b. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. c. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. d. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. e. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. - Monitoring Subsequent Falls and Fall Risk a. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. b. If interventions have been successful in preventing falling, staff will continue the interventions or re-consider whether these measures are still needed if a problem that required the intervention. c. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. d. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 3. The MDS assessment dated [DATE] for Resident #14 shown [DIAGNOSES REDACTED]. The MDS indicated Resident #14 scored a 5 out of 15 on the BIMS, indicating the resident severe cognitive impairment. The MDS indicated the resident needed extensive assist to total dependence of 1-2 staff with transfers, bed mobility, dressing and personal hygiene. The MDS indicated the resident is high risk for skin damage and has moisture associated skin damage. During observations of the resident #14 on 12/14/20 the following noted: a. At 12/14/20 at 11:30 p.m., sitting in wheelchair at a table in the main dining area with head down on table and eyes closed. Resident remained at the table at 12:00 p.m. b. At 2:30 p.m., sitting at a table in activity in the main dining area slumped forward in her wheelchair with head down on the table. c. At 3:30 p.m., laying face forward on the ground in front of wheelchair in the main dining area. Staff D, LPN assessed the resident and directed CNA's to get resident back into wheelchair and then to bed. Review of the Resident's Morse Fall Scale Form noted the following entries: a. On 12/1/20 revealed Resident #14 was found lying in front of her wheelchair. Resident states she was reaching for item on cabinet that is sitting in hallway when slid out of the chair. b. On 12/4/20 reveals the Resident #14 fell out of wheelchair onto the floor in the main dining room the nurse observed her on her stomach. c. On 12/8/20 revealed the resident was found on the floor next to her bed. d. On 12/14/20 revealed Resident #14 was observed laying in prone position with bilateral feet under her wheelchair. Resident had on pants, shirts, gripper socks incontinent of urine. Resident unable to give description. The Care Plan for Resident #14 with a revision date of 12/3/20 indicated she is at moderate risk for falls related to gait and balance problems. The Care Plan fails to reveal any interventions regarding falls out of wheelchair or positioning interventions. During an interview with Staff A, Certified Occupational Therapy Assistant (COTA) states they have not seen the resident for wheelchair positioning related to falls. They did provide treatment for [REDACTED]. During an interview on 12/21/20 at 3:15 p.m. the DON stated after a resident falls, the nurse should do a head to toe assessment for injury and figure out what caused the fall. The staff should have follow up and assess the need for new interventions to prevent falls.

Based on resident and staff interviews and record reviews, the facility failed to follow physician orders for three out of twelve residents reviewed (Residents #4, #7, and #8). The facility reported a census of 56 residents. Findings Include: 1. Resident #4's Minimum Data Set (MDS) Significant Change Assessment completed [DATE] documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, required extensive staff assistance with most activities of daily living. APIXABAN/ELIQUIS (a medication used as a blood thinner): The Care Plan dated as last revised [DATE] for admission date of [DATE] identified the resident with the problem of the resident on anticoagulant therapy and directed staff to administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness each shift. A review of the facility Nurse's Notes revealed the following: a. On [DATE] at 5:00 p.m., X-Ray tech stated 2 views of front, unable to turn the resident as she had too much pain. View does show a [MEDICAL CONDITION] formal neck. Called on call physician and received orders to send to the emergency room to evaluate and treat. b. On [DATE] 5:20 p.m., Medic here to transport the resident to the emergency room , appropriate paperwork given to medics. c. On [DATE] 10:53 a.m., called hospital to follow up on resident, nurse reported resident had surgery this morning for fractured femur. Review of the Discharge Summary from the hospital for Resident #4 dated [DATE] showed the resident admitted [DATE] and discharged on [DATE] back to the facility. Admission [DIAGNOSES REDACTED]. On [DATE] the resident underwent [REDACTED]. On [DATE], rapid response was called after the resident complained of left-sided chest pain. The resident identified with AFib ([MEDICAL CONDITION] an abnormal heart rhythm) with RVR (rapid ventricular response) and started with an [MEDICATION NAME] (medication to control heart rhythm) IV drip and later transitioned to oral [MEDICATION NAME]. When discharged back to the facility the resident prescribed [MEDICATION NAME] 400 milligrams (mg) by mouth (po) twice a day to continue 5 more days, followed by 200 mg daily and continue on her regular dose of Apixaban/Eliquis, which on discharge orders noted to be 5 mg by mouth, twice a day. A review of the [DATE] Medication Administration Record (MAR) revealed the following order: Eliquis (Apixaban) 5 mg one tablet two times a day related to PE (pulmonary [MEDICAL CONDITION]) - no start date had been documented. A hold date from [DATE] at 7:12 p.m. to [DATE] at 1:31 p.m., no doses signed out as given during this week. No notation of the Eliquis restarting once the resident returned from the hospital on [DATE], per Hospital Discharge Orders and was not given the rest of the month of November. A review of the timeline provided by the Director of Nursing (DON) revealed the resident returned from the hospital post-surgical repair of a [MEDICAL CONDITION] on [DATE] and readmitted to the hospital on [DATE]. A review of the hospital Physician's History and Physical dated [DATE] at 10:55 p.m. had documentation the patient recently admitted to the hospital from [DATE] through [DATE] with a left femoral fracture and underwent Open Reduction Internal Fixation (ORIF - surgical repair) on [DATE]. During her hospital stay, also had AFib ([MEDICAL CONDITION] an abnormal heart rhythm) with RVR (rapid ventricular response) which was controlled with [MEDICATION NAME]. discharged back to the facility with [MEDICATION NAME] and was supposed to follow up with the cardiologist, but she did not follow through. CT scan of the chest was obtained which was suspicious for scattered [MEDICAL CONDITION] emboli. Started with IV [MEDICATION NAME] drip for possible [MEDICAL CONDITION] embolism. Patient is already on Eliquis at nursing home for [DIAGNOSES REDACTED] A Fib. A review of the [DATE] MARs revealed the following order: a. Apixaban tablet 5 mg by mouth two times a day related to PE - no start date documented. b. No order transcribed to MAR from [DATE] through [DATE]. c. The first dose of Apixaban not documented as given till [DATE] at 8:00 p.m. A review of the Physician Orders documented on the hospital transfer form dated [DATE] had orders for Apixaban (Eliquis/blood thinner) 5 mg (milligrams) by mouth twice daily. [MEDICATION NAME] HCL (an medication affecting the rhythm of the heart):: A review of the Care Plan revealed it failed to address the resident with cardiac history and the need to administer [MEDICATION NAME] and potential side effects to monitor for. A review of the Nurse's Notes had documentation of the following: On [DATE] 1:03 p.m., clarification on [MEDICATION NAME] order completed by the DON. The resident returned from the hospital with conflicting [MEDICATION NAME] orders, needs to be clarified with the cardiologist prior to being filled. A review of the Physician Orders on the transfer document dated [DATE] had documentation of the following orders: [MEDICATION NAME] 200 mg (milligrams) tablet - one tab daily for 30 days. [MEDICATION NAME] 400 mg orally twice daily for 5 days followed by 200 mg orally daily afterward. A review of the [DATE] MAR revealed the following orders: a. [MEDICATION NAME] HCL tablet 200 mg give one tablet by mouth two times a day for 30 days - signed out as given at 8:00 a.m. on [DATE], 15, 16, 17, 18 and at 8:00 p.m. on [DATE], 14, 15, 16, 17 b. [MEDICATION NAME] tablet 200 mg give 2 tablets twice a day for 5 days - discontinue date [DATE] - no doses signed out as given The resident received the wrong dose from [DATE] through [DATE] and should have received 200 mg two tablets for 5 days then 200 mg one tablet daily afterward. During an interview on [DATE] at 2:24 p.m., Staff D, Licensed Practical Nurse (LPN), reported it is the nurse's job to enter the Admission Note, the Assistant DON or DON will then enter the orders into the computer, then the floor nurse can fax the orders to the pharmacy. The medications need to be entered into the computer in order for the pharmacy to process the medications. In an interview on [DATE] at 1:17 p.m., Staff F, LPN, reported the admitting nurse is responsible for entering the orders into the electronic medical record and sends to the pharmacy. The facility did not have a double check system. She reported she would always go back and review everything twice. During an interview on [DATE] at 4:41 p.m., Staff M, LPN, reported she thought she entered the orders into the computer, however, there had been 3 residents admitted that same day. The nurse who admitted the resident is responsible for entering the orders into the computer. She also reported she had never been trained at the facility. She could not recall the orders for Apixaban and [MEDICATION NAME] as she took care of 49 residents. In an interview on [DATE] at 4:20 p.m., Staff V, Registered Nurse (RN), reported the nurse who admitted the resident should enter the orders into the computer and fax them to the pharmacy. She took care of the resident the day after she returned from the hospital on [DATE]. The nurses should double check the orders, however, this does not always happen. Once the orders have been entered and checked, they are placed into a basket that is kept in a cupboard behind the Nurse's Station. There is no system to show that the orders have been double checked when looking at the MARs on the computer. It can take weeks after the actual order is written and scanned into the computer. She could not recall the orders for Resident #4 for Apixaban and [MEDICATION NAME]. During an interview on [DATE] at 9:12 a.m., the DON reported the nurse on duty would be responsible for entering the orders into the computer and did not think the nurses were double checking the orders. She verified the resident should have received Eliquis 2.5 mg two tablets twice daily. The admitting nurse forgot to add it to the list of the medications. Regarding the order for the [MEDICATION NAME], the DON found the order was a significant change from what she had prior to being hospitalized . The resident should have received 200 mg one tab BID (twice daily). This was another order that was missed. The order when she came back from the hospital was 200 mg one tablet once daily for 30 days, then it also says 400 mg (200 mg x 2 tabs) by mouth twice daily for 5 days followed by 200 one tab mg by mouth once daily. On [DATE], she had the floor nurse call the medical director, who later directed us to hold the [MEDICATION NAME] until the order had been clarified with the cardiologist. When the resident came returned from the hospital, the cardiologist wanted her to have 200 mg one tablet once a day. The orders should have been clarified as soon as she returned from the hospital. She verified [MEDICATION NAME] 200 mg one tab one dose had been given on [DATE] She did not receive any doses after that. The orders were not discontinued from the computer that should have been discontinued. 2. Resident #7's MDS Admission Assessment completed [DATE] documented the following Diagnoses: [REDACTED]. It also identified the resident required extensive staff assistance with all activities of daily living and had not been assessed for cognitive status. The resident noted admitted to the facility [DATE] and did not have a Care Plan documented prior to her death on [DATE]. A review of the Physician Orders on the Order Summary Report dated [DATE] to [DATE] revealed the following orders dated [DATE]: a. Budenoside-[MEDICATION NAME] aerosol ,[DATE].5 mcg/act 2 puff inhale orally two times a day. b. [MEDICATION NAME] sulfate 325 mg (milligrams) one tablet every morning. c. [MEDICATION NAME] 40 mg one tablet one time a day. d. [MEDICATION NAME] 300 mg one capsule two times a day for 14 days. e. [MEDICATION NAME] 5% apply to back topically at bedtime for 30 days, apply 3 patches. f. Montelukast Sodium tab 10 mg one tab at bedtime for asthma for 30 days. g. NAME] 40 mg one tablet two times daily. h. [MEDICATION NAME] Hcl 30 mg 2 tabs daily for depression for 30 days. i. Potassium chloride ER (extended release) tablet 20 meQ (milliequivelents) give two tablets two times a day. Review of the [DATE] MAR revealed no medications had been signed out as administered for Resident #7. During an interview on [DATE] at 9:12 a.m., the DON reported the resident had been admitted during the evening shift, the pharmacy did not send the medications prior to her expiring at the facility, and unsure why. The expectation would be for the nurse to notify the DON, look for medications in the Ebox or call the pharmacy again if the medications are not in the facility within 2 hours. She also verified after reviewing the [DATE] medication administration records that none of the medications ordered had been signed out as administered. In an interview on [DATE] at 12:24 p.m., the Consultant Pharmacist reported there are orders that had been entered on [DATE] and the pharmacy had been closed for the holiday. The facility should have called the pharmacy on call number and it does not appear that they called the on call service which is available 24 hours. There is no record that they called before the [DATE]. The orders were waiting to be filled when the pharmacy staff returned to work on Friday [DATE]. They never received notification that this resident had been admitted . It showed an admission date of [DATE], which is when electronic orders came over. The Consultant Pharmacist stated were closed that day and we filled the orders on [DATE]. If orders are called after hours, our Regional Pharmacy is in Des Plaines, Illinois. There also is a 24 hour Pharmacy near the facility that could have sent a 3 day supply. He also reported there had been a time they had a difficult time contacting the facility as the phones had not been working. 3. Resident #8's MDS Quarterly Assessment completed [DATE] documented the following Diagnoses: [REDACTED]. It also identified the resident required extensive staff assistance with most activities of daily living. He had not been assessed for cognitive status, however, the facility identified the resident as interviewable. The Care Plan with the target date of [DATE] identified the resident with a diabetic ulcer to both legs related to diabetes and directed staff to put on shoes only when he is up and to have wound care to see. The Care Plan also identified the resident with the problem of potential for and actual impairment to skin integrity related to [MEDICAL CONDITIONS], fragile skin and directed staff to monitor/document location, size and treatment of [REDACTED]. A review of the physician orders revealed the following: a. On [DATE] Right lateral foot: cleanse with normal saline, apply [MEDICATION NAME] blue slightly moistened cover with Vaseline gauze, 4 x 4, roll gauze, tape. Change dressing 3 times per week- every other day and as needed. b. Surgical shoe to right leg. c. On [DATE] Left lateral foot: Left Lateral foot cleanse with normal saline apply [MEDICATION NAME] blue slightly moistened cover with Vaseline gauze, 4 x 4, roll gauze, tape. Change dressing 3 times per week- every other day and as needed surgical shoe to left leg. Review of the [DATE] treatment administration record (TAR) revealed the following: a. an order for [REDACTED]. Change dressing 3 times per week- every other day and as needed. b. Surgical shoe to the left leg one time a day every other day for wound care. c. The treatments not signed out as completed on [DATE], 10, 18, 20, and 22. d. Order for Right lateral foot: cleanse with normal saline apply [MEDICATION NAME] blue slightly moistened cover with Vaseline gauze, 4 x 4, roll gauze, tape. Change dressing 3 times per week every other day and as needed. e. Surgical shoe to Right Lower Extremity (RLE). f. One time a day every other day for wound care. f. Treatments had not been signed out as completed on [DATE], 10, 18, 20, and 22. A review of the [DATE] TAR revealed the following: a. Order for Left lateral foot: Left Lateral foot cleanse with normal saline apply [MEDICATION NAME] blue slightly moistened cover with Vaseline gauze, 4 x 4, roll gauze, tape. Change dressing 3 times per week- every other day and as needed (PRN). b. Surgical shoe to left leg one time a day every other day for wound care. c. Treatments had not been signed out as completed on [DATE] and 12. d. Order for Right lateral foot: cleanse with NS apply [MEDICATION NAME] blue slightly moistened cover with Vaseline gauze, 4 x 4, roll gauze, tape. Change dressing 3 times per week- every other day and as needed. e. Surgical shoe to right leg. one time a day every other day for wound care. f. Treatments not signed out as completed on [DATE] and 12. During an interview on [DATE] 12:06 p.m., the resident reported he went to the Wound Clinic and they say the dressings need to be changed every day. He would need to hunt down the nurse to change the dressings. The nurses are not changing the dressings for at least 3 days. When he had first arrived to the facility, he developed an infection to the wounds, they would begin to heal but later became infected as the nurses were not changing the dressings. He reported 4 days would go by before the dressings would be changed. In an interview on [DATE] at 9:37 a.m., the resident reported the nurses did not change his dressings on [DATE]. Usually most of them will do it, but they get so busy, they end up not doing it which is how the wounds got infected the second time, they didn't change the bandages, his socks used to get wet. The wounds would heal, then the dressings would not get changed and the wounds would get infected again since he is diabetic. In an interview on [DATE] at 2:24 p.m., Staff D, LPN reported the resident's dressings had been ordered to be changed every other day and should be signed out on the treatment administration record when completed. A review of the undated facility policy titled: Medication Administration had documentation of the following: a. Review MAR (medication administration record) to identify medication to be administered. b. Administer medication as ordered in accordance with manufacturer specifications. c. Sign the MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. A review of the facility policy with the last revision date of [DATE] and titled: Medication Orders and Receipt Record had documentation of the following: a. The charge nurse will maintain medication order and receipt records. b. The medication order/receipt record shall contain: aa. The prescription number; bb. The resident's name; cc. Name, quantity ordered, and strength of the drug; dd. Order date; ee. Name and title of person placing the order; ff. Name of the dispensing pharmacy; gg. The date and quantity received; and hh. Name and title of the person receiving the order. c. The Director of Nursing services will designate individuals to be responsible for completing medication order/receipt forms. d. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. e. Emergency medications ordered/received shall also be entered onto the medication order and receipt record. f. The receiving nurse shall record medication orders received on the receipt record. The receiving nurse shall verify each delivered medication and check off the order form. Controlled substances shall be verified in the presence of the person delivering the drug order. g. Noted discrepancies shall be reported to the dispensing pharmacy. h. The facility shall retain medication order/receipt records for at least one year or as otherwise required by applicable law and regulations.

Based on clinical record review and staff interview, the facility failed to monitor [MEDICATION NAME] Time and International Ratio (PT/INR) levels for 1 of 3 sampled (Resident #5) on [MEDICATION NAME] (blood thinner). Resident #5 re-admit to the facility on [DATE] and received [MEDICATION NAME]. On 2/28/20, the physician debrided Resident #5's wound which bled profusely and resulted in hospitalization . The staff failed to identify no lab orders to monitor the [MEDICATION NAME] and failed to notify the physician to clarify the orders. The facility reported a census of 69. Findings include: 1. Resident #5 admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident required extensive assistance with transferring, dressing, bathing and toileting and did not ambulate. Nurse notes dated 12/24/19, documented the resident entered the facility at 12:29 p.m., Progress notes dated 12/25/19, documented the resident complained of chest pain and was sent to the hospital at 1:05 p.m. The resident was readmitted to the facility on [DATE] after being hospitalized . Physician orders dated 1/6/20, directed staff to administer [MEDICATION NAME] 10 milligram (mg) one tablet every day related to personal history of [MEDICAL CONDITION] embolism. Documentation in the Medication Administration Record [REDACTED]. The plan of care identified a focus area of anticoagulant therapy. The plan directed staff to implement the following interventions: a. administer anticoagulant medication as ordered by physician. Monitor for side effects and effectiveness every shift. b. Daily skin inspection. Report abnormalities to the nurse. c. Labs as ordered. Report abnormal lab results to the physician. d. Monitor/document/report as needed, adverse reactions of anticoagulant therapy. Facility policy updated September 2019, indicated Resident's on [MEDICATION NAME] therapy will be monitored for therapeutic dosing. The facility procedure indicated All residents on [MEDICATION NAME] therapy will have pertinent labs drawn per MD orders. All abnormal labs will be reported to MD promptly. New orders regarding dosage adjustment and further lab draws will be followed up on promptly. Nurse notes dated 2/18/20 at 11:55 p.m., documented the first shift nurse reported the wound doctor came and did a wound debridement on the resident. The resident was taking [MEDICATION NAME] and was having episodes of heavy bleeding. The In- house physician ordered a stat INR (International normalized ratio) and Vitamin K administration. The wound doctor was able to stop the bleeding but not for long due to the resident moving. The wound doctor stayed around and monitored the resident until approximately 10:30 p.m., when the in house physician ordered the resident be sent out. The resident's blood pressure was low, reading 70/60. Medics arrive at 11:00 p.m. and transported the resident. The Emergency Department Physician note documented the resident presented with increasing gluteal bleeding after wound debridement earlier. The resident was chronically on [MEDICATION NAME] and the INR was found to be greater than 9. The bleeding was unable to be stopped and thus the resident was transferred to the emergency room . While in the emergency room the bleeding could not be controlled effectively and the resident was given FFP (fresh frozen plasma) as well as vitamin K via IV (intravenous). The resident's hemoglobin was found to be much lower than it had been previously in the 7 range, where the residents baseline was in the 12-13 range. Clinical record review revealed the resident's INR was 2.1 when readmitted to the facility on [DATE]. Clinical record review revealed no further INR's were completed until 2/18/20. There was no physician order for [REDACTED]. During interview on 3/3/20 at 4:02 p.m., the director of nursing confirmed an INR had not been ordered for the resident until 2/18/20. During interview on 3/3/20 at 3:10 p.m., the physician stated he visited the resident every week and reviewed the resident's wounds. On 2/1820 the buttock wound had eschar separating and started bleeding on its own and was debrided and kept bleeding. The physician did not have supplies available as he would if at the hospital. The physician stated he asked if the resident was on [MEDICATION NAME] and when saw the bleeding ordered a stat INR. The physician stated if a resident does not come with an order for [REDACTED]. During interview on 3/4/20 at 12:34 p.m., the Nurse Practitioner (NP) stated the resident was admitted on [DATE] and the physician wrote admit orders. The NP addresses acute incidents. If [MEDICATION NAME] a wound the physician should know if the resident is on [MEDICATION NAME] and what the INR was. She would have checked on the INR if doing any procedure. The NP stated protocol in the nursing home is to check the INR every 4-6 weeks. The NP never saw the wound until the physician asked her about the bleeding, however she thought it was usual after a debridement. The NP ordered an INR after seeing the bleeding and it was 9 and the resident needed to be sent out.

Based on observation, record review, and interview, the facility failed to offer an alternate for residents with food allergies for 2 of 2 residents reviewed. Resident #1 had a shellfish allergy. On 1/18/19, the facility served her shrimp for dinner. As a result, Resident #1 displayed signs of an allergic reaction (swelling and respiratory problems) that required her to be transferred to the ER (emergency room ) and intubated (tube inserted in the mouth and down the throat to maintain an airway). The resident then had to be sent to another hospital and admitted to the Intensive Care Unit for airway protection and sedation. This situation constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 55 residents. Findings include: The Admission Record dated 1/25/19 revealed Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 experienced severe cognitive impairments. The MDS dated [DATE] revealed Resident #1 required consistent carbohydrate diet with ground or chopped meat, regular bread, and desserts. The Plan of Care revealed Resident #1 had an allergy to shellfish, no teeth, and a history of dysphagia (difficulty swallowing. The Care Plan directed staff to monitor for chewing ability and oral intake at meals. The Dietary Progress Note dated 10/30/18 revealed Resident #1 on consistent carbohydrate diet with ground meat and 1500 milliliter fluid restriction, feeds self with good/excellent oral intake at meals and no chewing or swallowing problems. The Active Orders revealed Resident #1 had an order for [REDACTED]. Resident #1's tray card revealed Resident #1 had a mechanical soft diet and shellfish allergy on the breakfast lunch and dinner card. The Allergies List revealed Resident #1 and Resident #8 had shellfish allergies. The Daily Spreadsheet revealed the Week One Friday Dinner Menu of popcorn shrimp, cocktail sauce, crispy French fries, creamy coleslaw, lemon cheesecake bar, homemade hushpuppy, 2% milk, coffee/hot tea and condiments. The ground diet instructions directed to grind the popcorn shrimp with mayonnaise, serve mashed potatoes instead of French fries and serve a soft biscuit instead of the hushpuppies. The Production Sheet Week One Friday Dinner sheet dated 1/18/19 revealed the start temperatures on popcorn shrimp regular, ground shrimp and puree shrimp. The sheet revealed omissions in temperatures for the oven fried fish fillet, puree coleslaw, unfrosted yellow cake, puree lemon cheese bar, hushpuppies and soft biscuit. The Progress Notes dated 1/18/19 at 9:48 p.m. revealed the nurse entered Resident #1's room to administer medications. Resident #1 complained of a sore throat, speech within normal limits lung sounds diminished throughout, continues on oxygen at 3 Liters and no signs of distress. The Progress Notes dated 1/18/19 at 10:45 p.m. revealed the nurse received a call from Resident #1's family member asking the staff to check on Resident #1. The nurse entered Resident #1's room. Resident #1 had the phone in his/her hand attempting to call family member. Resident #1's family member called and talked to Resident #1. The Progress Notes dated 1/18/19 at 11:15 p.m. revealed Resident #1's family member arrived at the facility and went to Resident #1's room. A few minutes later Resident #1's family member asked the staff why they didn't call him/her. The family member asked the staff for a copy of Resident #1's medication list and the address and phone number of the facility. The family member then wheeled Resident #1 in the wheelchair by the nurse's station with no indication of where Resident #1 was going or why Resident #1 was leaving the facility. The Progress Note dated 1/19/18 at 1:47 a.m. revealed the staff called the emergency room and the emergency room staff reported Resident #1 intubated due to [MEDICAL CONDITION] and transferred to another hospital to an intensive care unit. An interview on 2/12/19 at 2:49 p.m. the family member reported he/she and another family member visited Resident #1 after supper and then left the facility. The family member reported Resident #1 was fine during the visit. Around 8:00 p.m., the family member received a call from Resident #1. The family member reported Resident #1's words were slurred and he/she could only understand Resident #1 saying hospital. The family member called the facility and asked the nurse to check on Resident #1. The family member then called Resident #1's room and could hear the nurse and then the phone disconnected. The family member drove to the facility to check on Resident #1. The family member reported Resident #1 was struggling to breathe. The family member called 911. The Medic Emergency Medical Services final report dated 1/18/19 revealed the medics arrived to the facility at 11:27 p.m. for a report of difficulty breathing. Resident #1 sitting in the wheelchair with swelling in the face and tongue only. Resident #1 unable to speak due to swelling. No visible rash noted. The family reported Resident #1 began swelling 10 minutes prior to calling 911. The family reported Resident #1 allergic to shellfish, but not any medications. The Emergency Department Physician Notes dated 1/18/19 at 11:40 p.m. revealed Resident #1 had mild respiratory distress, moderate tongue swelling, drooling and speech obstructed by tongue. Resident #1 received [MEDICATION NAME] 25 milligrams, [MEDICATION NAME] 20 milligrams and Solu-[MEDICATION NAME] 125 milligrams intravenously. Resident #1 received endotracheal intubation. The notes revealed a differential [DIAGNOSES REDACTED]. Resident #1 transported to another hospital to an intensive care unit. The Hospitalist History and Physical dated 1/19/19 at 3:10 a.m. revealed Resident #1 admitted Intensive Care Unit intubated for airway protection and sedated. In an interview on 3/5/19 at 11:36 a.m. the Hospitalist reported an allergy to Losartan is very rare. The Hospitalist reported it's even more unlikely as Resident #1 was on Losartin for several months. The Hospitalist reported he/she would look for other causes and when asked, stated was not aware Resident #1 possibly ate shrimp. The Hospitalist reported a shellfish allergy can cause [MEDICAL CONDITION], the same as any other food allergy. An interview on 2/12/19 at 11:17 a.m. Staff I (Cook) reported he/she followed the planned menu. Staff I could not remember what he/she served Resident #1. Staff I reported Resident #1's diet card had the shellfish allergy listed. Staff I could not recall what alternate he/she prepared that evening. Staff I reported he/she did not obtain a temperature on an alternate meat dish that evening. During an interview on 2/7/19 at 2:08 p.m. Staff G (Nurse Aide) reported he/she thinks Resident #1 received shrimp for supper. Staff G reported there was not an alternate that night. Staff G asked Staff I (Cook) what the alternate was and Staff I reported there was not one. Staff G reported he/she saw Resident #1's family arrive. Staff G went over to Resident #1 and observed Resident #1 ate 100%. Staff G reported Resident #1 had breaded popcorn shrimp. During an interview on 2/7/19 at 2:32 p.m. Staff H (Nurse Aide) reported an alternate was not served. Staff H reported everyone received shrimp. During an interview on 2/27/19 at 9:22 a.m. Resident #8 reported if he/she gets a headache from eating raw shrimp. Resident #8 reported he/she can eat a few cooked shrimp and it doesn't bother him/her. Resident #8 reported several weeks ago the staff served him/her small breaded shrimp for supper. Resident #8 ate the shrimp and it didn't bother him/her. Resident #8 did not know if there was an alternate that night. Resident #8 reported he/she just eats what the staff serve. The facility abated the Immediate Jeopardy on 1/20/19 by educating the facility staff. The In-Service Education sheet dated 1/20/19 revealed all facility staff received training on residents with food allergies, inspecting trays prior to serving, preparing food for residents with allergies and the location of resident allergies on the tray card.

Based on record review, observations and staff interviews, the facility failed to timely assess and provide appropriate care and services to pressure ulcers and failed to provide timely interventions to prevent the development of avoidable ulcers, promote healing and prevent infection (Residents #1, #3, #4, #6 and #7). The sample consisted of 8 residents and 7 of the 8 residents had pressure ulcers. The facility identified a census of 56 residents. Findings include: 1. Review of the Admission Record for Resident #6 identified an admission into the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, with a reference date of [DATE], identified Resident #6 had an admission into the facility from the hospital. The MDS identified the resident had memory problems and moderately impaired for daily decision making. The MDS indicated Resident #6 required total staff assistance with bed mobility and transfers. The MDS identified the resident had an indwelling catheter (tube in the bladder to drain urine into a bag) and experienced frequent episodes of bowel incontinence. The MDS indicated the resident came to the facility with 2 Stage II pressure ulcer. The MDS assessment identified the following definitions for staff to follow regarding types of pressures: Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III is a full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. The slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is a full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable-Slough and or eschar and cannot assess the wound bed. The Initial Plan of Care #1 in use on [DATE] directed the staff to provide mobility with a walker to a wheelchair, an indwelling catheter, independent with eating, hair and nail care by staff, provide a bed bath, and provide physical and occupational therapy. The Braden Scale for Predicting Pressure Sore Risk Original, dated [DATE] at 3:20 p.m. identified the resident had a score 14. A score of l4 represented the resident had a moderate risk for the development of pressure ulcers. The Initial Nursing Assessment (Admission) dated [DATE] at 3:20 p.m. indicated Resident #6 needed to be admitted due to being post-surgery. had drowsiness, a temperature of 101.1 degrees Fahrenheit (normal is 98.6), pulse 81 (normal ,[DATE]), respirations 20 (normal ,[DATE]) and blood pressure ,[DATE] (normal). The assessment indicated the resident as agitated and drowsy. The resident had an indwelling catheter, chair fast (cannot bear own weight, must be assisted into chair), slides down in chair or bed and does not lift up completely during move. Resident #6 had an incision to the right hip with staples present, some discoloration to the right hip, skin tear to the right elbow and a purple area noted on the right side of the leg next to the perineal area (the assessment did not identify pressure ulcers). The Progress Note dated [DATE] at 10:00 a.m. indicated the resident continued to have fevers of various temperatures since admission. The note indicated the resident had a temperature of 100.3, pulse 92, respirations 18 and blood pressure ,[DATE] (normal). The note at 5:27 p.m. indicated the staff placed a pillow boot on the right foot and a heel riser placed on the bed. The resident used an abductor pillow (to keep legs from crossing). The Progress Note dated [DATE] at 12:41 p.m. identified the resident continued with physical and occupational therapies. The resident continued to be confused and the resident ' s urine was negative for a urinary tract infections. The resident would be getting out of bed tomorrow. The Progress Notes dated [DATE] 1:54 p.m. identified the resident had a new onset/change in skin integrity as evidenced by an ulcer. Resident #6 had an open area on the left side of the coccyx and a blister on the right heel. The physician (facility medical director) was notified at 2:00 p.m. The Progress Notes dated [DATE] at 9:20 a.m. indicated the resident had no temperature today and the resident ' s lung sounds were clear. The Progress Note dated [DATE] at 11:12 a.m. revealed the Medical Director visited Resident #6 at the facility. The Medical Director documented Resident #6's skin had normal temperature, tone, texture, no rashes, [MEDICAL CONDITION] or ulcers. Review of the October and [DATE] Treatment Record identified the staff documented the first treatment to the coccyx and right heel on [DATE] (pressure ulcers first identified 11 days ago). The November Treatment Record had a treatment dated [DATE] for Duoderm to the coccyx and buttocks and to change every three days and [MEDICATION NAME] to each heel twice a day. Review of the Skin Integrity Reports for Resident #6, revealed a sheet for the left buttock, a sheet for the right buttock, a sheet for the sacrum and a sheet for the coccyx. The sheets had assessments for [DATE] to [DATE]. Resident #6 discharged to the hospital on [DATE]. The sheets revealed the wound as a Stage II. Review of the Skin Integrity Reports revealed Resident #6 had two sheets for the right heel with assessment dates of [DATE], [DATE], [DATE] and [DATE] on one sheet and the other sheet had dates on [DATE], [DATE] and [DATE]. Resident #6 discharged from the facility on [DATE]. One sheet had an initial wound date of [DATE] and the other sheet had a date of [DATE]. Both sheets had assessments on [DATE]. One sheet had measurements of 6.0 centimeters (cm) length x (by) 8.0 cm width. The other sheet had measurements of 11.0 cm length x 11.5 cm width. The sheets identified the wound as Stage II. The Wound Clinic visit dated [DATE] identified Resident #6 had an unstageable pressure injury obscured full thickness skin tissue loss pressure ulcer to the coccyx. The area measured 14.5 centimeters (cm) length x 12.0 cm width x 2.5 cm depth. The wound had adipose tissue exposed, the periwound (perimeter around wound) had signs and symptoms of infection and tan eschar present. The Wound Clinic visit dated [DATE] identified Resident #6 had an acute deep tissue pressure injury to the right heel. The pressure ulcer had persistent non-blanchable deep red, maroon or purple discoloration. The area measured 11.0 cm length x 13.0 cm width x 0.1 cm depth. No signs or symptoms of infection noted. The heel was debrided. The physician noted Resident #6 [MEDICAL CONDITION] with fever. The physician contacted the emergency department for expedited care. The History and Physical documentation dated [DATE] the resident received Acne (antibiotic and Tylenol along with 3 liters of intravenous fluid in the emergency department. The report indicated the physician ordered the resident to be admitted into the hospital due [MEDICAL CONDITION] from a large sacral decubitus ulcer (pressure ulcer). Resident #6 admitted to the hospital with [REDACTED]. The Certificate of Death filed on [DATE] identified Resident #6 died on [DATE] at 10:05 p.m. The immediate cause of death [MEDICAL CONDITION] due to or as a consequence of decubitus ulcer. On [DATE] at 1:29 p.m. Staff A (Rehab Director) was interviewed and stated Resident #6 was not able to follow commands. Staff A reported Resident #6 did not get out of bed for therapy until [DATE]. Staff A stated the resident got out of bed on [DATE] and used the parallel bars. Staff A stated she saw a large blister located on the right foot on [DATE]. On [DATE] at 12:48 p.m. Staff E (Licensed Practical Nurse) was interviewed and Resident #6 was not getting out of bed when he/she first admitted to the facility. Staff E reported when the staff note a skin issue they notify Staff B (Wound Nurse). Staff B then looks at the area and obtains a treatment order. Staff E reported Staff B doesn't always get to it and Staff B has to be told several times. Staff E went to the Director of Nursing with concerns about Staff B not getting an order for [REDACTED].>On [DATE] at 6:41 p.m. Staff F (certified nursing assistant) was interviewed and stated Resident #6 did not get out of bed till physical therapy got him/her up. Staff F worked with Resident #6 on [DATE], [DATE], and [DATE]. Staff F reported Resident #6 did not have an open area on his/her buttocks at the time of admission. Staff F reported Resident #6 had a blister on his/her heel on admit. Staff F reported this to a nurse. Staff F reported Resident #6 constantly moved the right leg and kicked the heel protectors off. On [DATE] at 11:54 a.m. Staff G (Registered Nurse) was interviewed and stated she completed the initial care card for Resident #6. Staff G reported Resident #6 had a abductor pillow. Staff G stated she never puts heel protectors or float the heels on the care card. Staff G reported Resident #6 did not get out of bed. Staff G reported Resident #6 had skin breakdown because he/she was not turned and repositioned. Staff G noted the skin breakdown on [DATE] and told Staff B (Wound Nurse). Staff G stated she put a heel riser in place on [DATE]. Staff G stated she put a dry dressing on Resident #6's buttocks and changed it daily and Staff B did not get a treatment. Staff G reported weeks went by and Staff B did not do anything. Staff G asked Staff B about getting a treatment 4 to 5 times. Staff B told Staff G she would get to it. Staff G was concerned and talked to the Director of Nursing. Staff G reported the charge nurses do not obtain treatments for wounds. The wound nurse takes over when a resident has a skin issue. Staff G received an order for [REDACTED]. On [DATE] at 1:45 p.m. and 2:01 p.m. the Director of Nursing was interviewed and stated the charge nurse completes a weekly skin check during the resident's bath. Any new or old concern is documented on the weekly check. On [DATE] a skin check was completed by Staff E. Staff E did not note the area on Resident #6's heel and buttocks. The Director of Nursing stated the staff are to notify Staff B when they note a new skin condition. Staff B looked at the area and obtained a treatment order. If Staff B is not in house, then the charge nurse obtains a treatment. On [DATE] at 2:12 p.m. and 4:35 p.m. Staff B (Wound Nurse) was interviewed and stated the charge nurse informed her of skin issues. Staff B reported she looks at the area right away and obtains an order for [REDACTED].#6 was admitted . Staff B stated she saw the areas but did not chart it. Staff B stated she waited to get an order for [REDACTED]. The surveyor showed Staff B the Treatment Record with no treatment till [DATE]. Staff B stated she completed assessments on [DATE], [DATE] and [DATE]. Staff B reported she did not check the Treatment Record prior to completing an assessment. Staff B stated she placed a dry dressing on Resident #6's coccyx and [MEDICATION NAME] on the heel. Staff B stated she completed the treatments without a physician's orders [REDACTED].#6 and did not complete late entries. Staff B reported skin assessments were misplaced and she made duplicate assessment sheets. Staff B did not know the date the assessments were rewritten. An interview on [DATE] at 8:52 a.m. the emergency room Physician reported Resident #6's family reported Resident #6 had a bowel movement at the nursing home and it was not cleaned up. This contributed to the infection. The facility could have done a much better job. The facility could have provided prompt care and it would not have been so severe. The Physician could tell it advanced quickly. The physician identified the pressure ulcer as Stage IV. On [DATE] at 8:59 a.m. the Wound Clinic Physician was interviewed and stated she saw Resident #6 one time at the Wound Clinic. The Physician recalled looking at Resident #6's wounds and being appalled. The wounds were infected; Resident #6 had a temperature, had [MEDICAL CONDITION] (low blood pressure) and needed immediate treatment. The physician had Resident #6 transported to the emergency department. The physician did not know how the wounds could be that bad unless Resident #6 was on his/her back the whole (entire) time. On [DATE] at 2:40 p.m. the facility Medical Director was interviewed and stated she received a fax from the facility on [DATE] which informed her of the area on the coccyx and heel. The Medical Director stated she faxed the facility back and informed them Resident #6 needed to be seen on rounds. The Medical Director alternated weekly visits at the facility with a Nurse Practitioner. The Medical Director did not know if she saw Resident #6 at the facility. 2. According to the Admission Record dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, with a reference date of [DATE], identified Resident #1 had severe cognitive impairments, and verbal and other behaviors. Resident #1 had total dependence on staff for all activities of daily living. Resident #1 had range of motion impairments bilaterally on the upper and lower extremities. The MDS revealed Resident #1 had 2 Stage III pressure ulcers. The current Care Plan and initiated on [DATE], identified the resident had the potential for skin breakdown related to contractures, impaired sensation, moisture/excessive perspiration, limited mobility and a history of breakdown. The interventions directed the staff to cleanse hands with soap and water daily and dry thoroughly, encourage to consume all meals, monitor for nonverbal signs of pain related to wound, monitor for skin breakdown, refer to restorative therapy, schedule orthopedic appointment, weekly skin assessments, The Braden Scale for Predicting Pressure Sore Risk dated [DATE] identified Resident #1 scored a 12. A score of ,[DATE] revealed the resident to be a high risk. On [DATE] at 12:45 p.m. the Director of Nursing (DON) was interviewed and stated Resident #1 had an open area on the right thumb and the first finger in June of 2016. The DON reported the area healed [DATE]. The area opened again [DATE]. The [DATE] Treatment Record identified the staff placed a folded wash cloth in the right palm through the web of the first finger every shift An interview on [DATE] at 1:03 p.m. the Director of Nurses reported the [DATE] Restorative Nursing records could not be located. The [DATE] Treatment Record revealed the staff placed a folded wash cloth in the right palm through the web of the first finger every shift. The [DATE] Restorative Nursing Record sheet revealed the staff provided passive range of motion to both hands 22 out of 31 days. The sheet directed the staff to perform activities for 15 minutes or more each day. The [DATE] Treatment Record indicated the staff placed a folded wash cloth in the right palm through the web of the first finger every shift. The sheet identified the treatment was discontinued on [DATE]. The [DATE] Restorative Nursing Record sheet revealed Resident #1 did not receive passive range of motion exercises from [DATE] to [DATE] when the area opened. Review of the Treatment Administration Record for August and [DATE] identified the facility had a folded wash cloth in the palm of the right hand through the web of the thumb and over the first finger. The staff checked the placement three times a day. The Skin Integrity Report revealed Resident #1 developed a Stage III pressure sore on the right thumb on [DATE]. The Skin Integrity Report assessment dated [DATE] identified Resident #1 had a Stage III pressure ulcer to the right thumb that measured 0.4 cm length x 0.3 cm width. The facility did not provide an assessment of the other pressure ulcer. The Wound Clinic noted dated [DATE] revealed the Stage III pressure ulcer to the right medial anterior thumb measured 0.9 centimeters (cm) length x 0.3 cm width. The Stage III pressure ulcer to the right second finger measured 2.0 cm length x 0.8 cm width x 0.2 cm depth. On [DATE] at 11:10 a.m. Staff A (Rehab Director) reported Resident #1 received therapy from [DATE] to [DATE] for the right hand contracture. Staff A reported Resident #1 had a wound on the right hand at that time. Staff A reported Resident #1's contracture count not be measured due to the severity. Staff A reported a wash cloth could fit in Resident #1's hand to allow separation. Staff A reported the wound was due to pressure. Resident #1 did not have a hand splint in the last 3 years. Staff A reported a splint would have prevented the contracture from getting worse and preserved Resident #1's skin integrity. Staff A reported Resident #1 was discharged from therapy on [DATE] due to behaviors. Therapy made a recommendation for restorative program for stretching exercises. An interview on [DATE] at 12:45 p.m. the Director of Nurses reported she planned to look into a splint to prevent the area from breaking down again. 3. According to the Admission Record dated [DATE] Resident #4 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed moderate cognitive impairments. The MDS revealed Resident #4 totally dependent on the staff for bed mobility and transfers. The Initial Plan of Care directed the staff to reposition Resident #4 if necessary every two hours to relieve pressure, weekly head to toe skin assessments, encourage to get out of bed as tolerated and pressure relieving devices as ordered and hospice care. The Braden Scale for Predicting Pressure Sore Risk Original dated [DATE] revealed Resident #4 scored a 16. A score 15 - 18 revealed a mild risk. The Progress Note dated [DATE] at 3:15 p.m. revealed Resident #4 had a pressure ulcer to the buttock area. The Progress Note revealed the physician was notified at 5:00 p.m. The Skin Check dated [DATE] revealed Resident #4 had a new pressure area to the buttock area. The assessment did not include measurements or staging. Review of the October Treatment Administration Record revealed no treatment to the area on Resident #4's buttocks. The electronic order dated [DATE] revealed an order to apply barrier cream to the buttocks and coccyx as needed for broken down skin. An interview on [DATE] at 9:46 a.m. Staff B (Registered Nurse/Wound Nurse) reported on [DATE] she was informed by the Director of Nurses that all residents needed assessed including hospice residents. Staff B reported he/she thought that the hospice nurse was assessing Resident #4's open area. Staff B reported she completed the first assessment on [DATE]. Staff B did not obtain a treatment order. Staff B reported Resident #4 did not like to lie down. The staff allowed Resident #4 to sit up in the chair. An interview on [DATE] at 1:40 p.m. Staff D (Hospice Registered Nurse) reported Resident #4 was bed bound towards the end of life. Staff D reviewed the hospice notes and reported there was no documentation of the buttock wound. Staff D reported each time he/she visited Resident #4 was lying on his/her back. Staff D never observed Resident #4 on his/her side. An interview on [DATE] at 12:36 p.m. the Director of Nurses reported Staff B (Wound Nurse) is having a difficult time getting used to the facility documentation system and protocols. The DON reported the staff notify Staff B when they identify a wound. If Staff B is not in the facility the nurse notifies the physician and obtains an order for [REDACTED]. 4. According to the Admission Record dated [DATE], Resident #3 had an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] revealed Resident #3 had no cognitive impairments. Resident #3 had total staff dependence for activities of daily living. The MDS assessment identified the resident at risk for pressure ulcers but had no pressure sores. The Care Plan dated [DATE] identified the resident had an actual skin breakdown and at risk for further breakdown due to decreased mobility and awareness. The interventions directed staff to use a heel riser, turn and reposition, educate and monitor with skin checks. The Braden Scale for Predicting Pressure Sore Risk Original sheet dated [DATE] revealed Resident #3 scored a 16. The sheet indicated a 16 as mild risk for pressure ulcers. The Progress Note late entry dated [DATE] at 11:22 a.m. identified a skin check performed and the staff found an open blister on the resident ' s right heel. Review of the September and [DATE] Treatment Record indicated the facility started a treatment to the right heel on [DATE] (14 days later). The [DATE] Treatment Record directed the staff to cleanse the right heel with wound cleanser daily and apply a 4 X 4 gauze square and Kerlix (gauze roll). The Skin Integrity Report indicated the facility had weekly skin assessments of the right heel starting [DATE] (2 months from identification). The assessment dated [DATE], identified a Stage II pressure ulcer to the right heel. The area measured 3.5 centimeters (cm) length by 4.2 cm width by 0.3 cm depth. The heel had a moderate amount of serosanguineous (blood and serous) drainage. The Wound Clinic initial encounter dated [DATE] indicated an assessment of the right heel. The heel had a Stage IV pressure injury that measured 3.2 cm length x 4.8 cm width x 0.4 cm depth with tendon and adipose tissue exposed. No signs or symptoms of infection present. A culture of the wound was obtained and the wound was debrided the note indicated the resident had a level 4 throbbing pain on a scale of ,[DATE]. The resident stated the [MEDICATION NAME] relieved the pain. The resident informed the clinic; she/he received a heel protector this morning from the facility. On [DATE] at 7:52 p.m. and [DATE] at 12:25 p.m. the Director of Nursing (DON) was interviewed and stated Staff C (Registered Nurse) noted Resident #1 had an open area on the heel on [DATE]. Staff C did not complete a change of condition skin assessment. The DON reported Staff C did not contact the physician for a treatment. The DON reported a treatment was not started till [DATE]. The DON reported the resident went to the hospital on [DATE] and returned on [DATE] and went to the hospital again on [DATE] and returned [DATE]. The DON reported the treatment was overlooked when Resident #3 returned from the hospital on [DATE]. The DON reported the facility did not initiate weekly skin assessments until [DATE]. The DON reported Staff B began as wound nurse the second week of [DATE]. The DON reported the staff received an order for [REDACTED]. The Wound Clinic notes dated [DATE] indicated Resident #3 had a Stage IV pressure ulcer to the right heel. The area measured 3.5 cm length x 5.5 cm width x 0.7 cm depth. The notes revealed tendon, bone and adipose exposed. On [DATE] at 6:58 a.m. Staff B was observed measuring the right heel pressure ulcer. Staff B incorrectly identified the ulcer as a Stage II. Staff B reported the heel measured 3.5 cm length x 5.0 cm width. Staff B did not measure the depth. The resident stated she/he obtained the wound from lying in bed here. The resident stated when first got here, she/he was in bed and could not move self in bed very well. On [DATE] at 2:22 p.m. the Medical Director was interviewed and stated on [DATE] to be the first time she had been informed of the heel pressure ulcer. The Medical Director stated this was the date of the order for Duoderm (moisture retentive dressing) to be placed on the heel. 5. According to the Admission Record dated [DATE], Resident #7 had an admission date of [DATE]. admitted to the facility on [DATE]. The admission MDS assessment, with a reference date of [DATE], identified Resident #7 had cognitive moderately impaired decision making. Resident #7 required extensive assistance of one staff with bed mobility and transfers. The MDS identified the resident had an unstageable pressure ulcer. The facility had pressure relieving devices for the chair and bed and had a turning/repositioning program. The resident received nutrition and hydration interventions to manage skin problems. The initial Plan of Care #2 dated [DATE], included and directed the staff to reposition if necessary every two hours, keep skin clean, dry and free of irritants and pressure relieving devices as ordered. The Progress Noted dated [DATE] at 5:54 p.m. revealed Staff B noted Resident #7 had a dark purple area on the sacrum that measured 1.8 centimeters (cm) length x 9.0 cm width. Resident #7 also had an area on the left heel 2.0 cm length x 1.0 cm width and 1.0 cm length x 1.0 cm width. Resident #7 had an area on the right that measured 1.3 cm length x 4.2 cm width. Dressings applied to all areas. The Hospice Skin assessment dated [DATE] identified Resident #7 had a coccyx wound that measured 10.5 (cm) length x 4.5 cm width. The assessment revealed the wound possibly a Kennedy ulcer (develops when nearing death and rapidly declines). A [MEDICATION NAME] dressing applied to the area. Resident #7 also had Stage II blisters to the left and right heel. A [MEDICATION NAME] dressing applied and heels elevated. Collaboration regarding the plan of care reviewed with Staff B at facility. The Hospice Physician order [REDACTED]. Review of the [DATE] and [DATE] Treatment Records indicated Resident #7 had a treatment initiated to both heels and the coccyx on [DATE] (18 days from the hospice physician order). The Braden Scale for Predicting Pressure Sore assessment dated [DATE] indicated Resident #7 scored a 12. A score of 10 - 12 revealed a high risk for pressure ulcers. The Skin Pressure Ulcer assessment dated [DATE] at 11:00 a.m. revealed Staff B noted a untraceable deep tissue injury to the sacrum and heel. The Skin Integrity Report dated [DATE] revealed Resident #7 had a Stage II pressure ulcer to the sacrum that measured 1.8 centimeters (cm) length x 9.0 cm width. The Nursing Assessment - Initial (Admission) identified Resident #7 had a bruise to the right antecubital space and a bruise to the top of the right foot/ankle. On [DATE] at 12:37 p.m. Staff E (Licensed Practical Nurse) reported she admitted Resident #7 to the facility. Staff E completed Resident #7's admission nursing assessment within two hours of arrival to the facility. Staff E reported she checked Resident #7's coccyx and heels and did not note any issues. On [DATE] at 1:14 p.m. Staff D (Hospice Registered Nurse) was interviewed and stated she was present on admission. Staff D reported Resident #7 had a bruise on the coccyx that had the shape of a butterfly. Staff D reported the area opened on [DATE] and hospice wrote a standing order for [MEDICATION NAME] dressing to change every 7 days. Hospice delivered the order to Staff B (Wound Nurse). Staff D reported Hospice does not recommend dry dressings. Staff D stated that hospice follows a written protocol for wound care. On [DATE] at 1:11 p.m. and 2:13 p.m. the Director of Nurses (DON) was interviewed and stated Resident #7 had all three areas on admission to the facility. The DON reported that hospice did not want any treatment to the areas. The DON stated the treatment on [DATE] did not get transcribed on the Treatment Record. The DON reported a treatment was not initiated until [DATE]. The DON could not locate the order. The order was written on the Treatment Record by Staff B (Wound Nurse). The policy and procedures titled Skin Integrity Management identified the purpose is to provide safe and effective care to prevent reoccurrence of pressure ulcers, manage treatment and promote healing of all wounds. The policy directed the staff to review pre-admission information to plan for the resident's needs on admission, complete a comprehensive assessment on admission to the facility and complete a risk evaluation on admission and identify resident's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment intervention Note: At the time of the complaint investigation, the complaint was coded at a K, a pattern of immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the E level. On [DATE], the Director of Nursing completed body skin check of all residents, notified physicians if needed. By [DATE] the Care Plans were updated. The Director of Nursing re-educated all licensed nursing staff on [DATE] about assessment, staging and documentation of skin integrity alterations. An outside wound care service provided education to all nursing licensed staff regarding assessment and documentation on [DATE]. On [DATE], the Administrator held a QA (Quality Assurance) meeting with the performance improvement team to review the policy/procedure for skin care. As of the [DATE] exit conference, the facility needed to · Re-educate licensed staff that are on a leave of absence, FMLA, and or vacation prior to returning to work. · Newly hired licensed nursing staff will be educated on the assessment, staging and documentation of altered skin prior to their first job assignment. · Continue to monitor resident's skins to ensure the facility policy and procedures for skin integrity management is followed. · Continue to monitor the residents with pressure ulcers, to ensure there is an improvement of healing and no infection. · Continue to monitor the physician's orders [REDACTED].

Based on observation, record review and staff and resident interviews, the facility failed to prevent the development of a heel pressure ulcer and failed to provide services to promote healing for 1 of 2 residents reviewed (Resident #1). The facility identified a census of 53 residents. Findings include: 1. Resident #1 admitted to the facility on [DATE]. Resident #1 had an admission MDS (Minimum Data Set), dated 12/9/15. The MDS identified the resident required extensive assistance of 1 staff for bed mobility, transfers, toilet use and limited assistance of 1 staff for personal hygiene. The resident showed no behaviors. Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 15, a score of 15 indicated the resident had intact cognitive status. The MDS showed the resident at risk for developing pressure sores and had the following treatments in place; pressure reducing device on the bed and chair, a nutrition/hydration intervention in place to manage skin problems and application of ointments/medications other than to feet. The MDS showed there was no turning/repositioning program for the resident. The resident currently did not have skin issues or pressure ulcers. The resident was morbidly obese. Review of the undated Initial Plan of Care directed the staff to provide routine skin care. The care plan initiated 1/6/2016 (which was after the identification of left heel ulcer) indicated that Resident #1 had an actual skin breakdown related to impaired sensation and informed refusal to aspects of care. The goal was for the heel to decrease in size. Some of the interventions listed on the careplan directed staff to float heels while in bed, provide wound treatment as ordered and provide pressure reduction to left heel as ordered by the physician. Review of The Braden Scale for Predicating Pressure Sore Risk forms revealed the following information: a. On 12/9/15, Resident #1 had a score of 17 which indicated a mild risk for development of pressure sores. b. On 12/23/15, Resident #1 had a score of 15 which indicated a mild risk for development of pressure sores. Review of Resident #1's Progress Notes dated 12/27/15 at 2:07 p.m. revealed a facility nurse noted a 6 centimeter (cm.) diameter fluid blister with blue coloration to the left heel. A Physician's Telephone Order dated 12/28/15 directed staff to offload (keep pressure off the heel) and monitor the resident's left heel. A Progress Note dated 1/6/16, showed a new order for the left heel pressure area, apply skin prep to the area every shift for 14 days and re-evaluate. The Treatment Administration Record (TAR) dated December 2015 failed to show any documentation of off loading and the monitor of the left heel pressure sore. The TAR failed to identify any preventative measures for skin cares. The TAR's for January 2016 showed to off load and monitor the left heel every shift and apply skin prep every shift. The TAR's for April 2016 staff applied a pillow boot to left heel while in bed starting April 1st. A change of treatment included to apply [MEDICATION NAME] every shift to the left heel and continue with the Allevyn dressing to the buttocks. The TAR's for May 2016 showed no wound cares for the left heel until 5/14/16. Starting 5/14/16 staff applied a thick layer of Santyl ointment and covered the wound every day. The right buttock showed a treatment to apply Allevyn every 3 days and as needed for 14 days and re-evaluate. The Weekly Pressure Ulcer Assessment showed the following for the left heel: - 12/31/15 (no assessment completed for the initial wound date of 12/27/15) showed a stage 2 pressure ulcer with 6 cm. by 6 cm., with no depth, and a wound base color of pink. The current treatment noted off loading. - 1/7/16 showed a stage 2 pressure ulcer with 6 cm. by 6 cm., with no depth, and a wound base color of pink. The current treatment noted off loading and skin prep. -1/14/16 showed a stage 2 pressure ulcer with 6 cm. by 6 cm., with no depth, and a wound base color of bluish-purple. The current treatment noted skin prep every shift. - 1/21/16 showed a stage 2 pressure ulcer with a length of 5.8 cm., width of 5.40 cm., no depth, and a wound base color of bluish-purple. The current treatment noted skin prep every shift. A Progress Note dated 3/5/16 showed skin prep applied to bilateral feet and the area had not changed and continued to have a large black pressure ulcer to the left heel. The assessment showed eschar which indicated an unstagable pressure ulcer, not a Serous blister or a blood blister as shown on the Skin Integrity Report. The Skin Integrity Report for weekly measurements dated 2/4 through 4/8/16 of the left heel showed a stage 2, decreasing in size of the pressure ulcer with no depth. The report showed the appearance as a serous blister until 3/31/16 and 4/8/16, where it showed an appearance of a blood blister. A Skin Pressure Ulcer report (via computer) dated 4/14/1,4/28/16, 5/5/16, and 5/12/16 identified the heel ulcer as unstageable. The MDS assessment with a reference date of 3/24/16 indicated the resident at risk for pressure ulcers and had a stage 2 pressure ulcer, showing eschar. The MDS assessment tool described eschar as black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges. The MDS indicates an unstagable ulcer as slough and/or eschar which is known but not stainable due to coverage of wound bed by slough and/or eschar. The MDS failed to identify the pressure ulcer as unstagable, which a sore with eschar is unstagable. The assessment failed to identify any measurements. The resident continued to have a pressure relieving mattress on the bed and chair but did not have a turning/repositioning program. The treatment did show pressure ulcer care. The Resident's Care Plan dated 1/6/16 identified the resident had skin breakdown related to impaired sensation and refusal to aspects of care. The approach directed the nursing staff to float heels while in bed and provide pressure reduction to left heel as ordered by the physician. A Progress Note dated 4/1/16 (after an initial wound date of 12/27/15) showed a new order received for pillow boot while in bed, remove for skin check every shift. Apply skin prep every shift for 14 days and re-evaluate. Observation on 5/16/16 at 1:50 p.m. revealed the resident transferred to bed by staff. Staff F, Certified Nursing Aide (CNA) removed the gripper sock to the left heel. The left heel had no dressing on, exposing the pressure ulcer. The pressure ulcer showed a large, approximately 3 cm. by 3 cm. dark brown eschar. The ulcer had slight amount of yellowish drainage. A slight separation showed on the outer edge of the eschar. Staff applied a big blue boot to the resident's left foot. The resident remarked they just started an ointment treatment. The resident also remarked the heel hurts some. Observation on 5/16/16 at 2:46 p.m. showed Staff H, Licensed Practical Nurse (LPN) performing wound cares. Staff H cleansed the left heel, applied Santyl ointment, covered with a [MEDICATION NAME] pad and wrapped with gauze, secured with tape. Observation during the day on 5/17/16 showed the resident with a dressing on the left heel laying directly on the metal foot rest from breakfast time until placed in bed at 1:30 p.m. The left heel had no pressure reduction present. An interview on 5/16/16 at 2:50 p.m., Staff E, LPN, Nurse Practice Educator, Wound Care Nurse, reported the area started as a blister, seen on weekly skin checks. Staff E reported the resident dug heels onto the floor while self propelling in the wheelchair in gripper socks. The resident did not have shoes. When showed the Skin Reports, asked why the report showed a stage 2 ulcer while the ulcer showed eschar. Staff E replied it should have been documented as unstagable. When asked when did the eschar start, Staff E, didn't know. An interview on 5/17/16 at 3:30 p.m. the Director of Nursing (DON), Registered Nurse (RN) reported the resident did not cooperate with therapy, got confused, and had a lot of behaviors when first admitted . The resident would refuse to get out of bed. The DON noted those behaviors were not reflected in the progress notes. She believed the resident obtained the pressure ulcer from self propelling in the wheelchair with the feet onto the floor, wearing gripper socks. The DON reported of being unsure if the pressure ulcer could have been prevented as the resident had many issues with [MEDICAL CONDITION], diabetes and being uncooperative. An interview on 5/18/16 at 7:05 a.m. the MDS Coordinator, reported of starting the position in February of this year and the resident had the pressure ulcer at that time. She reported if a resident had diabetes, obesity, [MEDICAL CONDITION] and at moderate risk for developing pressure ulcers should have the weekly skin checks, skin checks with showers twice a week, and maybe wear fleece boots. An interview on 5/18/16 at 8:10 a.m. the resident reported the left heel wound hurts about 75% of the time. The resident remarked it is a mild pain most of the time. An interview on 5/18/16 at 1:35 p.m. the DON reported Diabetic residents need more than weekly skin checks. A resident with diabetes, [MEDICAL CONDITION], and obesity could have had worn diabetic socks (compression socks that breathe). Floating heels in bed is routine care and should have been done. The DON noted the Progress Notes don't show the heels were floated. The resident probably could have used a heel raiser and were now ordering one for the resident. The DON noted they should have done more for the resident, especially if the Braden Score had dropped. An interview on 5/18/16 at 210 p.m., Staff G, LPN, reported of floating the heels for the resident and commented they do that for all residents while in bed. An interview on 5/18/16 at 3:30 p.m. Staff J, LPN, reported what ever cares where done for the resident's pressure wounds would be found on the resident's TAR's.

Based on record review, observations, resident and staff interviews and review of the facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards in the environment and failed to provide safe transfers for 2 of 3 residents reviewed (Resident #1, #4). The facility reported a census of 58 residents. Findings include: 1. According to the physician's visit sheet dated 1/21/15 Resident #1 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment with a reference date of 12/2/15, indicated Resident #1 had no cognitive impairments. Resident #1 required extensive assistance of two staff with transfers. The BIMS (Brief Interview for Mental Status identified the resident had a score of 15. A score of 15 indicated the resident had no cognitive problems. The Care Plan updated on 12/2/15 identified the resident had a problem with self- care deficits. The approaches directed the staff to transfer Resident #1 with two staff members and a gait belt to the wheelchair. The resident needed to encourage the resident and not getting up very much due to current illness. The resident had a history of [REDACTED]. The RMS Event Summary dated 2/4/16 at 6:00 p.m. reflected the staff transferred Resident #1 from the recliner to the bed. The staff reported Resident #1 bumped his/her knee on the bed and said ouch. The staff stopped the transfer and went to get the nurse. The nurse checked the left leg and did not observe any redness, bruising or deformities. The nurse administered Tylenol. During cares the next morning Resident #1 complained of the left leg hurting. The nurse notified the physician who ordered to send Resident #1 to the emergency room for an evaluation. The Final Report x-ray dated 2/5/16 revealed an oblique fracture of the left tibia and fibula (lower leg bones). The Major Injury Determination Form dated 2/5/16 indicated the physician determined Resident #1 sustained a major injury. The February 2016 MAR (Medication Administration Record) indicated Resident #1 received Acetaminophen 325 milligrams (2 tablets) by mouth at 12:00 a.m. and 8:00 a.m. The nurse sent the physician a facsimile dated 2/5/16. The resident voiced complaints of alot of pain in the left knee and reported he/she hit knee on the bed yesterday. The knee had swelling, sensitive and cool to touch. The Progress Note dated 2/5/16 at 6:52 p.m. (late entry for 2/5/16) indicated the staff called the nurse to Resident #1's room. Resident #1 complained of knee pain. Resident #1 reported he/she hit the knee on the bed. An interview on 2/16/16 at 9:27 a.m. Staff D (nurse aide) reported she went in the room and told Staff C how to transfer Resident #1. Staff D reported he/she uses a technique he/she calls the fire hydrant transfer. Staff D reported Resident #1 is assist of two for transfers but he/she always transfers Resident #1 by him/herself. Staff D reported Staff C stood in front of Resident #1 and lifted Resident #1 up and immediately put Resident #1 back in the chair. Staff D stepped in and transferred Resident #1 to the bed using the fire hydrant technique. Staff D reported she did not use the gait belt. An interview on 2/16/16 at 4:27 p.m. Staff C (nurse aide) reported he/she asked Staff D how to transfer Resident #1 to bed. Staff C reported he/she stood in front of Resident #1 and grabbed the gait belt and stood Resident #1 up. Resident #1 complained of pain and Staff C immediately sat Resident #1 down. Staff C thought he/she did something wrong. Staff D told Staff C he/she did not do anything wrong. An interview on 2/17/16 at 9:48 a.m. Staff J (charge nurse) reported he/she could not remember if Resident #1 was in the bed or recliner when he/she was called to the room by the staff. An interview on 2/17/16 at 12:37 p.m. the Director of Nurses (DON) reported Resident #1 required one staff for transfers. The DON could not locate the Care Card from Resident #1's room. The DON reported the Care Plan was incorrect. On 2/16/15 at 11:04 a.m. Staff K (nurse aide) was interviewed and stated she worked the overnight shift and she asked Resident #1 what happened to his/her leg. Resident #1 told Staff K that the staff bear hugged him/her in order to transfer and banged his/her knee on the bed. An interview on 2/22/16 at 4:17 p.m. the Assistant Director of Nurses (ADON) reported the care card could not be located that was in Resident #1's room. The ADON reported he/she looked at the care card on 2/4/15 or 2/5/15 and recalled it directed to transfer Resident #1 with one staff. The ADON verified the care plan updated 6/18/15, 9/17/15 and 12/2/15 all directed to transfer Resident #1 with two staff. On 2/4/15 around noon the ADON was in the room to get Resident #1 out of bed before a planned power outage. Resident #1 had an air mattress. Staff H delivered a room tray to Resident #1. The ADON asked Staff H to help transfer Resident #1 to the wheelchair. The ADON and Staff H transferred Resident #1 to the wheelchair and then from the wheelchair to the recliner chair. An interview on 2/17/16 at 8:34 a.m. Resident #1 reported two staff were present in the room but only one staff transferred Resident #1. The girl stood in front of Resident #1 and told Resident #1 to bear hug him/her. The girl stood Resident #1 up and turned sideways and Resident #1's knee hit the bed. Resident #1 heard a cracking sound. Resident #1 told the staff his/her knee hurt. The nurse came in and looked at Resident #1's leg. The policy titled Gait Belt, revised on 1/1/13, directed the staff to instruct the patient to assist by reaching back to the chair arms or bed and pushing off. Do not allow the patient to grasp you (staff) around the neck during transfer. The policy directed the staff to brace the patient's leg just below the knee with the staff's leg. 2. The Admission Record for Resident #4, dated 2/17/16, reflected the resident had [DIAGNOSES REDACTED]. The Minimum Data Set assessment with a reference date of 1/13/16 identified Resident #4 had no cognitive impairments. Resident #4 required extensive assistance of two staff members for bed mobility and transfers. The Care Card (hanging in room) dated 4/29/15 directed the staff to transfer Resident #4 with two staff members and a gait belt. The Care Plan, updated 11/4/15, directed the staff to transfer Resident #4 with assist of one staff members and a gait belt. Observation on 2/17/16 at 4:15 p.m. revealed Staff F and Staff G transfer Resident #4 from the wheelchair to the bed. The staff had a gait belt around Resident #4's waist. Staff G used the gait belt during the transfer. Staff F placed his/her right arm under Resident #4's right arm and lifted Resident #4 from the chair to the bed. Resident #4 stated, that hurt. Staff F did not use the gait belt for the transfer. The policy titled Gait Belt, revised 1/1/13 directed the staff to place both hands on the gait belt reaching around the back of the resident during the transfer.

Based on observation, record review, staff and visitor interviews, and review of video surveillance, the facility staff nurse failed to display respect to Resident #1 when speaking to or caring for them as a constant affirmation of their individuality and dignity as a human being. Resident #1 could make his/her own decisions and obtained a salt shaker. The Care Plan reflected the resident should not have salt on his/her food. The resident and staff nurse had an altercation and the nurse forcefully removed a salt shaker from the resident ' s hand and caused a skin tear. The sample consisted of 11 residents and the facility identified a census of 63 residents. Findings include: 1. Resident #1 had a Minimum Data Set assessment with a reference date of 1/9/09 which identified [DIAGNOSES REDACTED]. The assessment determined the resident to have a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 identified no cognitive impairment. The MDS reflected the resident required extensive assist of staff for transfers, ambulation, dressing, toilet use, and personal hygiene, supervision and set up assist for eating. The MDS revealed the resident used a walker and a wheelchair for mobility and received a therapeutic diet. The resident ' s Care Plan identified a problem for the resident at risk for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] related to insulin dependent diabetes, resident is very non-adherent to diet and snacks that is required to stabilize blood sugars and risk versus benefits have been explained to the resident. The approaches directed staff to encourage adherence to the diet and if indicated, report to the resident's physician if resident is non-compliant as resident is non-compliant with the diet. The Care Plan directed staff to provide the resident with a medium carbohydrate diet, no added salt, low potassium, offer double meats and eggs. The resident ' s Care Plan identified a problem with the resident to be at risk for cardiac distress related to [DIAGNOSES REDACTED]. The approaches included for staff to provide a calm and non-stressful environment. The resident ' s Care Plan identified the resident had a problem with displaying physical and socially inappropriate and disruptive behavior. The approaches directed the staff when the resident becomes agitated or non-compliant, then staff should redirect the resident to a quiet environment and to not argue with the resident. The approaches directed staff to talk with the resident in calm, voice when the behavior is disruptive and unacceptable and remove the resident from the public area. Review of the facility's video surveillance dated 8/24/14, of the facility's north dining room, revealed Resident #1 propelled self in a wheelchair from the dining room table to another table and obtained a salt shaker. Resident #1 then returned to his/her table. The video revealed Staff E, LPN (Licensed Practical Nurse) standing in the common area in front of the nurse ' s station and other staff approached Staff E. Staff then went immediately over to the resident at the table and grabbed at the resident's arm. The video revealed Staff E and the resident, arm wrestled for several seconds and the resident backing up in wheelchair during this time. The video revealed Staff E then had the salt shaker in hand and walked towards the nurse ' s station and set the salt shaker down. The video revealed the resident returned to the dining room table and continued with the supper meal. Review of the Departmental Notes dated 8/24/14 at 6:30 p.m. revealed Nurse Staff E documented the resident as non- compliant about fluid restriction by filling up a large plastic cup of 1000 cc (cubic centimeters) of fluid. The resident gets into the cupboards and gets plastic cups from the south dining room. The resident also gets into the juices in the south dining room during meal times and brings them back to the north dining room for supper and drinks the juice. The resident ate and asked staff member for salt and told no by staff person. The resident proceeded to another table and took the salt shaker from that table and returned to his/her table and poor a lot of salt onto plate of food before Staff E could get to the resident and take the salt away. Staff E documented, continued to try and pry the salt shaker away from the resident's hand and the resident wouldn't give the salt shaker to Staff E. Staff E stated the resident grabbed Staff E with his/her left hand onto Staff ' s right arm and squeezed so hard that it left finger prints and redness on Staff E ' s arm. Review of the Wound Assessment Report, dated 8/25/14, revealed the resident had an altercation with another individual. The resident ' s right hand (top surface) had a skin tear present which measured 3 centimeters by .2 centimeters. The staff notified the resident ' s physician and obtained treatment orders. The staff notified the family of the incident. Review of the Facility Investigation Report dated 8/25/14 at 1:30 p.m. reflected on 8/24/14 at approximately 6:30 - 6:40 p.m. in the north dining room; Nurse Staff E took a salt shaker out of the resident's hand. The resident was discovered to have a skin tear to the right hand from the incident. The report revealed the facility reported the incident to the Department of Inspection and Appeals as required. On 9/10/14 at 3:58 p.m., Staff C, CNA (Certified Nursing Assistant/Certified Medical Assistant) was interviewed and stated Nurse Staff E approached the resident and said to the resident to give the salt shaker to him/her. Staff E told the resident he/she knew they are not to have it. Staff C stated that Nurse Staff E then grabbed the resident's hand that had the salt shaker and attempted to take the salt shaker when a struggle started between the resident and Nurse Staff E. The resident did not want to give up the salt shaker. Staff C stated during this struggle, she told Nurse Staff E to let it go and then a family member in the dining room approached the resident and Nurse E and attempted to separate them. Staff C stated the resident did let go of the salt shaker and Nurse Staff E took it and walked away and the resident went back to table and ate the supper meal. Staff C stated the resident was noted to have a skin tear to the right hand that Nurse E later cleaned it and applied a dressing. Staff C stated Staff E should have approached the resident and salt shaker differently. Staff C stated that staff are aware of the resident being non-compliant, including Nurse Staff E. Staff A stated she did not believe Staff E intentionally meant to hurt the resident. On 9/10/14 at 3:15 p.m., Staff D, CMA (Certified Medication Aide/ Certified Nursing Assistant), was interviewed and stated she was in the dining room vicinity passing medications when the staff told Nurse Staff E the resident had a salt shaker. Staff D stated Nurse Staff E went immediately over to the resident. Staff D stated she heard the resident yelling that he/she wanted the salt shaker for flavoring and Nurse Staff E yelled at the resident. Nurse Staff E informed the resident that he/she was not to have the salt shaker. Staff D stated she saw a family member of another resident get up from where they were sitting and approach the resident and Nurse Staff E and pull them apart. Staff D stated Nurse Staff E had the salt shaker and walked away with it and the resident went back to the table for the supper meal. Staff D continued to pass medications and later that night noted a band aid on the resident's right hand. Staff D stated she had been told Nurse Staff E had scratched the resident. On 9/11/14 at 12:47 p.m., a visitor of another resident was interviewed and spoke of visiting at supper time on Sunday, 8/24/14. The visitor reported seeing Resident #1 looking for a salt shaker and the staff reported this to Nurse Staff E. The visitor stated he saw Nurse Staff E approach the resident in an angry way and reached for the salt shaker which was held in the hand of the resident. The visitor stated Nurse Staff E grabbed the resident ' s arm and dug her finger nails into the resident's arm and attempting to bend the resident's fingers back away from the salt shaker. The visitor stated he approached the resident and patted the resident on the back and instructed the resident twice to give the salt shaker back to the nurse. The visitor stated the resident propelled self in the wheelchair after finishing the meal and he noticed the resident ' s wrist was bleeding. On 9/9/14, the Administrator was interviewed and confirmed Nurse Staff E to be very inappropriate with the resident regarding the salt shaker. The Administrator stated Staff E should have educated the resident on the risk and benefits of being non- compliant. The Administrator identified the resident as capable of making his/her own decisions. Review of the facility written statement of Nurse Staff E dated 8/26/14, revealed she tried to follow the resident's physician orders. Staff E indicated he/she shouldn't have tried taking the salt shaker away from the resident. Staff E documented his/her intentions were to help the resident and not cause a skin tear on the resident (skin). Staff E documented she did not want anything to happen to the resident and she had informed the resident that she only wanted to protect him.