Every finding on record at Jackson Ridge Healthcare Center

Based on observation, document review, and staff interview the staff failed to ensure a safe and homelike environment to address missing or loose floor molding, door frames, and wall scrapes/gouges. The facility identified a census of 62 residents. Findings include:Observations on 8/4/25 at 1:10 PM and 8/5/26 at 12:34 PM of the Unit 2 revealed the following:a. room [ROOM NUMBER] approximately 24 inches of the right lower door frame pulled over one inch out from the wall. b. room [ROOM NUMBER] approximately 14 inches of floor molding pulled away from the wall by the left head of the bed and approximately 16 inches of florr molding pulled away from the wall below the right side of the bed. c. room [ROOM NUMBER] approximately 12 inches of the right lower door frame and approximately 7 inches on the lower left door frame missing with jagged edges. d. room [ROOM NUMBER] approximately 8-9 inches of floor molding missing to the left side of the door frame. e. room [ROOM NUMBER] approximately 16 inches of the right lower door frame and approximately 18 inches of the left lower door frame missing with jagged edges. f. The front wall by the entrance door of the unit below the door code pad had approximately 9 inches of molding missing with a three by two-inch hole in the drywall. g. The back corner of the lounge had an approximate four feet of floor molding missing with numerous white scrapes and gouges in the drywall approximately three feet up from the floor in a two foot by two-foot area. Interview on 8/5/26 at 1:08 PM, Staff B, Certified Medication Aide (CMA) reported they have a [Brand Name Redacted for work orders] System that they logged any maintenance concerns or repairs into the system. She reported she had not recently placed any repairs into the system, but would log the repairs today. On 8/5/26 at 1:52 PM, the Maintenance Director reported he had replaced several of the boards on the lower door frames and the residents or the CNAs ram them with the wheelchair and take them out again. He hadn't looked to see if there was anything that they could do differently. He just replaced them when needed. He didn't know what more they could do, but hadn't looked further at it. He reported they used a [Brand Name Redacted] system to log the maintenance repairs. He would have someone run a list of the maintenance logs since the facility's last annual survey. An 8/5/26 at 1:53 PM, review of the [Brand Name Redacted] Work Order documented the following for Unit 2:a. room [ROOM NUMBER], wall trim coming unglued, created date 2/18/26, completed date 3/28/26.b. room [ROOM NUMBER], broken trim board around door, created 6/16/26, completed 6/16/26.The [Brand Name Redacted] Work Order failed to document where the specific repairs were completed in the identified room/area. The [Brand Name Redacted] Work Orders failed to identify repairs needed for rooms 35, 40, 42, 46, and the lounge in Unit 2. There had been no new work order system log ins to repair room [ROOM NUMBER] since 6/16/26.On 8/5/26 at 2:15 PM, the Administrator stated, in part, they had a hyperlink on their Electronic Healthcare System (EHS) and could document into [Brand Name Redacted work order] system the repairs needed. The expectation was to prioritize the repairs. Anything safety was immediate. She liked everything completed within 24-72 hours of when it was brought to maintenance. They had a lot of residents in wheelchairs that bang into the walls and doors. They had more residents that had the ability to ram into those areas, not knowing their peripherals. Maintenance looked at the rooms quarterly for repairs.

Based on observations, record review, policy review, and staff interviews the facility failed to accurately assess and implement appropriate interventions in a timely manner for skin areas for 1 of 2 residents reviewed (Resident #28). The facility reported a census of 62 residents. Findings include:Review of Resident #28's Minimum Data Set assessment dated [DATE] showed documented he had severely impaired cognitive skills for decision making. The MDS documented the resident had skin tear(s) and 4 venous and arterial ulcers. Resident #28's Care Plan dated 8/25/25 documented he was at risk for alteration in skin integrity related to fragile skin, decreased functionality, and diabetes. The Intervention dated 8/25/25 revealed staff (nurses/CNAs) to inspect resident's skin with cares/showers and alert resident's nurse, who would in turn alert Primary Care Physician of any significant findings. The Intervention dated 8/25/25 revealed, In the event that a skin injury does occur, I need the staff to identify/document potential causative factors and eliminate/resolve where possible. The Care Plan lacked interventions interventions to protect the skin from bumping on the wheelchair.Resident #28's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated July 2026, as well as MAR dated August 2026, lacked documentation of any supplements to support wound healing. On 8/03/26 at 1:09 PM observed Resident #28 with several bruises to the hands and arms. A dressing was noted to the resident's left lower leg lower leg. Resident #28 had several scabbed areas noted on the bilateral legs and on the left elbow area. On 8/04/26 at 9:30 AM observed Resident #28 tried to get up out of his wheelchair, and staff tried to redirect him. He was hitting his legs on the pedals of the wheelchair. On 8/05/26 at 10:05 AM Staff A, Licensed Practical Nurse (LPN) reported she did Resident #28's skin assessments yesterday. She reported she did not measure all the bruises because he had several. She just measured the biggest one. She reported he had been dealing with skin issues since admission in August. On 8/05/26 at 10:10 AM to 10:55 AM, observed Resident #28 tried to get out of his wheelchair and hit his legs on the pedals of the wheelchair. Observation further revealed one of the left lower leg scabs bleeding due to hitting on the wheelchair. On 8/05/26 at 11:00 AM, observed Resident #28's left elbow noted to bleed from one of the scabs. Resident #28's skin assessment dated [DATE] lacked documentation of the scabs noted to the left elbow, and bruises to the bilateral hands and arms (the assessment only noted one to the right hand). On 8/05/26 at 12:43 PM the Director of Nursing reported on shower day once a week the nurses would do skin assessments. If an area opened, it should be measured. If scabbed areas were measurable, they needed to be measuring. For any new skin area needed to notify the physician. Nursing interventions should be put in place. Review of the facility policy titled Skin Condition Assessment and Documentation dated 2025 documented staff were to ensure timely identification, assessment, documentation, monitoring, and communication of all skin conditions, including bruises, skin tears, open areas, abrasions, scabs, rashes, blisters, and other alterations in skin integrity. It further documented the nurses were to initiate interventions and continue to monitor the areas until healed.

Based on observation, record review, staff interview, and facility policy review the facility failed to implement an individualized program for application of a hand splint, failed to care plan for use of a hand splint, and clarify OT recommendations for use of a splint to prevent a potential decrease in range of motion for 1 of 1 resident reviewed with a splint (Resident #57). The facility identified a census of 62 residents. Findings include: Resident #57's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating cognitively intact status. Resident #57 had a diagnosis of cerebrovascular accident (CVA) and hemiplegia or hemiparesis (weakness/paralysis of one side of the body). The MDS indicated Resident #57 had impairment to range of motion on one side of the upper and lower extremity. The MDS revealed Resident #57 was dependent on staff for transfers and personal hygiene. The nursing restorative program documented splint or brace assistance for 7 days. Review of Resident #57's Care Plan revised on 5/14/25 for Resident #57 revealed she needed assist with activities of daily living and functional mobility related to CVA with hemiparesis, weakness, balance deficits and history of falls, which placed her at risk for falls/injury/skin breakdown. The Care Plan lacked interventions for staff to follow regarding a splint or brace to the left hand. The OT Discharge summary dated [DATE] revealed the resident had met the following goal on 9/4/25: Patient to tolerate left upper extremity/hand orthotic times 2 hours without signs/symptoms of skin breakdown to assist with contracture management and maintenance of skin integrity. Prior medical history per the Discharge Summary noted, in part, CVA with left sided hemiplegia. The Discharge Recommendations and Status section of the OT Discharge Summary revealed the resident had a restorative program established. Restorative splint and brace program established. Referred restorative nursing for orthotic schedule. The discharge summary failed to have directions for left hand splint for Resident #57. Review of the Physician Order Summary report dated 6/11/26 failed to reveal an order for splint for Resident #57 for splint or brace to left hand. The Documentation Survey Report V2 for July and August 2026 revealed a Splint/Brace Assistance Program Goal: Resident #57 will maintain current range of motion of left hand to promote skin integrity for handwashing every shift 6AM-6PM. The report did not have a created or effective date. On 8/03/26 at 2:35 PM observed Resident #57 in her room in her wheelchair. The resident watched television. Resident #57 did have splint on her left hand and she stated they did help her put this on daily. On 8/04/26 at 8:34 AM Resident #57 at breakfast. The resident did not have a splint on her left hand and fingers curled. Resident #57 ate breakfast independently with her right hand. On 8/04/26 at 12:41 PM observed Resident #57 in the main dining room ready to eat lunch. Her left hand continued to not have her splint in place. At 12:45 PM observed splint sitting on top of dresser in Resident #57's room. On 8/04/26 at 1:30 PM during an interview with Resident #57, she said staff must have forgot to put the splint on today. The resident further explained occasionally they will forget to put it on in the morning, but normally she wore it everyday. She did not refuse the splint. She stated her hand did get swollen and she had pain in her left hand and the splint helped with it. No splint currently on her left hand, and the left hand was larger than her right hand. On 8/04/26 at 3:28 PM Resident #57 lay in bed with her eyes closed. She had a splint on her left hand. On 8/05/26 at 8:02 AM and 12:31 PM, Resident #57 in the dining room and had a splint on her left hand. On 8/06/26 at 8:29 AM Resident #57 observed in the dining area in her wheelchair. The resident sat at the table with drinks in front of her. No splint observed on her left hand. On 8/06/26 at 9:04 AM, Staff K, OT stated per the discharge summary, Resident #57 had a resting hand splint that would go on overnight. The splint would be the restorative program. Staff K would make a recommendation to the restorative nurse and then would do it in writing. Staff K reported there should be record of it somewhere. She stated the splint was supposed to be on at night. Resident #57 was wearing a splint related to status post CVA, and it was preventative for hand contracture, skin integrity, and range of motion. Staff K acknowledged she had the staff put that type of brace on overnight so it did not impact activities of daily living, wheelchair mobility ,and dignity when out of the room. Staff K confirmed the splint should be worn at bedtime and off in the AM. On 8/06/26 9:10 AM Staff L, Certified Restorative Nurse Aide (CRNA) explained they got therapy recommendations from the therapist, they write up an order, and nursing put it in the computer. Then, restorative aides got a copy. She searched her book and stated did not have a paper order for Resident #57. She had range of motion passive to the left side, and right side was depending on the resident. Staff L revealed Resident #57 had a splint for left hand and it went on in the night and came off in the morning. Typically the nurses put it on and then when Staff L came in the morning, would take it off her hand. The days Staff L didn't work, then it will be the other restorative aide. Sometimes Staff L had seen it on during the day, if Staff L see it during the day, would take it off and do range of motion. She explained the Certified Nursing Aide (CNA) didn't take it off or put it on that Staff L was aware of. On 8/06/26 at 9:24 AM Staff I, Registered Nurse (RN) checked her electronic health record (EHR) for Resident #57 and revealed the splint for her left hand did not come up for orders. She stated there was usually orders for splints or how would Staff I know what needed to be done. Staff I revealed Resident #57 wore it at night and during the day, and it depends on her and what she wanted. Staff I checked the EHR and stated it should be on at bedtime and remove in AM. Staff to complete skin check pre and post orthotic application or removal. Staff L stated sometimes Resident #57 wanted it on during the day, and the resident had told Staff I she doesn't have pain when she had the splint on. On 8/06/26 at 9:36 AM the Director of Nursing, RN, (DON) revealed she was aware of a left hand splint for Resident #57. The DON stated the last the DON knew, it was applied at night and then it got moved to days. The expectation for staff was to put orders in the electronic health record and it would say CNA or restorative. That was how they tell if it was their job. She stated they should have a physician order for a splint, it would be the recommendation from therapy, and then the physician would be aware of it. The DON revealed she would expect them to follow what was in the EHR, what the restorative nurse put in, and what therapy recommended. She also noted it should be on the care plan. The facility provided an undated policy titled Restorative Nursing Program Policy: Splint and Brace Management which directed residents receiving restorative splint or brace services shall receive care according to physician orders, therapy recommendations, and/or the individualized care plan. The policy revealed to obtain a physician or licensed practitioner (therapist recommendation) order prior to initiating splint or brace use. The therapy recommendations shall specify: type of device, wearing schedule, application instructions, removal schedule, skin monitoring requirements, cleaning instructions and precautions. The Policy further revealed to apply according to manufacturer's instructions and/or therapy recommendations.

Based on observation, clinical record review, policy review, and staff interview the facility failed to perform hand hygiene prior to gloving, failed to keep catheter supplies on a clean barrier, failed to ensure the catheter bag drain tube did not contact the graduate when emptying, and failed to keep catheter bag tubing from contacting the floor for 1 of 1 resident sampled (Resident #40). The facility also failed to follow up on a urinalysis (UA), Culture and Sensitivity (C & S) laboratory results for six days, and failed to monitor vital signs and for urinary tract infection (UTI) symptoms while UA results were pending for Resident #40. The facility identified a census of 62 residents. Findings include:Resident #40's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating a severe cognitive loss. Resident #40 utilized an indwelling catheter for a diagnosis of obstructive uropathy. The Care Plan dated 2/2/26 documented Resident #40 had an indwelling catheter related to obstructive uropathy. The Care Plan directed the staff to maintain enhanced barrier precautions (EBP) per the Centers for Disease Control and Prevention (CDC) guidelines. The Care Plan failed to direct staff to keep the urinary (catheter) drainage bag tubing off the floor. A Progress Note written by Staff A, Licensed Practical Nurse (LPN), dated 7/10/26 at 6:11 AM documented Resident #40's catheter leaking with no urine output in the urinary drainage bag. Attempted to irrigate and would not go in. The old catheter was removed and a new catheter inserted easily. Urine returned readily. A Physician Order dated 7/13/26 documented to change the 18 French Coude (a urinary drainage tube with a curved or bent tip) with a 10 cubic centimeter (CC) balloon as needed. A Nurses Note dated 7/31/26 at 6:20 PM documented by Staff H, Registered Nurse (RN) revealed Resident #40 with dark tea colored urine with a foul odor. The on-call physician gave a new order for a urinalysis (UA). A Nurses Note dated 7/31/26 at 10:17 PM written by Staff H documented, urine specimen collected and the specimen sent to the lab. A Unit 2 Communication Sheet dated 8/2/26 documented Resident #40's UA, C &S results were faxed to the doctor with vital signs - temperature 97.3, pulse 68, respirations 20, blood pressure 125/73. Resident #40's Nurses Notes and vital signs record lacked documentation of the vital signs in the medical record. Observation on 8/3/26 at 12:08 PM revealed Resident #53 pulled Resident #40 back from the dining room table as he sat in the wheelchair. Resident #40 had over 5 inches of his catheter bag tubing dragging along the floor. Staff A, LPN diverted Resident #53 away from Resident #40. Resident #40 remained seated in the wheelchair at the table waiting for his lunch tray. He rocked back and forth in the wheelchair as he stepped on and rolled the catheter tubing with his right foot that lay directly on the floor. Staff A and Staff B, Certified Medication Aide (CMA) continued to walk by the resident to the service window and take meal trays out to residents without addressing the catheter tubing on the floor. Observation on 8/3/26 at 1:55 PM revealed a CDC EBP sign in Resident #40's bathroom that directed staff to clean their hands, including before entering and when leaving the room. Providers and Staff must also: wear gloves and a gown for high contact activities which included care of urinary catheters. Further observation revealed a graduate inside a plastic bag on top of a three-drawer plastic bin that contained personal protective equipment (PPE, i.e. gowns/gloves).On 8/4/26 at 1:04 PM Resident #40 sat in the wheelchair in the dining room with his right foot on top of the catheter bag tubing which lay in direct contact with the floor. Staff C, RN sat approximately 15 feet away. At 1:06 PM, Staff B sat down in a chair by Resident #40 but failed to address the catheter bag tubing on the floor. At 1:09 PM, Resident #40 was observed seated at the dining room table with his right foot on top of the catheter bag tubing which was in direct contact with the floor. At 1:10 PM Staff C went up to Resident #40 to deliver a card from a family member. She failed to address the catheter tubing in direct contact with the floor. Staff B continued to sit on Resident #40's left side and work with another resident. Observation on 8/4/26 at 1:33 PM revealed Staff D, Certified Nursing Assistant (CNA) and Staff B walked down the hallway toward Resident #40's room. Staff B pushed a standing lift down the hallway into Resident #40's room. Staff B and D applied gloves without performing hand hygiene. Staff D opened a drawer on the plastic bin and removed two isolation gowns, handing one to staff B. Both staff proceeded to open, and then put on, the gowns. Staff B and D assisted Resident #40 to transfer with the standing mechanical lift from the wheelchair to the bed. Staff D stood at the head of the bed and Staff B stood at the foot of the bed. They assisted Resident #40 to lay in bed with Staff D's gown contacting the side of the mattress and bed frame. Staff D placed two paper towels on the floor, then placed the graduate on the paper towels. She proceeded to squat down and placed the alcohol preparation pads and a paper towel on the lower front of her isolation gown. Staff D unclamped the urinary bag drain, emptied the urine from the bag touching the drain twice to the side of the graduate, then rested the drain against the upper rim of the graduate. Staff D repeatedly wiped the end of the drain with a paper towel that had been sitting on the bottom of her isolation gown. She rested the drain on the upper rim of the graduate as she opened the alcohol preparation pad then cleansed the drain. Staff D dumped the odorous, tea-colored urine into the toilet.On 8/05/26 9:45 AM Staff E, LPN stated she sent a UA last Friday due to Resident #40's odorous, tea color urine. The catheter tubing should be tucked in the privacy bag, not on the floor. If the tubing was in contact with the floor, she would expect the staff to sanitize the tubing and tuck it back inside the privacy bag. On 8/5/26 at approximately 10:00 AM the Director of Nursing (DON) reported she would try to get a copy of Resident #40's UA report. On 8/5/26 at 10:28 AM Staff F, CNA explained they were to wash hands before putting on gloves. They had to place all items to empty the catheter bag on a clean barrier. When queried more specifically on emptying into the graduate, Staff F voiced the catheter bag drain should not touch the sides of the graduate when emptied. Staff F further explained had to hold the drain in the middle when you drained the bag.On 8/5/26 at 10:37 AM Staff G, CNA/CMA reported when a resident was on EBP, staff should wash hands right before put on a gown and gloves. All catheter items had to be placed on a clean barrier like a towel or a paper towel, and when emptied the catheter bag, the drain should be placed in the center so it doesn't hit the sides of the graduate. On 8/5/26, review of Resident #40's UA with C & S dated 7/31/26 showed greater than 100,00 Colony Forming Units (CFU) per Milliliter (ML) of Proteus mirabilis (a Gram-negative bacterium that commonly causes complicated catheter-associated urinary tract infections). The time stamp documented the UA was received by the hospital lab on 8/1/26 at 7:33 AM. The C &S was reported on 8/03/26 at 8:26 AM.Review of Resident #40's Nurses Notes and Temperature, Pulse, Respiration, Blood Pressure, and pain Vital Sign Records from 7/31/26 to 8/4/26 lacked documentation of any assessment or monitoring of UTI symptoms while his UA, C & S were pending. Review of the Progress Notes for the same date lacked documentation of vital signs. A Nurses Note dated 8/5/26 at 12:45 PM written by Staff E documented she called the physician's office regarding the UA results. The office nurse reported the office did not receive the results. Staff E re-faxed the UA, C & S results to the office. A Physician Prescription sent on 8/5/26 at 2:06 PM documented a physician order for Amoxicillin-Pot Clavulanate 875-125 Milligrams (MG) Oral Tablet twice a day, for a 7 day supply.On 8/5/26 at 2:55 PM the Infection Preventionist explained she expected handwashing to be completed prior to applying gloves for EBP. Staff should have kept the catheter bag drain away from the sides of the graduate when emptying. There would have been cross contamination with the tubing on the floor. Staff should clean off the tubing with alcohol and place the tubing back in the privacy bag, if seen. She further reported the nurses should have followed up sooner on the results of the UA. Interview on 8/5/26 at 3:02 PM the Director of Nursing (DON) verbalized she expected staff to wash their hands before applying gloves. Clean supplies should not have been placed on the isolation gown. The catheter bag drain should not hit the sides of the graduate when emptying the urinary bag. The staff needed more education. A Progress Note dated 8/05/26 at 7:30 PM written by Staff A documented a new order for an antibiotic for UTI for 7 days. On 8/06/26 at 10:34 AM Staff A reported when they sent a UA to the hospital, they usually got the results back the same day or the next day. The hospital lab would send the UA reports to the facility and the doctor's office. The weekend did affect the UAs, pending which fax number the hospital faxed. She would call the next day to follow up on the lab if she didn't hear anything back. It was not normal for it to take six days to get a UA addressed. She worked Unit 2 on Monday (8/3/26) and nothing had come through report that Resident #40 had a UA sent. Staff A further verbalized she didn't know why Resident #40 had a UA sent. They reported resident labs through shift to shift reports and they used a communication sheet. At 10:44 AM, Staff A reviewed the communication book, report sheets, and only found a communication sheet for 8/2/26 which documented Resident #40's UA, C&S had been sent to the clinic. She stated she couldn't find any other report sheet from 7/31/26. They generally checked a resident's temperature and monitored for signs of a UTI when a UA went to the lab. On 8/06/26 at 10:49 AM, Staff I, RN explained the UAs went to the hospital laboratory. They got a preliminary report pretty quickly, the same day or the next day. The preliminary report got sent by the hospital laboratory to the provider's office as well, so they did not do anything. They just held on to the preliminary UA report. The C&S results could take longer. If they did not see anything in a few days, then they called the Provider. Staff I verbalized it shouldn't take six days for a resident to get a UA addressed and put on antibiotics. They communicated resident labs through the shift report or in the electronic medical record communications. Staff I checked the electronic communication records from 7/31/26 to 8/5/26 and stated she didn't see anything in the communications regarding Resident #40. On 8/06/26 at 10:55 AM the Infection Preventionist reported once a UA was received, they would send it to the physician's office. If it was not addressed, then they would call the physician's office. If the nurses didn't get a response after the UA results were faxed to the office, then the nurses should have called to follow-up. If the UA looked concerning, they should call the Provider. If a UA had been sent to the lab, she would expect the nurses to check vital signs and assess for urinary symptoms of a UTI and follow up with the doctor. It should not take 6 days to follow up with the Provider. During an interview on 8/06/2026 at 10:59 AM, the Director of Nursing (DON) reported she did not have an answer for why it happened and why it was not followed up on. The UAs were to be followed up on when they come in. She would expect the nurses to take vital signs, watch urine output, behaviors, and monitor for typical symptoms of a UTI. The Catheter Care-Urinary Catheter Drainage Bag Policy, undated, directed to perform hand hygiene and apply gloves. The Policy further revealed to position the drainage bag below the level of the bladder, avoid allowing the drainage spout to touch the cylinder, toilet, floor or any other surface, open the drainage spout, and empty urine directly into the cylinder. Clean the spout with alcohol and close the drainage spout after the bag has been emptied. The policy failed to address the use of a clean barrier for supplies. The Lab Orders Policy, undated, provided by the facility documented the facility shall ensure that all laboratory tests are ordered, collected and tracked, reviewed, communicated and acted upon in a timely manner to promote resident safety, quality of care, and compliance with federal and [State] regulations. No laboratory result shall remain unreviewed or without appropriate follow-up. The Policy documented all laboratory orders shall be entered into the electronic health record. The charge nurse or designee shall monitor pending laboratory results daily. Missing or delayed results shall be investigated promptly with the laboratory. Nursing staff shall review incoming results for abnormal findings requiring immediate action. Nursing Staff shall notify the provider promptly for significant abnormal results requiring treatment or further evaluation. The Policy further directed pending urine cultures shall be tracked until final results are received. Positive cultures shall be communicated to the provider for evaluation.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure that records including dishwashing, refrigerator, and food temperatures logs were consistently documented, completed, and monitored. The facility reported a census of 58 residents.Findings include: On 5/28/26 at 1:00 PM, observation revealed that the facility lacked documentation of appropriate sanitizing of the dishwashing machine, and food and refrigerator temperature logs. Review of the Dishwashing Record, Low-Temperature/Chemical Log for May 2026 indicated staff were instructed to report in parts per million (ppm) is less than (space left blank) ppm. Report if temperature is less than (space left blank) Fahrenheit. The following dates failed to have any temperature or chemical sanitization ppm documented:a. All three meals on: 5/2/26, 5/3/26, 5/11/26, 5/17/26, 5/22/26, 5/25/26, 5/29/26, 5/30/26, 5/31/26.b. Lunch and Dinner meals on: 5/10/26, 5/16/26, 5/24/26, and 5/28/26.c. Dinner meals on: 5/1/26, 5/4/26-5/9/26, 5/13/26-5/15/26, 5/18/26-5/20/26, 5/26/26-5/27/26. Review of the Food Temperature log for May 2026 revealed the following dates and meals lacked documentation of food temperatures taken:a. Lunch meal on: 5/18/26 and 5/19/26 b. Dinner meal on: 5/17/26, 5/22/26, 5/27/26, and 5/28/26c. Breakfast and lunch meal on 5/26/26 Review of the Refrigerator/Freezer logs for May 2026 revealed the following dates failed to have the temperatures recorded:a. 5/26/26, 5/29/26, 5/30/26, and 5/31/26. On 6/3/26 at 11:17 AM, Staff A, Dietary Aide, confirmed the expectation of the staff was to take the dishwashing machine temperatures/sanitizing strip checks at breakfast, lunch, and dinner meals and record on the Dishwashing machine log. On 6/3/26 at 11:17 AM, Staff B, Cook, confirmed the expectation of the staff was to take food temperatures at all meal times and to record on the food temperature log. On 6/3/26 at 3:53 PM, the facility Administrator confirmed the expectation of the staff was to do the food temperatures and dishwashing machine temperature/sanitizing strip checks and record/document on the log sheets. The Low-Temperature Dishwasher Policy, undated, documented the purpose was to ensure that all dishes, utensils, cookware, and food-contact surfaces are properly cleaned and sanitized using the low-temperature machine in compliance with health department regulations and food safety standards, and to record the results on the Dishwasher Log each meal. The Food Temperature policy, undated, documented that the temperatures of the food items will be taken and properly recorded by the cook. These temperatures will be recorded on the food temperature log.

Based on clinical record review, staff interview, and facility policy, the facility failed to provide professional standards of quality by not following physician orders for blood sugars to be completed upon admit for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 58 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated severely impaired cognition. Resident #2 was able to be understood and understood others, and had no behaviors. Per the MDS, the resident admitted to the facility on [DATE] from a short term general hospital. The resident required substantial to maximal assistance with toileting, transfers, dressing, and personal hygiene. The MDS included diagnoses of heart failure, diabetes mellitus, non-Alzheimer's dementia, and depression. The Care Plan initiated 7/29/25 indicated Resident #2 had diabetes mellitus that was managed with diet control and injectable hypoglycemic medications. The interventions included, part, the following: I need staff to administer my diabetes medication as ordered the doctor, and to monitor/document for side effects and effectiveness (intervention date 7/29/25). I need the staff to obtain Blood Sugar checks as ordered by the doctor, and alert my primary care physician (PCP) to any significant findings/trends (intervention dated 7/30/25).The Order Summary Report signed and dated by the Primary Care Provider on 7/17/25 instructed to check blood sugars twice a day for diabetes mellitus.The Medication Administration Record (MAR) dated 7/1/25-7/31/25, instructed staff to check blood sugars twice a day for diabetes mellitus. Review of the July MAR, revealed blood sugars were not checked on 7/17/25 at 9:00 PM, and on 7/18/25 at 8:00 AM and 9:00 PM. On 6/3/26 at 1:45 PM, the facility Director of Nursing (DON) was not able to explain why the blood sugars were not checked upon admit with Resident #2 and that the expectation of the staff was to follow the physician's orders as written and the facility policy/procedure. The Physicians Orders Policy dated 3/25, revealed that the purpose was to ensure that all physician orders were accurately received, verified, implemented, documented, monitored, and followed in a timely manner to promote resident health, safety, and quality of care in accordance with federal regulations, and facility standards. The Policy further noted, Physician orders shall be carried out accurately, completely, and within the time frame specified by the ordering practitioner .New orders received as a result of monitoring shall be implemented without delay.

Based on observation, document review, clinical record review, policy review, and staff interview, the facility failed to serve the Dietician approved menu for 5 of 5 residents receiving a pureed diet. (Residents #1, #8, #19, #43, #46). The facility identified a census of 59 residents. Findings include: An untitled document provided by the facility on 6/23/25 documented Residents #1, #8, #19, #43, and #46 on pureed diets. A 6/24/25 Week Two Dietician approved Menu for Tuesday documented the following puree menu: a. Beef cube pepper steak, 1 serving (4 ounces (Oz.) b. French onion rice, 1 serving (4 Oz) c. Buttered peas, #12 scoop d. Seasonal fresh fruit, 1 serving Observation on 6/24/25 at 10:42 AM Staff A, [NAME] reported the facility had five residents on pureed diets and she planned to puree five servings of each item. Staff A placed five, 4 Oz. servings of peas into the Avamix blender, adding 1 ¼ cups milk to blend the mixture. She poured the mixture into a large measuring cup and reported the total volume as 2.5 cups. Staff A utilized the Pureed Diet Portion Sizes/Scoop Chart and stated the serving size was a #8 scoop. Staff A covered the steam pan with two servings of peas with foil and wrote peas #8 on top. During an observation on 6/24/25 at 10:52 AM Staff A placed 5 servings of beef cube pepper steak into the Avamix blender, added 1 cup milk and blended. She reported the total volume of the mixture as 3.5 cups. Staff A utilized the Pureed Diet Portion Sizes/Scoop Chart and voiced the serving size as #6 slightly heaping (SH) scoop. Staff A covered both steam pans with foil and label one steam pan unit, meat #6 SH and the other pan East, meat #6 SH. Observation on 6/24/25 at 11:04 AM Staff A placed five, #8 (4 Oz.) servings of French onion rice into the Avamix blender, added 1 ½ cups milk for volume and blended. Staff A reported the total volume of the mixture as 4 cups. She utilized the Pureed Diet Portion Sizes/Scoop Chart and verbalized the serving size as two #10 scoops. Staff A covered both steam pans with foil and wrote, unit, rice, #10 x 2 on one pan and East, rice, #10 x 2 on the second steam pan. Observation on 6/24/25 at 11:52 AM revealed Staff A served a #6 scoop of beef cube pepper steak, portion under the rim of the #6 scoop (not heaped) and one #10 scoop of the French onion rice to Residents #8, #19, and #43. At 12:31 PM Staff A served Resident #46 a #6 non-heaped scoop of beef cube pepper steak and one #10 scoop of French onion rice. At 12:33 PM Staff A plated a #6 non-heaped scoop of beef cube pepper steak with bits of blacked, burned pieces on top after scraping the steam pan; placed a half of a #10 scoop of French onion rice with dark blackened pieces on the plate and ¼ of a #8 scoop of peas on Resident #1 plate. The plate was served out to Resident #1. A 6/24/25 review of Resident #1 Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 with a significant weight loss (5% or more in the last month or loss of 10% or more in last 6 months) and not on a physician prescribed weight loss regimen. The Electronic Healthcare Record (EHR) revealed Resident #1 went from 129 pounds to 102.5 pounds in six months. On 6/24/25 at 12:50 PM Staff A voiced it was 'her bad.' They had run out of pureed food and that happens a lot. The scoops are weird. She further verbalized she hadn't prepared an extra serving and that was the problem. She got nervous and didn't prepare an extra portion today. Interview on 6/24/25 at 3:05 PM Staff B, [NAME] reported there are five residents on puree diets and she always prepares an extra serving and corrects the pureed total volume to a lower measured level so when she uses the chart it will ensure a larger serving size. She doesn't run out of pureed food. She writes down the puree serving sizes in a notebook and places the correct scoop into each steam pan to ensure she serves out the correct serving size. During an interview on 6/24/25 at 3:15 PM the Certified Dietary Manager (CDM) voiced she expects staff to use heaping measurements for each serving during the puree preparation and to prepare an extra serving to ensure there is plenty of pureed food. Interview completed on 6/25/25 at 4:35 PM, the Consulting Dietician explained the facility prepares the exact number of puree diet portions to the number of residents on pureed diets. She expects the dietary staff to put in a little extra food to accommodate for the loss of food when the food is transferred from container to container during the preparation process. If food runs out during the meal, she would expect the staff to prepare another pureed portion of the menu item. The staff are to follow the approved menu as written. The undated Pureed Process Procedure directed to measure the total volume of the food after it is pureed and divide the total volume of the pureed food by the original number of the portions. See the Puree Scoop Chart. The undated Menu Policy lacked direction to the staff to follow and serve the Dietician approved menu.

Based on observation, policy review, and staff interview, the facility failed to minimize the risk of foodborne pathogens by storing dishes wet; failed to cover food during transport, and failed to maintain proper food temperatures. The facility identified a census of 59 residents. Findings include: Observation on 6/24/25 at 11:08 AM revealed Staff C, Dietary Aide (DA) continually taking wet dishes from the dish rack and placing back in storage. Finally, Staff C removed a glass 8-cup measuring cup and two white spatulas from a dish rack on the clean side of the dishwasher. Staff C hung the measuring cup and two spatulas above the preparation table where Staff A, [NAME] prepared the puree food items for the noon meal. The 8-cup measuring cup observed with water droplets all along the top rim of the cup and the two spatulas had water droplets on the backside of the spatulas which hung touching each other on the rack. Observation on 6/24/25 at 12:44 PM Staff B pushed a cart with Resident #10 and #17 room trays out of the kitchen and down the hallway without covering the fruit bowls. Staff C transported the uncovered fruit approximately 45 feet to Resident #10 room and approximately 90 feet to Resident #17 room. During an interview on 6/24/25 at 12:45 PM Staff A reported all food items are to be covered when transporting food down the hallways to resident rooms. Final food temperatures taken 6/24/25 at 12:46 PM at the completion of meal service revealed the following: a. Mechanical soft beef cube pepper steak 133 degrees Fahrenheit (F) b. Pureed French onion rice 110.2 degrees F A palatability test at 12:50 PM revealed the French onion rice tasted warm at best. Interview completed on 6/24/25 at 12:49 PM, Staff A reported they are required to hold hot foods on the steam table at 135 degrees. An interview conducted on 6/24/25 at 3:05 PM Staff B verbalized hot foods are to be held at 135 degrees on the steam table. All food items have to be covered when transported out of the kitchen. They have plate and lid covers of all sizes to cover glasses and bowls. During an interview on 6/24/25 at 3:16 PM the Certified Dietary Manager explained she has trained the staff to ensure equipment is dry before storing to prevent bacteria from growing on dishes/equipment. She expects all food items to be covered when food is transported back to resident rooms. They have lids to cover all food items for transport. Staff are trained to hold hot food at 135 degrees or higher on the steam table. No food shall be served out to residents if less than 135 degrees. Interview completed on 6/25/25 at 4:35 PM the Consulting Dietician explained she had been with the facility for around two years. She audits the kitchen for sanitation, food preparation, and food temperatures. She couldn't recall if the facility had issues with dish storage on the prior survey, but dishes should always be put away once dry. All food is to be covered when being transported out of the kitchen. The undated Room Tray Policy directed all food and drink would be covered for transport and served at the proper temperatures. The undated Food Temperatures Policy directed all hot food must be served to the resident at the temperature of at least 135 degrees at the time of the resident receiving it.

Based on observation, document review, policy review, and staff interview, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address a previously identified quality deficiency, resulting in a repeated deficiency identified on two consecutive recertification surveys within 10 months. The facility reported a census of 59 residents. Findings include: The Center for Medicare and Medicaid (CMS) 2567 Form from the recertification survey dated 7/29/24 - 8/07/24 documented the facility failed to ensure dishes were dry before storing. The facility Plan of Correction (POC) dated 8/08/24 documented a stop and dry sign was created and hung above the clean storage side of the dishwasher. The Registered Dietician or designee would complete weekly audits for sanitation and drying of equipment. An audit would be conducted for 12 weeks and then reviewed by the QAPI committee for compliance. The facility's current survey 6/23/25 to 6/26/25 resulted in deficient practices regarding the storage of wet dishes in the kitchen. Observation on 6/24/25 at 11:08 AM revealed Staff C, Dietary Aide (DA) continually taking wet dishes from the dish rack and placing back in storage. Finally, Staff C removed an 8-cup measuring cup and two white spatulas from a dish rack on the clean side of the dishwasher. Staff C hung the measuring cup and two spatulas above the preparation table where Staff A, [NAME] prepared the puree food items for the noon meal. The 8-cup measuring cup observed with water droplets all along the top rim of the cup and the two spatulas had water droplets on the backside of the spatulas which hung touching on the rack. During an interview on 6/24/25 at 3:16 PM the Certified Dietary Manager explained she has trained the staff to ensure equipment is dry before storing to prevent bacteria from growing on dishes/equipment. A 6/25/25 8:38 AM observation of the kitchen dishwasher revealed no stop and dry sign on the clean side of the dishwasher. Staff F, Dietary Aide reported she thought there had been a stop and dry sign on the clean side of the dishwasher, but it hadn't been there for some time. Interview completed on 6/25/25 at 4:35 PM the Consulting Dietician explained she had been with the facility for around two years. She audits the kitchen for sanitation. She couldn't recall if the facility had issues with dish storage on the prior survey, but dishes should always be put away once dry. During an Interview on 6/26/25 at 10:10 AM the Administrator reported she oversees the QAPI program. She thought the sign reminding to put dishes away when dry was still hanging by the dishwasher on the dirty side of the dishwasher. Observation 6/26/25 at 10:15 AM with the Administrator revealed a Low Temp Dish Machine Guideline Poster hanging on the dirty side of the dishwasher. Under Daily Warewash Procedures the poster directed staff to allow dishes to drain and air dry in small print. Further interview with the Administrator on 6/26/25 at 10:21 AM revealed, the Administrator, Consulting Dietician, and Staff G, Consultant all assist with doing random kitchen audits which included observation for storage of dry dishes. The process had been run through the QAPI program and the random audits continued. They all work on kitchen audits. Staff C is a newer employee within the past three months and was not involved in the prior kitchen survey. On 2/26/25 at 10:52 AM the Administrator provided Huddle Meeting documentation dated 2/27/25 for Staff C. The Huddle Team Meeting Notes, 2/27/25, Topic Machine Dishwashing directed to never overload the dish racks and to air dry all items. The Huddle Team Meeting notes directed to use the Low Temp Dishmachine Guidelines Poster as a resource. The undated QAPI Plan Policy outlined goals are specific, measurable, actionable, relevant and have a timeline for completion. Methods used to monitor care and services include survey results (2567). The Administrator and QAPI team will analyze the information. The QAPI team will be responsible to monitor and ensure that interventions or actions are implemented and effective in making improvements.

Based on observation, record review, and staff interviews the facility failed to follow a Care Plan intervention for 1 out of 3 residents reviewed with weight loss. (Resident #1) The facility identified a census of 59 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 indicated a Brief Interview for Mental Status (BIMS) score of 2 which indicates severe cognitive impairment. It further indicated diagnoses including: hypertension, non - Alzheimer's Dementia, and cerebrovascular accident. The MDS indicated Resident #1 required extensive assist from staff for transfers, bathing, dressing, and personal hygiene. Resident #1 was independent with eating. The MDS indicated Resident #1 had a weight loss. On 06/23/25 at 12:28 PM to 1:15 PM during a continuous observation Resident #1 ate her dessert and then got up per self and staff assisted back to her recliner in the main lounge area next to the dining area. The regular lunch had not been served yet. Resident drank a glass of milk per self but did not drink the orange drink in front of her. During the meal service no one offered her a plate of food or assisted her back to the table to eat the main part of the meal. On 06/24/25 at 08:08 AM observed Resident #1 at the table in the main dining room with a water glass and 3 cups with liquids in them drinking them independently. Resident attempted to get up per self and staff assisted her to the recliner in the main lounge area. Dietary started serving food at 8:15 AM no one ever offered her a plate of food or attempted to redirect her back to the table for the breakfast meal or brought a tray to the recliner. Review of the Care Plan revealed an intervention dated 12/14/24 which directed staff Resident #1 is independent with intakes of foods/fluid after set-up from the staff. She likes to eat in the recliner in the main lobby of the facility. Resident #1 needs cueing from the staff as she often refuses meals. On 06/26/25 at 09:57 AM Staff H, Certified Nursing Assistant (CNA) regarding Resident #1 when she walks away she goes over to her recliner and we try to redirect and she refuses but then we will give her the drink in her recliner. Then when the food comes out we try to redirect her back to table. We have not tried to set up a tray at the recliner. At least while I have been working, dietary has never brought out the food and put it on an over-bed table. We know what the Care Plan instructs us to do by the kardex in our charting or on the computer in the electronic health record. If there are changes to the Care Plan there is a binder with communication sheets which entails any changes like their transfers or diets. 06/26/25 10:04 AM Staff D, Registered Nurse (RN) stated Resident #1 has supplements we give her at meal times and we give her snacks throughout the day. When she walks away from the table we do try to redirect her. It's kind of hit and miss and they should redirect her back to the table. She has ate some meals at the recliner, we definitely have tried to get her to eat but she will refuse there also. It's more redirection and attempt to give her what she wants to eat. You can look at the kardex or look at it on the electronic health record for her Care Plan. On 06/26/25 at 10:20 AM the Director of Nursing stated she would expect staff to follow the Care Plan. She states Resident #1 refuses the meals we offer and the staff will offer snacks all day long. The facility provided an untitled policy dated 11/17 which directed responsible staff will be informed of the interventions that are identified in the care plan. They will receive notification initially and when changes are made.

Based on observation, policy review, manufacturer's directions for cleaning and disinfection, and staff interview, the facility failed to properly sanitize a blood glucose meter used for multiple residents (Residents #5, #7, and #21). The facility identified a census of 59 residents. Findings include: Observation of the 6/25/25 morning medication administration revealed the following: On 6/25/25 at 7:20 AM Staff D, Registered Nurse (RN) reported there is one blood glucose machine (Assurance Platinum meter) on each medication cart that is used for multiple residents. She voiced there are two residents that share the machine on the East hallway, Residents #5 and #21. Observation on 6/25/25 at 7:22 AM revealed Staff D entered Resident #5 room to perform a blood glucose check. She placed the blood glucose meter, cotton balls, lancet, and alcohol prep pads at the foot end of Resident #5 unmade bed. After applying gloves, she moved the blood glucose machine, alcohol pads, lancet, and cotton balls to the Resident's bedside table without a clean barrier underneath. Staff D pulled a container of blood glucose strips out of her right uniform pocket, opened and placed a strip in the machine. At 7:26 AM Staff D completed the blood glucose check, walked out to the medication cart and placed the blood glucose meter and bottle of strip on top of the medication cart without a clean barrier or disinfecting the items. Staff D wiped down the blood glucose machine with a Sani Cloth in a back and forth motion on each side of the machine, less than 10 seconds, threw the Sani Cloth in the garbage and placed the meter in the medication cart. Interview completed 6/25/25 at 1:34 PM Staff E, Licensed Practical Nurse (LPN) explained they clean the blood glucose meter after each use. They wipe down the machine with a Sani Wipe, throw away the wipe and let the meter air dry on its own. Staff E first stated she didn't think there was a required time to keep the meter wet, then Staff E went to the medication cart, checked the container, and said it is two minutes. On 6/25/25 at 1:50 PM the Infection Preventionist provided a list documenting Resident #5 utilized the blood glucose meter before meals and at hour of sleep; Resident #21 utilized the blood glucose meter twice a day and Resident #7 utilized the blood glucose meter as needed. A 6/25/26 review of Resident #5, #7, and #21 June 2025 Electronic Treatment Administration Record (ETAR) revealed all the resident's had utilized the blood glucose meter. During an interview on 6/26/25 at 8:04 AM the Infection Preventionist explained she expects the nurses to sanitize the blood glucose meter with a Sani Cloth and let it sit in the Sani Cloth for the required wet time, then air dry the meter on a paper towel. The nurses are all required to place blood glucose supplies on a clean barrier in the resident rooms. The Policy for Care of Multi Use Glucometer (Blood Sugar Meter) and Blood Sugar Sampling directed the nurses to cleanse the machine with a manufacturer recommended wipe product and follow the product specifications for use. The Policy failed to address the use of a clean barrier under supplies when completing a blood glucose check. The Super Sani-Cloth Germicidal Disposable Wipe General Guides for Use documented to use a wipe to remove visible soil prior to disinfecting, unfold a clean wipe and thoroughly wet surface, allow treated surface to remain wet for two minutes, let air dry. The Arkray Technical Brief, Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System (BGMS) documented the meter should be cleaned and disinfected after use on each patient. The Brief directed the Cleaning Procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The Disinfecting Procedure is needed to prevent the transmission of blood-borne, pathogens. The Brief Cleaning and Disinfecting FAQ included the cleaning and disinfecting cannot be accomplished with one wipe. Each time the cleaning and disinfecting procedure is preformed, two wipes are needed. One wipe to clean the meter and a second wipe to disinfect the meter. The Brief further documented Cleaning and Disinfecting the blood glucose meter is a high priority as meters are at a high risk of becoming contaminated with blood-borne pathogens such as Hepatitis (inflammation of the liver) B Virus, Hepatitis C Virus, and Human Immunodeficiency Virus (HIV, a virus that attacks the body's immune system). Transmission of these viruses from resident to resident has been documented due to contaminated blood glucose devices. According to the Center for Disease Control and Prevention, cleaning and disinfecting the meters between resident use can prevent the transmission of these viruses through indirect contact.

Based on observation, policy review, resident and staff interviews the facility failed to serve foods that was warm and palatable for 1 of 1 meal services observed. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed diagnoses of anemia, hypertension, hyperlipidemia, thyroid disorder, and dysphagia. During an interview on 7/29/24 at 10:52 AM Resident #32 reported the food is terrible and is not hot enough when the meal is served. Observation 07/30/24 at 11:35 AM dietary Staff A, cook wheeled the steam table to Unit I/Unit II dining area. Staff A, cook recorded food temperatures held in the warming pans of the steam table. The dietary supervisor and consultant dietitian were approximately 5 feet away from the steam table observing. The food temperatures revealed the following: a. Pureed fried rice - 127 degrees Fahrenheit (F) b. Pureed egg roll - 134 degrees F c. Pureed broccoli - 131 degrees F Staff A, cook proceeded to plate 10 meals for Unit 1. The plated meals were covered and placed on a meal tray rack and delivered to the unit. A sample plate was requested. After the last resident meal tray was served, the consultant dietitian tested the food temperatures of the sample plate with the surveyor. The food temperatures revealed the following: d. Broccoli - 116 degrees F e. Orange Chicken - 132.5 degrees F f. Egg roll - 110 degrees F g. Fried rice - 114.1 degrees F At 12:35 PM the steam table was wheeled back to the kitchen to serve residents in the main dining room. A second sample plate was requested to taste the meal. The dietitian again tested the food temperature with the surveyor. The food temperatures revealed the following: a. Broccoli 125 degrees F and tasted cold. b. Fried rice 110 degrees F and tasted cold. During an interview with Staff A, cook on 07/30/24 at 1:22 PM, revealed that she received training on proper food temperatures for serving and was instructed to not serve foods at improper temperature. During an interview with Staff B, dietary supervisor on 7/30/24 at 2:14 PM, reported training is provided at monthly meetings and the expectations are food will not be served at improper temperatures. Staff B, dietary supervisor stated she tries to monitor the food temperatures daily. A record review of the food temperature logs revealed the following: a. 7/8/24 Breakfast protein puree - 132 degrees F b. 7/8/24 Lunch protein puree - 129 degrees F c. 7/8/24 Lunch vegetable puree - 128 degrees F d. 7/9/24 Breakfast protein mechanical soft - 132 degrees F e. 7/9/24 Breakfast protein puree - 124 degrees F f. 7/17/24 Breakfast protein mechanical soft -132 degrees F g. 7/17/24 Breakfast protein puree - 126 degrees F h. 7/18/24 Breakfast protein puree - 124 degrees F i. 7/22/24 Breakfast protein puree - 132 degrees F j. 7/22/24 Lunch protein puree - 132 degrees F k. 7/22/24 Vegetable puree - 128 degrees F l. 7/23/24 Breakfast protein puree - 128 degrees F m. 7/23/24 Lunch protein regular - 128 degrees F An undated facility policy for General Food Preparation and Handling revealed all meats need to be heated throughout to a minimum temperature of 145 degrees F for fish or beef roasts for 15 seconds; 155 degrees F for ground beef and pork for a minimum of 15 seconds, 165 degrees F for poultry and any leftovers.

Based on observation, policy review, and staff interviews the facility failed to demonstrate proper food handling of utensils when serving, allowing dishes, steam table pans, and storage containers to air dry completely, and storing wet wiping cloths in an approved sanitizing solution. The facility reported a census of 47 residents. Findings include: During initial kitchen observation on 7/29/24 at 10:30 AM, observed Staff A, cook removing items from the clean dish rack and did not allow the items to air dry. An 8-inch plastic plate was stacked in a plastic tub near the steam table and 2 clear plastic storage containers (one approximately 6 inches in diameter and one approximately 8 inches in diameter) were stacked on top of other storage containers while still wet. During observation on 7/30/24 at approximately 11:20 AM, Staff A, cook was in the process of preparing pureed items. Staff A, cook had pureed broccoli and rinsed the equipment and placed in the dish rack and slid the dish rack into the dish machine. Staff A went to the hand washing sink, washed her hands, turned the faucet off with her wet hand, turned the dial to dispense a paper towel, dried her hands with the paper towel and went to a drawer where she pulled out 2 towels. She used one of the dry towels to wipe off the stainless-steel prep table. Staff A tossed the 2 towels on the middle shelf of a stainless-steel cart located behind her to her left when standing at the food prep table. She pulled the robot coupe container, blade, measuring container, and spatula from the clean dish rack and carried them to the prep table. Staff A proceeded to puree 6 egg rolls. While the robot coupe was operating she picked up the used towel from the stainless-steel cart and wiped the robot coupe off while it was running. Towel again placed on the middle shelf of the stainless-steel cart next to the unused towel. Staff A, cook scraped the pureed egg roll into a steam table warming pan, covered it and placed it in the steam table. Staff A rinsed the robot coupe canister, measuring cup, and spatula and placed items in a dish rack for washing in the dishwasher. Staff A picked up the same towels, walked over to the sink and used the spray nozzle to wet the towel down. Staff A returned to the prep table and wiped the table down. The towel was then tossed into a 5-gallon bucket of towels under the sink with the spray nozzle. No sanitizing solution bucket was observed in the area during this time. The dietary supervisor and the consultant dietitian were both present during this observation. During observation on 7/30/24 at 12:48 PM, Staff A, cook had scooped fried rice and tossed the scoop into the steam table pan causing the scoop to land entirely in the pan. The scoop was a gray handled #8 size 4-ounce scoop. The handle of the scoop laid in the fried rice. Staff A grabbed the scoop with her bare hand and continued to plate food up for residents in the main dining room. An undated facility policy for General Food Preparation and Handling revealed that staff are to handle utensils, cups, glasses and dishes in such a way as to avoid touching surfaces with which food or drink will come in contact. During an interview on 08/01/24 08:27 AM with Staff B, dietary supervisor revealed there were sanitation buckets available but the staff member did not have one in her area during the observation on 7/30/24. The expectation is for staff members to use the sanitizing solution and towels when wiping off a food prep area. During an interview on 08/01/24 at 8:37 AM with Staff A reported her process for sanitizing the food prep area are to grab a dry towel, wet it down with the spray nozzle at the sink and use it a couple of times before getting a new towel. She was unaware of the sanitizing solution buckets until recently. During a record review on 08/01/24 at 11:37 AM, the facility Sanitation of Dietary Equipment policy lacked direction in sanitizing the food prep area.

Based on observations, policy review, and staff interview the facility call light system failed to alert staff of call light initiated to a central staff work area or directly to a staff member. The facility identified a census of 47 residents. Findings include: On 07/29/24 at 12:36 PM Resident #40 observed in her bathroom, room [ROOM NUMBER], on the toilet by herself, stated she put her call light on but no one came to answer it. The call light has a white and red bulb outside the door to notify the staff the resident had pushed the button. The light outside the room failed to light up even after the surveyor pushed the button in the bathroom. On 07/29/24 at 12:38 PM Staff J, Certified Nursing Assistant (CNA), assisted Resident #40 out of the bathroom she stated the call light is supposed to make a ringing noise at nurses station. This one does not make ringing noise and one other one so we have to make visual checks just for the bathroom due to the call light does not work. On 07/31/24 at 3:37 PM Staff D, Registered Nurse (RN), stated I am primarily in the South Unit (men's unit) so there is no buzzing and we have to watch for them. I am not able to tell you what the East hall has for call lights not all of them buzz. On 07/31/24 at 3:54 PM Staff L, housekeeping supervisor, stated some of them buzz to the nurses station and some of them don't buzz. I don't know why they don't buzz some work and some don't, there are a bunch of boxes on the wall and not sure which ones should be the call lights. The bathroom lights all turn red. She verified room [ROOM NUMBER] bathroom call light does not work. On 07/31/24 at 3:49 PM Staff M, CNA stated the call lights don't all ring to the nurses station or anywhere but they do light up. On 07/31/24 at 3:53 PM Staff G, CNA stated the call lights on East hall only the lower half ring to the nurses station. The rest for East hall do not ring at the nurses station. The South or unit 2 don't ring to central area just light up. There is not a central panel over in the memory care unit that light up. On 07/31/24 at 3:56 PM the Maintenance Supervisor replaced bulb in room [ROOM NUMBER] it worked and then did not, replaced 3 x and it kept burning out. He stated he has a bad batch of bulbs. On 08/01/24 at 12:46 PM Staff L, housekeeping supervisor stated the room that light rings to main nurses station are only rooms 26, 28, 29, 30, 31, 32, & 33 and I am not sure why the sound does not work on any of the rest of them. The South unit has a main panel that lights up but the North unit does not have a panel that lights up or rings to any nurses station. I am not sure when the call lights quit working but they must have at one time because some of them still do work. On 08/01/24 at 1:48 PM the Director of Nursing (DON) stated, I am not aware they were not correctly working I knew a couple did not make noise I was not aware of room [ROOM NUMBER] bathroom not working I would expect staff to let us know as soon as possible if they are not working so we can replace the light. On 08/01/24 at 2:07 PM the Administrator stated the call light system is two bulbs, bathroom and bed side, so they can be pulled both sides East there is a panel that shows the lights outside the door and their is a panel that lights up for the men's unit wing, she confirmed there is no central location for the memory unit and the lower half of the East hall. We looked at the panel and only the one on the lower half of the East hall lit up or alarmed at the nurses station. The facility provided an dated policy titled Call Lights which directed staff to monitor call lights for malfunction and report any problems immediately. Until the necessary repairs are completed, check on resident frequently.

Based on observation, record review, family and staff interview, the facility failed to document the physician and family were notified of 2 of 2 changes in condition (Residents #23 after a fall with skull fracture and #49 after a significant amount of bloody urine returned after an indwelling catheter was inserted). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #23 as cognitively impaired with a BIMS (Brief Interview for Mental Status) of 03 and had the following diagnoses: Coronary Artery Disease, Heart Failure, and Non-Alzheimer's Dementia. The MDS identified Resident #23 was dependent on staff for assistance with oral hygiene and personal hygiene and required substantial/maximal assistance with toileting and dressing. The MDS also identified Resident #23 had 2 falls with no injury and one fall with minor injury. On 11/3/23, the Care Plan identified Resident #23 at risk for falls related to Alzheimer's Disease and psychotropic medication use. Interventions included: a. Bed alarm in place to alert staff to resident movement for safety due to recent cognitive changes resulting in poor safety awareness b. If fall occurs, follow facility fall protocol A review of the Incident Report dated 7/14/24 at 7:00 AM had documentation of the following: Nursing description: Called to room by staff as heard bed alarm going off and witnessed resident fall hitting head on wall on back upper head and landing on left side of hip. Resident Description: I was walking A review of the Nurse's Progress Notes had documentation of the following: 7/14/24 at 7:00 AM Staff heard alarm going off and saw Resident #23 fall, hit his head on wall and landed on his left side. Assessed head to toe. No new skin areas noted. A slightly reddened area 2 cm (centimeters) by 1 cm on the back of his upper head. ROM (range of motion) as usual. Pupils equal and reactive. Denies any pain or discomfort no nausea or vomiting, alert and responsive. Vital signs table Assisted up per Hoyer lift and two staff to standing. The note did not have documentation to show the physician or family had been notified of the fall. 7/14/24 12:01 PM Telephone call to Resident #23's Family Member and she requested Resident #23 be sent to ER (emergency room ) to be evaluated. Physician called and received a new order received to send to ER to be evaluated. Sent to ER. 7/14/24 4:42 PM Received call from the hospital. Resident #23 will be coming back to facility. No new orders. CT scan showed a fracture of the temple area. In an interview on 7/31/24 at 1:08 PM, Staff I, LPN reported the following: a. When a resident has a fall and hits their head, the nurse should complete a head to toe assessment, do neuro checks, contact the doctor and family, neuro assessments every 15 minutes for 1 hour, every 30 minutes for 1 hour and every 8 hours until 72 hours has passed. b. The doctor and family should be notified before the shift ends. c. Assessments should be charted on the neuro flow sheet, condition report for the doctor and in the progress notes d. When a resident is sent to the ER, the nurse should document vitals, condition, a head to toe assessment, that she contacted the doctor and family, and whoever is on call, call the ambulance, give a report and how they were transported to the ER. e. When Resident #23 fell on [DATE], she reported she did not witness the fall. It had been reported to her by Staff H, CMA who said she witnessed the fall. Staff H reported he fell against the wall and hit his head. Staff I assessed Resident #23 and found a little reddened area to the right posterior part of his head. The area was not raised or open and was about 2 centimeters in size. This was the second fall Resident #23 had that day. Staff I was in Unit 1 when the fall occurred. She would usually stay on Unit 1 and a CMA would oversee Unit 2. f. The only fall precaution that she could recall that Resident #23 had was a pad alarm underneath him which goes off when he gets up. In an interview on 8/5/24 at 10:55 AM, Staff G, CNA reported the following: When Resident #23 fell on [DATE], she worked on East hall and when she arrived to Unit 2, Resident #23 was on the floor. His alarm was going off and by the time they got there, he was already on the floor. Staff C, CMA was in the room and Staff I, LPN came to assess him. After that fall, they started having a nurse stay back in Unit 2, the men's unit. Before that it was just one nurse between Unit 1 and 2 and that nurse usually stayed on Unit 1. After Resident #23 was supposed to be transferred with assist of one with gait belt and standby assist. Resident #23 did not go to the hospital until later that afternoon around 2:00 PM. The family was upset that he had hit is head and they were not called. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #49 as severely cognitively impaired without a BIMS score conducted. The MDS also identified Resident #49 had the following diagnoses: Non-Traumatic Brain Dysfunction, Non-Alzheimer's Dementia, and Renal Insufficiency (Kidney Failure). The MDS also identified Resident #49 required partial/moderate assistance with oral hygiene, toileting, dressing, and personal hygiene and required substantial/maximal assistance with showers. The MDS also identified Resident #49 to be incontinent of urine and stool. A review of the Nurse's Progress Notes had documentation of the following: 7/2/24 5:24 AM Resident #49 had 4 moderate amounts of red drainage from penis ranging from red to reddish/brown. Lower abdomen firm and tender to touch, slightly distended. There was no documentation to show the physician was notified. 7/3/24 1:24 AM Foley catheter inserted with an immediate return of 600 cc red drainage. There was no documentation to show the physician was notified. On 4/22/24, the Care Plan identified Resident #49 with the problem of recurrent prostatitis and directed staff to monitor/document for signs and symptoms of Prostatitis: need to urinate often, burning/stinging and/or pain with urination, decreased amount of urine with each urination, rectal pain/pressure, pain low back and/or pelvis, discharge from urethra during BMs (bowel movements). In an interview on 8/5/24 at 3:36 PM, the DON (Director of Nursing) reported the following: a. When a resident has an unwitnessed fall and hits their head, she would expect the nurse to notify the physician and family as soon as possible. b. She would expect them to complete an assessment right away for a baseline and document this in the risk management or nurse's notes. c. The family and physician should have bee notified immediately after Resident #23 fell , she had no explanation as to why there was a 5 hour gap between the fall and the initial call to the family and physician. A review of the Facility Policy titled: Change of Condition Resident Physician dated as last revised 12/23/16 had documentation of the following: a. Between the hours of 8:00 AM and 10:00 PM seven days a week, the attending Physician or Nurse Practitioner shall be notified of all conditions or health status changes. b. Between the hours of 10:00 PM and 8:00 AM, the attending physician or physician on call should be notified of any change in condition, health status or incident that: aa. Resulted in an injury that has the potential for physician intervention bb. Abnormal diagnostic values that fall out of the normal range cc. Acute symptoms, ie: unusual bleeding or other conditions as deemed necessary. A review of the Facility Policy titled: Change in Resident's Condition or Status, dated as last revised February 2021 had documentation of the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the physician of changes in the resident's condition. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment; d. a decision has been made to discharge the resident from the facility; and/or e. it is necessary to transfer the resident to a hospital/treatment center.

Based on observation, record review, and staff interviews, the facility failed to repair a bathroom light in one room (Resident #23) and door casings to 6 other rooms in Unit 2. The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #23 as cognitively impaired with a BIMS (Brief Interview for Mental Status) of 03 and had the following diagnoses: Coronary Artery Disease, Heart Failure, and Non-Alzheimer's Dementia. The MDS also identified Resident #23 was dependent on staff for assistance with oral hygiene and personal hygiene and required substantial/maximal assistance with toileting and dressing. The MDS also identified Resident #23 had 2 falls with no injury and one fall with minor injury. In an observation on 7/30/24 6:12 AM, Staff E, CNA and Staff O, CMA/CNA assisted resident to stand in his bathroom. Staff E tried to turn on the light switch, the light would not turn on. Both aides stood in the dark bathroom with the resident as he voided into the toilet. Resident #23 said turn the light on. however, the light still would not turn on. At 6:26 AM after both staff assisted Resident #23 back to his bed they went to the bathroom to wash their hands and the light then lit up. 2. In an observation on 7/30/24 11:06 AM, the door casing to left side of entrance to room [ROOM NUMBER] had a piece approximately 2.5 feet long missing with sharp edges exposed. On 7/31/24 at 8:28 AM, the door casing remains unchanged. 3. During a review of Unit 2 on 8/1/24 at 8:53 AM, observations revealed the following: room [ROOM NUMBER]- 1.5 feet portion missing from the trim with sharp edges exposed. room [ROOM NUMBER]- 3 inch area of rough exposed wood in door casing. room [ROOM NUMBER]- 2 feet portion missing from the casing with sharp edges exposed. room [ROOM NUMBER]- 1 inch gouge noted with sharp edges exposed. room [ROOM NUMBER]- 3 gouges from 1/2 inch to 2 inches wide, with sharp edges exposed. In an interview on 8/5/24 at 10:55 AM, Staff G, CNA reported a. Usually first thing in the morning Resident #23's light doesn't work, but after things get warmed up, they turn on without problems. b. If she sees door casings are missing pieces and have sharp edges, she would write it in the maintenance book. When the maintenance supervisor completes the work orders, he initials them and it stays in the book. In an interview on 8/5/24 at 11:12 AM, Staff E, CNA reported the other day in Resident #23's room was the first time the bathroom light wouldn't work. It has happened in another room. When things like that happen or when we see rough sharp edges around the door frame, the staff are supposed to tell the Maintenance Supervisor about it, fill out a work order and put it in the Maintenance Supervisor's door. In an interview on 8/5/24 at 3:03 PM, the Maintenance Supervisor reported the following: a. He was not made aware of the problems with light bulbs not working in the bathrooms in the residents' rooms. He had not received any work orders to address that issue. b. If staff find problems that he needs to repair, there is a notebook with work orders outside his office door. The other notebook is behind the East nurse's desk. He checks this book every day. After he completes the task, he documents it on the work order on paper. c. He was only made aware of two resident room doors that needed repair. He was waiting on parts to arrive. Some of the staff could not find pieces that were broken off the door. d. He was unsure of how long the door casings were in need of repair. The previous corporation would not allow him to buy anything to repair things. The new corporation is better about allowing him to purchase what he needs. In an interview on 8/5/24 at 3:36 PM, the DON (Director of Nursing) reported the following: a. When staff sees that door casings are broken with sharp edges exposed, she would expect them to write in the maintenance book. There is one on East by med refrigerator and there should be another one in Unit 2. b. The work orders for maintenance are kept in the notebook. c. When the work order is completed, the Maintenance Supervisor will sign each off as they are completed. d. She was not aware that there were lights in Unit 2 that were not working properly. Staff should have completed a work order and put it in the Maintenance Notebook. A review of the policy titled: Work Orders dated as last revised December 2004 had documentation of the following: a. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director. b. It shall be the responsibility of the department directors to fill out and forward such work orders to the maintenance director. c. A supply of work orders is maintained at each nurses' station. d. Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily. e. Emergency requests will be given priority in making necessary repair.

Based on record review and staff interviews the facility failed to update a Care Plan to indicate the residents correct transfer status for one out of one Care Plan reviewed (Resident #22). The facility identified a census of 47 residents. Findings include: The MDS for Resident #22 dated 6/10/24, listed diagnoses of atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), and diabetes mellitus (DM). The Brief interview for Mental Status (BIMS) reflected a score of 3, severely impaired cognition. The MDS reflected Resident #22 dependent on staff for transfers. Review of the Care Plan with intervention dated 6/4/24 revealed Resident #22 is dependent on 2 staff for Sara lift or Hoyer (mechanical lift) for transfers. The therapy recommendations dated 6/13/24 revealed assist times 2 staff with front wheeled walker. Staff to use assist times 2 with front wheeled walker wheelchair to follow for distance. The notes from weekly medicare meeting minutes dated 6/14/24 reflected to change Resident #22 to assist with two with front wheeled walker wheelchair to follow. The occupational therapy notes dated 8/1/24 revealed discharge recommendations for assist times two with front wheeled walker. On 08/01/24 at 10:13 AM Staff J, Certified Nursing Assistant (CNA) stated staff need to look on the kardex and the Care Plan for how much assist to provide with a transfer for residents. She looked at the the kardex/Care Plan in the electronic health record (EHR) for Resident #22 and stated it does say Sara lift or Hoyer. She stated this was changed when she completed therapy. On 08/01/24 at 10:19 AM Staff I, Licensed Practical Nurse (LPN) stated when physical or occupational therapy changes transfer status it should be updated on the Care Plan. Staff go to the Care Plan to know what amount of assist to provide a resident for transfers. On 08/01/24 at 10:22 AM the Director of Nursing (DON) stated everything should be updated on the Care Plan. The MDS coordinator should update during the medicare meeting if a residents transfer status changed. She stated if Resident #22 Care Plan says a mechanical lift [NAME] or Hoyer lift that is wrong she has been upgraded to a transfer with one. On 08/01/24 at 10:26 AM Staff K, Occupational Therapy stated Resident #22, she should be a 2 person assist for transfers the communication form was provided to the MDS Coordinator to update the Care Plan. The facility provided an untitled policy with a revision date of 11/17 which directed staff the comprehensive Care Plan will at a minimum identify the following: a. Services that will be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review, and staff interview, the facility failed to document 3 of 3 residents had been given showers twice a week. (Residents #6, #34, and #38). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #6 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) of 03 and had the following diagnoses: Stroke, Coronary Artery Disease, and Hemiplegia (paralysis of one side of the body). The MDS also identified Resident #6 was dependent on staff for all activities of daily living and had a feeding tube. Observations of Resident #6 include the following: 7/30/24 at 7:08 AM Resident #6 sat up in her wheelchair wearing clean clothing and gripper socks, however, her hair stuck straight up and appeared greasy as if it had not been shampooed for a few days. 7/31/24 at 8:16 AM Resident #6 was asleep in bed without any clothing on, had a [NAME] Strap across her abdomen and covered with a sheet from her lower abdomen to her feet. Her hair stuck straight up and appeared greasy, with a slight odor noted. 7/31/24 at 9:24 AM assessment unchanged A review of Resident #6's shower records for May, June, and July 2024 revealed the following: May 2024 Scheduled Wednesday and Saturday nights No documentation of showers for 7 days from May 2 through 8, June 2024 No documentation of showers for 6 days from June 3 through 8, for 7 days from June 20 through 26 July 2024 No documentation of showers for 7 days from 7 through 13, 6 days from July 21 through 26 On 4/17/23, the Care Plan identified Resident #6 with the problem of having an ADL (activities of daily living) self-care performance deficit related to a stroke and dementia. The Care Plan directed staff to provide assistance with showering 2 times per week and PRN (as needed). If she is being combative with cares, assist of two is recommended to ensure safety. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #34 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 03 out of 15. The MDS also identified Resident #34 with the following diagnoses: Non-Traumatic Brain Dysfunction, Alzheimer's Disease, and Atrial Fibrillation. The MDS also identified Resident #34 as dependent on staff for assistance with oral hygiene, required substantial/maximal assistance with toileting, showers, and personal hygiene. A review of Resident #34's shower records for May, June, and July 2024 revealed the following: May 2024 Scheduled Wednesday and Sunday nights No showers documented for 10 days from May 10 through 19, for 4 days from 23 through 26 June 2024 No showers documented for 6 days from June 7 through 12, 6 days from 21 through 26 July 2024 No showers documented for 6 days from July 12 through 17 On 4/7/23, the Care Plan identified Resident #34 with the problem of having an ADL (activities of daily living) self-care performance deficit related to Alzheimer's Disease and Dementia with Behavioral Disturbances. The Care Plan directed staff to provide assistance of one with showers twice a week and PRN. 3. The Minimum Data Set (MDS) dated [DATE] identified Resident #38 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) of 03 and had the following diagnoses: Non-Traumatic Brain Dysfunction, Non-Alzheimer's Dementia, and COPD (Chronic Obstructive Pulmonary Disease). The MDS also identified Resident #38 required substantial/maximal assistance with personal hygiene, showers, and toileting and required only set up assist with other activities of daily living. A review of Resident #38's shower records for May, June and July 2024 revealed the following: May 2024 Documentation showed showers given for all scheduled days. June 2024 No documentation of showers given for 6 days from June 19 through 24. July 2024 No documentation of showers given for 6 days from July 6 through 11 and for 6 days from July 24 through 29. On 1/12/24, the Care Plan identified Resident #38 with the problem of having an ADL (activities of daily living) self-care performance deficit related to impaired mobility and dementia with behavioral disturbances. The Care Plan directed staff to provide assistance with showering. Assist of two recommended when resistive behaviors are noted. In an interview on 8/5/24 at 3:36 PM, the DON (Director of Nursing) reported the following: a. Thee majority of residents are scheduled to have showers twice a week, there is one resident that wants it daily. b. When the resident refuses, she would expect the aide to re-approach and try again. The CNA will document in the electronic medical record that the resident refused, but they cannot document a narrative note. She would expect the nurse to document the reason why in Progress Notes. A review of the undated facility policy titled: Shower did not direct staff to attempt to provide at least 2 showers a week, the need to report if the resident refuses to shower, despite re-approaching the resident later and the need for the nurse to document why the resident refused and interventions taken.

Based on observation, record review, family and staff interview, the facility failed to utilize proper transfer techniques for 1 of 3 residents observed for transfers (Resident #22) and failed to utilize the proper technique to push 2 of 2 residents observed in wheelchairs (Residents #23 and #27). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #23 as cognitively impaired with a BIMS (Brief Interview for Mental Status) of 03 out of 15 and had the following diagnoses: Coronary Artery Disease, Heart Failure, and Non-Alzheimer's Dementia. The MDS also identified Resident #23 was dependent on staff for assistance with oral hygiene and personal hygiene and required substantial/maximal assistance with toileting and dressing. The MDS also identified Resident #23 had 2 falls with no injury and one fall with minor injury. On 11/3/23, the Care Plan identified Resident #23 at risk for falls related to Alzheimer's Disease and psychotropic medication use. In an observation of cares on 7/30/24 at 6:17 AM, Staff O, CMA/CNA pushed Resident #23 in his wheelchair without the foot pedals on and his feet skimming the floor from his bathroom to beside his bed.(approximately 15 to 20 feet). 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #27 as moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) of 07 and had the following diagnoses: Non-Traumatic Brain Dysfunction, Atrial Fibrillation (an abnormal heart rhythm), and Coronary Artery Disease. The MDS also identified Resident #27 was dependent on staff for assistance with toileting, showers, dressing, personal hygiene, and transfers. The MDS also identified Resident #27 had a history of one fall without injury. A review of the Care Plan revealed no interventions placed to address the need to place foot pedals on the wheelchair prior to transporting Resident #27. Observations of the staff transporting Resident #27 in his wheelchair revealed the following: 7/30/24 8:10 AM after Staff I, LPN administered insulin in the shower room, she pushed Resident #27 in his wheelchair without foot pedals on and with his feet skimming the floor. Staff I pushed Resident #27 from the shower room to the main dining room (approximately 50 feet). 7/31/24 8:47 AM Staff E, CNA pushed Resident #27 in his wheelchair with his left foot on one foot pedal, and the right foot without foot pedal and skimming the floor. In an interview on 8/5/24 at 3:36 PM, the DON (Director of Nursing) reported the following: Before staff are ready to transport a resident in a wheelchair, she would expect them to make sure there are foot pedals on the wheelchair and that the resident's feet are on the foot pedals. 37072 3. The MDS for Resident #22 dated 6/10/24, listed diagnoses of atrial fibrillation (irregular heartbeat), hypertension (high blood pressure) and diabetes mellitus (DM). The Brief interview for mental status (BIMS) reflected a score of 3, severely impaired cognition. The MDS reflected Resident #22 dependent on staff for transfers. During an observation on 07/29/24 at 2:04 PM surveyor heard screaming coming from Resident #22 room. The surveyor knocked on the door and entered room, Staff J, Certified Nursing Assistant (CNA) in room completed a transfer of Resident #22 with one person and gait belt. Staff J completed the transfer from residents wheelchair to her recliner. Resident #22 stated that is not the way the transfer is supposed to be completed. Staff J stated she did a pivot transfer with her and she will not be doing that again because it did not go well. Review of the Care Plan with intervention dated 6/4/24 revealed Resident #22 is dependent on 2 staff for Sara lift or Hoyer (mechanical lift) for transfers. The therapy recommendations dated 6/13/24 revealed assist times 2 staff with front wheeled walker. Staff to use assist times 2 with front wheeled walker wheelchair to follow for distance. The notes from weekly medicare meeting minutes dated 6/14/24 reflected to change Resident #22 to assist with two with front wheeled walker wheelchair to follow. The occupational therapy notes dated 8/1/24 revealed discharge recommendations for assist times two with front wheeled walker. On 08/01/24 at 10:13 AM Staff J, Certified Nursing Assistant (CNA) stated staff need to look on the kardex and the Care Plan for how much assist to provide with a transfer for residents. She looked at the the kardex/Care Plan in the electronic health record (EHR) for Resident #22 and stated it does say Sara lift or Hoyer. She stated this was changed when she completed therapy. On 08/01/24 at 10:19 AM Staff I, Licensed Practical Nurse (LPN) stated when physical or occupational therapy changes transfer status it should be updated on the Care Plan. Staff go to the Care Plan to know what amount of assist to provide a resident for transfers. On 08/01/24 at 10:22 AM the Director of Nursing (DON) stated everything should be updated on the Care Plan. The MDS coordinator should update during the medicare meeting if a residents transfer status changed. She stated if Resident #22's Care Plan says a mechanical lift [NAME] or Hoyer lift that is wrong she has been upgraded to a transfer with one. On 08/01/24 at 10:26 AM Staff K, Occupational Therapy stated Resident #22, she should be a 2 person assist for transfers the communication form was provided to the MDS Coordinator to update the Care Plan. On 08/01/24 at 10:27 AM the DON stated if Resident #22 is a 2 person assist I would expect the staff to be using 2 people to transfer her and a gait belt. They should follow the Care Plan for transfer status. The facility provided an undated policy titled Transfer Techniques which directed staff to obtain help when necessary, or as identified on the care plan/care card.

Based on observation, record review, and staff interview, the facility failed to ensure narcotics were properly secured for one of two medication carts reviewed and failed to properly dispose of an undated insulin pen for Resident #27. The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #27 as moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) of 07 and had the following diagnoses: Non-Traumatic Brain Dysfunction, Atrial Fibrillation (an abnormal heart rhythm), and Coronary Artery Disease. The MDS also identified Resident #27 was dependent on staff for assistance with toileting, showers, dressing, personal hygiene, and transfers. The MDS also identified Resident #27 had a history of one fall without injury. In an observation on 7/30/24 7:40 AM, Staff I, LPN removed a Lantus insulin pen from the medication cart and verified the Lantus pen was not dated when opened. Staff I obtained two new pens of Lantus and Humalog. Staff I then left the undated Lantus pen on top of the medication cart in the dining room where multiple residents sat waiting to be served breakfast. No other staff were noted in the dining room when Staff I failed to dispose of the undated Lantus pen before she pushed Resident #27 into the shower room. In an interview on 7/31/24 at 1:08 PM, Staff I, LPN reported the following: When she has an insulin pen that was not dated and replaces it, she would need to throw the undated pen away right away. She admitted she forgot to do that the other day. 2. On 7/30/24 at 4:27 AM, during a review of the medication cart on Unit 1 with Staff N, RN verified the narcotic drawer was not locked. Staff N immediately locked the drawer. In an interview on 8/5/24 at 3:36 PM, the DON (Director of Nursing) reported the following: a. If a nurse realizes one of the insulin pens is not dated and she gets a new one, she would expect the nurse to throw the undated pen away immediately. b. The drawer where narcotics are kept should be locked at all times. A review of the facility policy titled: Medication Storage dated as last revised April 2007 had documentation of the following: Compartments containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if left open or otherwise potentially available to others.

Based on clinical record review, facility policy and staff interviews, the facility failed to provide adequate supervision and failed to ensure the resident environment remained as free of accident hazards as is possible for one of four residents reviewed who fell and [MEDICAL CONDITION] the legs from a baseboard heater. [MEDICAL CONDITION] hospitalization , surgical intervention, grafts, a [DEVICE] and resulted in pain. (Resident #1) The facility reported a census of 49 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had the ability to sometimes make self understood and understand others, inattention, disorganized thinking and cognitive impairment. The resident required extensive assistance of two staff for bed mobility and to transfer from one surface to another. The MDS indicated the resident did not ambulate, had urinary and bowel incontinence, and [DIAGNOSES REDACTED]. The resident had a fall since the prior assessment without injury. The Care Plan initiated 8/4/20 revealed Resident #1 used a wheel chair for mobility, a history of falls and self transferring, incontinence, and hard of hearing. The care plan instructed staff to position the bed with one side against wall for safety. The bed contained upper half rails for positioning and for transfer assistance. Staff were to provide transfer assistance back to bed after meals and an antiroll wheel chair with brake extenders. The resident transferred using a mechanical sit to stand lift with staff assistance, a wheel chair for mobility and required incontinence cares. The physician's orders [REDACTED]. Progress Notes included: The resident had Covid 19 and hospitalized from [DATE] - 12/7/2020. 1/6/2021 - at 8:44 p.m. Staff B, LPN (Licensed Practical Nurse) documented staff found the resident on the floor on his/her knees with forehead resting on the floor. Staff assessed the resident and found no injuries and assisted him/her to bed with three staff. Prior to the fall, the resident sat in the wheel chair by bedside table for supper. 1/20/2021 - at 3:38 p.m. Staff found the resident sitting next to the bed on his/her bottom on the floor. Staff assisted the resident to bed approximately 15 minutes prior and last observed him in bed 10 minutes prior to sliding out of bed. Staff placed a fall mat next to the bed. 2/16/2021 - at 5:27 p.m. Staff C, LPN documented the resident self propelled the wheel chair to the dining room and staff found him with knees and elbows on the ground in front of the wheel chair. Staff observed the resident's buttocks almost in the chair. The resident sustained [REDACTED]. Staff assisted the resident back to the wheel chair using a Hoyer lift. The resident did not sustain other injuries and staff notified the physician. 2/20/2021 - at 2:00 a.m., Staff B, LPN documented staff entered the resident's room and found him laying against the baseboard heater. Staff assisted the resident back to bed with two staff and noted a large burn to the right knee to ankle and left knee. The physician directed staff to transfer the resident to the Emergency Department (ED) for evaluation. At 2:20 a.m, the ambulance arrived and transported the resident to the hospital. 2/22/2021 - University of Iowa Health Center informed the facility the resident required a feeding tube placed for nutritional support to aid in recovery. The Incident Report dated 2/20/2021 at 2:00 o'clock a.m. and prepared by Staff B, LPN included: Nursing description: Found resident on floor next to bed, right leg resting on heater and left knee pushed against corner of heater. Resident incontinent of bowel and bladder. Resident unable to give description. Injury Type: Burn left knee, front and right lower leg, front. Predisposing Environmental Factors: None Predisposing Physiological Factors: Confused and incontinent. Incident occurred in the resident's room with no witness to the event. Resident #1's 2/20/2021 Hospital ED Notes included: A complete history is unavailable secondary due to dementia. The last known normal was 2/19/2021 at 11:00 p.m. The patient, not able to provide any substantive history whatsoever, has significant dementia. Information came from Emergency Medical Services (EMS), and the nursing home. Somewhere between 11:00 P.M. and midnight, staff observed the patient, and patient doing fine. Thirty minutes prior to the ED arrival, staff discovered the patient fell off the bed and landed on a space heater. Total duration of time there is unknown. Assume the patient is in significant pain but cannot communicate well. Skin: Warm, dry, intact, patient has approximately 5% superficial [MEDICAL CONDITION] the medial (middle) aspect of the right leg. 20% of that is above the knee on the right with the rest below the knee on the medial tib-fib (tibia fibula bones in lower leg) area. There is already some blistering and desquamation (skin peeling) of skin. The area of involvement is on the medial aspect of the right leg. On the left leg, the medial aspect of the knee. There is approximately 0.75% deep partial burn through the epidermis (outer layer of the skin) and the dermis (layer underneath the epidermis) into the adipose (fat) tissue. The physician consulted the University of Iowa Hospital Burn Unit and Resident #1 transferred to the Burn Unit. The University of Iowa Health Care Progress Notes dated 2/23/2021 included: admitted : 2/20/2021 History of Present Illness: [AGE] year old who sustained a 5 - 10% body surface area contact burn on left lower extremity and right lower extremity on 2/20/2021, unknown time but after 11 P.M. on 2/19/2021 at the nursing home while he presumably slipped out of bed and landed with his bilateral lower extremities on a space heater. The resident is nonverbal and unable to tell us what happened. Extremities: Right lower extremity with about 2-3% total body surface area superficial to partial deep [MEDICAL CONDITION] from medial distal thigh to shin anteriorly, mostly blanching. Left lower extremity, medial prepatellar ( in front of the knee cap), with deep partial burn 1%. 2/24/2021 - Burn excision/debridement ( removal of damaged tissue) under general anesthesia with or without skin graft. A feeding tube was placed while patient under general anesthesia. 3/1/2021 - Burn excision/ debridement, wound vac (to assist with healing) placement and skin graft under general anesthesia. On 2/24/2021 at 9:00 a.m., Staff D, Administrator reported Resident #1 transferred from the facility to a local hospital and then to the University of Iowa hospital. The facility had difficulty reaching the resident's next of kin and had to contact police to assist. The resident had Covid-19 and lost strength but made progress working with therapy. At approximately 2:00 a.m. staff observed the resident on the floor on the left side of the bed near the window. The resident 's left knee landed on the base board heater and the right knee landed on top of it. The resident never yelled out for help. The bed contained U' bars for side rails and and an alternating air flow mattress. When the resident had an incontinent bowel and bladder episode, the chux (under pad) went with him out of the bed and the blanket remained on the bed. On 2/24/2021 at 9:55 a.m., Staff E, Maintenance checked the Resident's room temperature using an infra-red thermometer. The room temperature read 71.5 Fahrenheit and the baseboard heater temperature, cool to the touch, read 75.2 Fahrenheit. Staff D, Administrator, indicated thermostats were set at mid range, approximately 75 degrees Fahrenheit. Currently the bed sat approximately 16 inches from the wall. Staff D reported the facility moved beds away from the walls, which contained baseboard heaters, during winter months for safety. Staff D reported Resident #1 made no recent attempts to self transfer from the bed. At 1:30 p.m. on 2/24/21, Staff D, Administrator reported the facility followed up with staff working at the time of the incident to ensure they performed frequent rounds. Resident #1 resided on East Hall with a census of 16 residents. The night shift staffed one nurse in the facility from 10 p.m until 6 a.m and three CNA's (Certified Nurse's Aides), one on each unit. Staff D expected nursing staff to complete resident rounds every two hours and provide incontinence cares if needed. Staff D indicated she currently worked on a plan instructing staff to visually check each resident every thirty minutes. A report dated 2/20/21 completed by the Administrator, identified the reasonable conclusion regarding the incident as: Resident with alternating air mattress slid off the side of the bed without making enough noise to alert staff immediately. His inability to move, resulted in his legs resting against base board heater. Staff did appropriate tasks, completing rounds and assessing residents. On 2/24/2021 at 1:45 p.m., Staff A, DON (Director of Nursing) revealed she completed the initial investigation when Resident #1 fell from the bed. Staff working at the time of the incident reported they last observed the resident in bed around midnight. Staff found the resident on the floor at approximately 2 o'clock a.m. The resident was incontinent. The resident previously had Covid-19 and suffered from weakness since recovery. The facility pulled beds away from the walls for safety due to the baseboard heaters. On 3/1/2021 at 11 o'clock a.m., Staff A provided a copy of the education given to staff instructing them to provide residents with hourly checks and toileting or incontinence cares every 2 -3 hours. Staff A also provided a copy of staff education with instructions regarding how to help someone after a fall. On 2/24/2021 at approximately 2 p.m., Staff B, LPN reported working at the facility for four years on the night shift, from 6 p.m. until 6 a.m. After 9:30 p.m. the facility staffed one nurse for Unit One, Unit Two and the East Hall. The evening of the incident, Staff B checked every resident's room at approximately 10:15 p.m. and observed Resident #1 in a low bed, two half side rails in the up position and two blue boots on bilateral lower extremities. Staff left the television on in the resident's room so they could visualize him during the night. The resident had a habit of hanging his leg out over the side of the bed. The resident resided in the nearest room to the nurse's station without a roommate. At approximately 11 p.m. Staff B observed the resident in bed and Staff B went to assist a resident with bedtime cares. Staff B and Staff F, CNA started doing resident rounds on the opposite side of the hall and ended with Resident #1's room at approximately 2 a.m. Resident #1 slid off the bed, with lower extremities on the baseboard heater and incontinent bowel and bladder. One of the blue boots fell off and the other twisted sideways. Staff B observed the bed approximately 16 - 20 inches from the wall. Staff B unlocked the bed and moved it away from the resident. The room temperature felt comfortable and the heater felt hot to the touch. Staff B and Staff D used a stand up lift to get the resident off the floor and onto the bed. Observation showed the right leg contained blisters from the inside of the knee down to the ankle and the left knee contained an approximately three inch area that appeared indented where it pressed into the corner of the heater. The resident's blanket remained on the bed but the chux pad fell from the bed along with the resident. Staff B reported the resident had no prior similar incidents. On 2/24/2021 at 12:30 p.m., Staff F, CNA reported working for an agency and worked three shifts at the facility, with two of the shifts on East Hall. Between midnight and 1 a.m., Staff F answered a call light and observed Resident #1 in bed. At 1 a.m. Staff F and Staff B started resident rounds and provided incontinence cares per their usual routine. When they arrived at Resident #1's room at approximately 2:15 a.m., they observed the resident on the floor, in between the bed and wall, and laying on the heater. The resident had bowel and bladder incontinence. Staff F did not recall if the hand rail had been up or if the resident wore his blue boots. They assisted the resident to bed using the stand up lift. The resident did not use the call light and rarely spoke. After they transferred the resident to the bed, the resident said right there and pointed to his legs. Staff F let the resident know they called 911. The resident appeared in pain. The right knee contained an indentation as if it laid on a corner of the heater and the left knee from the inner shin to upper knee contained blisters and raw areas. Staff F's written statement provided to the facility after the incident, revealed Staff F observed all residents in bed at midnight and she and Staff B began rounds at 1:00 a.m. A 3/1/21 hospital procedure note identified the procedure performed as an OR (operating room) case: burn excision/debridement (major over 5% TBSA (total body surface area)) with split thickness skin graft to right lower leg and burn excision/debridement (minor less than 5% TBSA) without split thickness skin graft and wound vac placement. The burn wound physician performed the procedure under general anesthesia. The split thickness skin for grafting was harvested from the right thigh. On 2/24/2021 at 2:45 p.m , Staff E, Maintenance reported working at the facility for one year. Every room contained baseboard heat. Staff E started logging facility temperatures a couple of weeks prior when the outside temperatures were low. No resident ever complained and the inside temperature never dropped below 68 degrees Fahrenheit. Resident room thermostats are set at approximately 72 degrees Fahrenheit unless they request it be turned up. They moved all the beds away from the walls for safety. The facility had no baseboard heaters without covers. When Staff E learned of the incident involving Resident #1 he checked to be sure all beds were 18 inches away from the wall, and they were. The climatologist reported the temperature on 2/20/2021 at 1:00 a.m. at negative 9 degrees Fahrenheit. On 2/24/2021 with heat turned up, a probe thermometer read 127 degrees Fahrenheit when placed on a baseboard heater. The heater felt hot to the touch. A facility form provided from Staff A, DON revealed staff instructions for East Unit: Round times must be done every two hours, no exceptions, no skipping rounds. Round times: 11:30, 2:00 and 4:00 A.M. Staff education provided by Staff A on 03/01/2021 included: a. Please ensure that you are visually seeing each resident hourly and continue to complete toileting, repositioning and incontinence cares every 2 - 3 hours. b. Review of how to help someone up after falling: Only stand a resident with the assistance of two and a gait belt if the resident is able to transfer/ambulate independently or with a gait belt and one person. If there is a potential for injury or they cannot bear weight on at least one leg and usually require the use of a mechanical lift or two persons, a Hoyer lift must be used.

Based on observation, record review, resident and staff interviews, the facility failed to implement interventions to promote the healing of pressure ulcers for 2 out of 3 residents reviewed (Resident # 50 & #22). The facility reported a census of 64 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #22 dated 11/13/19 showed a Brief Interview for Mental Status Score (BIMS) of 14 indicating no memory impairment. The resident required extensive assistance of two staff with bed mobility, transfers, toileting, personal hygiene and documented as non-ambulatory with a risk of pressure ulcers. The resident's [DIAGNOSES REDACTED]. The MDS identified the following descriptions of pressure ulcers Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones, only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Observation of Resident #22 on 2/3/20 at 1:37 p.m. , noted the resident sitting in a wheelchair in her room with a cushion in the seat and also has a low loss air mattress on bed. The resident denies any pain or discomfort from buttocks, but does remark she has painful gallstones that will remain until the sore on her bottom healed. Observation on 2/4/20 at 11:49 a.m., Resident #22 propelling self in hallway towards dining room and has a cushion in place in the wheelchair. During an observation on 2/4/20 at 2:16 p.m., Staff H, Licensed Practical Nurse (LPN) provided a dressing change with the assist from the interim Director of Nursing (DON). Noted the gluteal crease with a large open area covered with yellow slough directly over the ischium with a black center. The wound packed with calcium alginate, covered with waterproof foam dressing, and then covered with Duoderm. The Braden Scale for Predicting Pressure Sore Risk, completed 11/12/19, identified a score of 14, indicated the resident at a moderate risk of developing a pressure ulcer. The Non-Pressure Skin Condition Report dated 12/14/19 revealed an open area to the left gluteal crease. The area measured 2.3 centimeters (cm) x 1.3 cm open with no depth and no signs and symptoms of infection. Condition Report to medical doctor dated 12/14/19 revealed the following concern of an open area 2.3 cm x 1.3 cm to the left of the gluteal crease, area caused by friction from the depends, will monitor until healed and start [MEDICATION NAME] twice a day until healed. The physician signed the report and returned order 12-16-19. The [MEDICATION NAME] treatment order fails to appear on the Treatment Administration Record (TAR) until 12-22-19. The Physician order [REDACTED]. Review of the resident's medical record failed to reveal any further documentation on the open wound until 12/31/19 the Nurse's Progress Notes stated the left buttock near the gluteal crease with an open area measuring 3.2 cm by 3 cm with 1 cm rolled edges. The area with 25 percent slough, scant drainage, and darkened tissue noted to the middle of wound with surrounding skin pale red in color. The resident denies pain with this area. A Condition Report sent to medical doctor on 12/31/19 and the facility requested a new treatment to apply moistened/activated collagen particles into the wound and then apply a border dressing every bedtime and as needed. The order signed by the physician on 1/2/20, noted and implemented by the facility on 1/2/20 according to Resident #22's Treatment Administration Record (TAR). The facility started a Wound Evaluation Flow Sheet on 1/6/20 indicating the wound now a Stage 3 pressure area with measurements of 3.7 cm by 3.6 cm with a 2 cm depth, also a 2 cm tunneling at 6 o'clock. The wound with a heavy amount of gray thick purulent drainage. The wound margins rolled with maceration and the surrounding tissue red and hard. The resident reported pain as 4 out of 10. The documentation stated the wound deteriorating. The Flow Sheet documented a modified Roho Cushion put in place on the wheelchair 12/31/19. The Nurse Progress Notes from 1/10/20 documented the Wound Specialist consulted, who suggested the Wound Clinic to provide debridement and to change the current treatment of [REDACTED]. A Condition Report facsimile to the attending physician on 1/10/20 noted the wound continues to deteriorate. Measurements currently 4 cm by 4.2 cm with a 1.2 cm depth. The previous tunnel now has turned to 2 cm undermining from 2 o'clock to 9 o'clock with edges rolled, macerated and surrounding tissue red, gray/black and hard. The area covered with 100 percent thick slough with a gangrenous odor. Requested and received order for a multivitamin with mineral and very high calorie supplement with meals. The Physician ordered a wound culture and then to start an antibiotic. A Physician order [REDACTED]. The Wound Clinic Notes dated 1/21/20 reveal the patient developed a left ischium pressure ulcer approximately 2 months ago which is gradually become worse and now she presents with a necrotic full thickness stage IV pressure ulcer that is essentially down to bone. Primary Diagnosis: [REDACTED]. The Physician order [REDACTED]. 1. Physiotherapy for Pressure Mapping and Roho cushion. 2. Apply a low air-loss bed mattress. 3. Dietary consult recommend Elemental Protein Supplement. 4. Plan for wound VAC after surgical debridement of Stage IV left ischium pressure ulcer. The Wound Evaluation Flow Sheet revealed the low air loss mattress not started until 1/24/20. The facility failed to have the Registered Dietician consult until 1/30/20 and no recommendations in the Progress Note for increased protein supplementation noted. A Surgical Consult dated 1/27/20, noted treatment of [REDACTED]. Discussed the patient briefly with an orthopedic surgeon who suggested referral for further evaluation and management to Iowa City. The Nurse's Progress Note dated 1/30/20, documented a Wound Nurse Specialist recommendation to add Zinc 50 mg daily (mineral used to aid in the production of proteins required for healing) and ProStat (medical supplement used to aid in healing wounds) 30 milliliter (ml) twice a day. The Licensed Dietician notes dated 1/30/20 revealed the Dietitian noted a Stage 4 wound on the resident's left buttocks. The Dietitian requested [MEDICATION NAME] or [MEDICATION NAME] for resident (medication used to stimulate appetite). No recommendations to increase resident's protein or add supplements charted. A Condition Report dated 1/30/20 to the attending physician charted the referring hospital cannot see the resident for pressure ulcer until labs obtained and at following levels: a. [MEDICATION NAME] >3 b. [MEDICATION NAME] >16 c. Protein >7 d. HgbA1c < 7 A Condition Report to the attending physician on 2/5/20 revealed the residents [MEDICATION NAME] level is low for the referring hospital requirements can we recheck [MEDICATION NAME] in one week. The Care Plan with a date initiated on 11/14/16 identified the resident with the potential for skin breakdown related to incontinence and decreased physical mobility. The interventions directed staff to assess and document skin integrity weekly, encourage resident to have adequate nutrition and hydration to promote skin integrity, report any skin breakdown to the physician, and to treat skin breakdown per facility protocol. The facility failed to address the pressure ulcer on the Care Plan until 1/30/20. During an interview on 2/4/20 at 2:16 p.m., the Interim DON reported we have a Dietitian but not sure, if she saw the resident yet, we have asked for recommendations due to the referring hospital will not see the resident for consult until her protein levels are higher. During an interview on 2/4/20 at 2:31 p.m., the Interim DON reported not sure, when the wound started, and reported the first time seeing the wound on 12/31/19. The Interim DON stated the prior DON responsible for skin measurements; the Interim DON updated the Care Plans, and she must have missed the wound on the Care Plan. The Interim DON explained staff follow the Kardex for providing cares and this comes from the Care Plan and I am the one responsible for updating and not sure why not updated. The Interim DON stated expected staff to start a treatment immediately when they receive an order. During an interview on 2/6/20 at 10:21 a.m., the Licensed Dietician (LD) stated not aware of the open area for Resident #22 until a couple of weeks ago. Normally she would increase their protein by about 20 grams when there is a pressure sore. Typically, she would recommend a protein supplement for a pressure ulcer and stated had no knowledge about the Wound Clinic referral for a Dietary Consult. She stated on 1/31/20, she met with the Assistant Director of Nursing (ADON) and the interim DON, and discussed the resident's nutritional needs and recommendations for the pressure sore. 2. The Minimum Data Set (MDS) Assessment for Resident #50 dated 12/12/19 showed a Brief Interview for Mental Status Score (BIMS) of 15 indicating no memory impairment. The resident required limited to extensive assistance of one to two staff with bed mobility, transfers, toileting and personal hygiene. The MDS identified the resident at risk of pressure ulcers. The resident's [DIAGNOSES REDACTED]. During an observation of wound care with Resident #50 on 2/6/20 at 11:33 a.m., Staff A, Registered Nurse (RN) provided cares to an area to the right side of the coccyx, over the tail bone which measuring 3.5 centimeter (cm) x 0.5 cm with a 0.1 cm depth, and a yellow slough covering. Staff A, RN states the area is now an unstageable pressure sore due to the wound covered with yellow slough. During this time, the surveyor noted the residents Roho (air cushion) in wheelchair completely flat. The resident states the Nurse Aide just put air in it the other day. The Braden Scale for Predicting Pressure Sore Risk, completed 12/9/19, identified a score of 18, indicating the resident at risk of developing a pressure ulcer. The Nurse's Progress Note dated 1/14/20, revealed a 3.5 cm by 0.7 cm area to right of the coccyx area and appears to be a broken blister, red edges with pink/yellow wound bed. Report sent to the physician. The Non-Pressure Skin Condition Report sheet on 1/21/20 documented noted area to be 4 cm by 0.8 cm with no depth noted. The medical record revealed no further documentation or measurements of the wound until 2/4/20. The Condition Report to attending physician dated 2/4/20 reveals a pressure ulcer to right side of coccyx is worsening in length and depth. Area with moderate amount of serous drainage and measuring 4.8 cm by 0.8 cm with a depth of 0.7 cm. The wound is painful for the resident. Review of the medical record revealed no documentation concerning a treatment to the area after initially found until 2/4/20 when attending physician sent a condition report. The Care Plan for Resident #50 failed to address the pressure ulcer on the right side of the coccyx. During an interview on 2/5/20 at 3:12 p.m., Staff G, Certified Nursing Assistant (CNA) states Resident #50 with an open area on her coccyx for at least a month and recently is more open the Nurse does the treatment using a cream on it. During an interview on 2/5/20 at 3:16 p.m., the Interim Director of Nursing (DON) states just made aware of Resident #50's pressure ulcer this morning. The Interim DON stated expected staff to let the nurse know when the area found and then the nurse should let the Management Team know so they can get interventions in place. The first interventions is to look at placing cushions in chairs and on the bed, and then look at nutrition. The Interim DON stated she expected family and physician notified immediately, and the staff get a treatment order immediately. Wound assessments need completed daily with dressing changes and measurements done at the time the wound found and then completed weekly and as needed depending on the condition of the wound. If no improvement in the wound, staff contact the physician or the Wound Nurse to change treatment or try some different interventions. During an interview on 2/5/20 at 4:12 p.m., Staff A, Registered Nurse (RN) states using [MEDICATION NAME] cream on Resident #50's buttocks area which has been open for quite a while but not sure how long. During a phone interview on 2/5/20 at 4:45 p.m., Staff E, Licensed Practical Nurse (LPN) states Resident # 50's pressure ulcer on the right side of the coccyx started on the date on the skin sheet she started. Prior to the date, no open areas noted. The area noted with no depth, just a superficial open area. The night Staff E found the area she sent a fax to the medical doctor stating would utilize the [MEDICATION NAME] order we already had for her skin. During an interview on 2/6/20 at 10:05 a.m., the Interim DON stated unable to find a fax to the medical doctor or an order for [REDACTED]. During an interview on 2/6/20 at 10:36 a.m., the Licensed Dietitian (LD) stated not aware of a pressure sore for Resident #50. No Dietary recommendations made for Resident #50 since not aware of the pressure sore. During an interview on 2/6/20 at 11:20 a.m. Staff B, CNA reported the resident's sore is right on her bottom and not sure how long it has been there but believes the nurses applying [MEDICATION NAME] on it. Staff B confirmed the Roho cushion in wheelchair flat when transferred resident out of wheelchair. During an interview with Resident #50 on 2/6/20 at 11:32 a.m., she states the sore does not hurt when sitting on it, but when laying down it is painful and rates the pain at 6 out of 10 on the pain scale. During an interview/observation on 2/6/20 at 11:47 a.m., the interim DON attempting to blow up the Roho cushion and states it does not look right and the cushion appears to be too small for this resident. During an interview on 2/6/20 at 1:16 p.m., the Interim DON stated she contacted the resident's physician office about the pressure sore on resident's coccyx and the office does not have record of the area or a treatment order. The Interim DON reported the physician's office does not keep faxes sent about the resident. During an interview on 2/6/20 at 1:35 p.m., the Occupational Therapist (OT) stated Resident #50 currently with Mosaic Roho cushion in her wheelchair and if she has an open area needs to switch to 2-inch Roho cushion. The OT explained that refers to the size of the fingers in the cushion and the amount of air in the fingers. The Mosaic is a standard cushion for skin prevention, once there is an open area; the resident should be using a different cushion with more fingers and is a higher level. During an interview on 2/6/20 at 1:51 p.m., the Interim DON confirmed a slow leak noted in the ROJO cushion currently on the resident's wheel chair and this could have contributed to the pressure ulcer worsening. During a telephone interview on 2/6/20 at 3:00 p.m., the Physician's Office Nurse stated they do not keep faxes after answered and signed from the facility; we send them back to the facility and feel they have the documentation. During an interview on 2/6/20 at 3:02 p.m., the Administrator stated unaware of Resident #50 having a pressure ulcer.

Based on record review, staff and resident interviews the facility failed to ensure residents were free from physical and mental abuse for 1 of 9 residents reviewed (Resident #4). The facility reported a census of 72 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) Assessment tool dated 2/3/16 revealed Resident #4 had [DIAGNOSES REDACTED]. Also documenting the resident with a score of 7 out of 15 for the Brief Interview for Mental Status (BIMS) indicating the resident had moderate loss of cognitive skills. The resident required extensive assistance of one staff with transfers, dressing, toileting, and hygiene. The Care Plan initiated on 9/30/14 showed the resident had potential for skin impairment. Interventions for this potential problem included for staff to attempt to assess and document skin integrity weekly, inspect skin with partials and baths, reporting to the nurse any red, open areas or bruises. The nursing staff also directed to approach the resident warmly and positively. An Incident/Accident Report dated 2/23/16 reported to the Assistant Director of Nursing (ADON), noted a bruise found on the resident's right forearm and had informed the nurse on duty on 2/23/16. Further review of the report noted the ADON to complete the form on 2//24/16. The report documented the resident to be alert and oriented. Review of the Progress Notes/Nurse's Notes for 2/23/16 shown no documentation in regards to the resident's bruise from Staff B, the Registered Nurse (RN) on duty that night. Review of Nurse's Note dated 2/24/16, reveals notes by the ADON, that reported a Certified Nursing Aide (CNA) informed this nurse the resident had a bruise on the right forearm. The ADON observed the resident with a 4.7 centimeter (cm) by 6.7 cm dark purple bruise on the resident's right forearm. When asked the resident 'what happened', the resident smiled and did not want to to say anything but replied 'you're going to yell at her, right?' The ADON explained the importance of knowing what happened. The resident reported a staff person grabbed his/her arm and jerked it, and stated this occurred yesterday before supper. Review of the CNA-Staff- Resident-Visitor Statement Form dated 2/24/16 at 2:30 p.m. noted to be completed by the ADON. The form states a Certified Nurse Aide (CNA) reported a resident (#4) to have a new bruise to the right forearm. The CNA also reported this to the Charge Nurse, Staff B on 2/23/16. The CNA reported felt dismissed and then reported this bruise to the ADON. The ADON reported looked through skin sheets and Nurse's Notes and found no notations on the bruise. The ADON documented a condition report and incident report prepared by him/her. Review of the Non-Pressure Skin Condition Report noted the report initiated on 2/24/16 per the ADON. The entry documented a 4.7 cm X 6.7 cm dark purple bruise with the anatomical picture of the body marked on the posterior right forearm to indicate the area bruised. Review of the CNA-Staff- Resident-Visitor Statement Form dated 2/24/16 at 3:02 p.m. noted to be completed by Staff D, CNA. The form documents reported an unusual mark to Resident #4 to the charge Nurse and felt that it was dismissed. Staff D then reported the incident to the ADON. During an interview on 8/2/16 at 5:15 p.m., the ADON reported on 2/24/16 that Staff D, CNA came to him/her and reported that Resident #4 had a bruise on his/her right arm. Staff D stated had reported this to the Nurse on the PM shift 2/23/16 but felt dismissed. The ADON reassured Staff D he/she would look into it. When talking to the resident he/she began to cry and described the person as the girl with short dark hair and glasses. The resident stated she had jerked on her arms to roll her in bed. The resident didn't want to get anyone in trouble and was reason for crying. The ADON reported the CNA (Staff C) thought to be involved was wrote up, but Staff C refused to sign the write up nor admit to anything. The ADON reported Staff C continued to work the same hall where Resident #4 resided and worked with the resident as the 2:00 p.m. to 10:00 p.m. CNA and resigned a couple months later. The ADON stated did not report this incident to DIA because the resident did not have a change in status and the facility knew how it happened. The ADON stated initially an Incident Report was not completed by the nurse that it was reported to, that he/she filled out one. The ADON also reported that Staff D, CNA who first reported the bruise on Resident #4 no longer worked at the facility. During an interview on 8/2/16 at 5:50 p.m., Staff B, RN reported that on 2/23/16, Staff D, reported to him/her that a resident (#4) had a bruise on his/her arm. Staff B stated assessed Resident #4, questioned the resident and notified management. When assessing the wound also measured the bruise size and did range of motion. Staff B asked the resident if remembered how he/she got the bruise. Resident #4 stated the one who put me to bed was rough with him/her. Staff B couldn't remember exactly what the resident told him/her, stated in would be in the Nurse's Notes. Staff B explained there would also have been a Witness Statement completed by the person who actually found the bruise and reported it. Staff B questioned on who he/she notified and reported the DON or ADON, since works 3rd shift (6:00 p.m. - 6:00 a.m.) it is usually a note or email. Staff B reported it was probably 10:30 p.m. or 11:00 p.m. when the CNA came to him/her to report the bruise. Stated the resident vague in his/her recollection of the incident, stated they were rough with me, and didn't describe anyone person to Staff B. During an interview on 8/4/16 at 10:27 a.m., the Administrator reported was aware of Resident #4's situation but the previous DON had explained it away and we felt it wasn't a reportable situation as the resident bruises easy and had a BIMS of only 7 at the time. The resident did say she/he didn't want to get anybody in trouble. The Administrator reported that the resident when a new bruise is noted will poo-poo what happened, and not answer till someone pressures her more to talk. The bruise from 2/24/16 we took as it happened when the resident assisted, he/she is thin skinned and it happens, he/she seemed to not want to make a big deal of this. The Administrator did admit talking to the resident but never wrote that up, and now knows needs to probably do that and document when talked to residents. The Administrator stated the resident not able to describe anybody, just said that girl. The Administrator did not talk to Staff C, CNA personally, but thought the previous DON had but with him/her gone cannot find any paperwork or documentation on the interview or disciplinary paperwork on Staff C. There is nothing else that can be found on this situation, but the documentation the ADON completed, he/she began the investigation. The Administrator reported would have expected the resident would have been red from the CNA caring for him/her that would be told to Staff B, RN, and Staff B would have assessed the skin and began a skin sheet, talked to Staff C, the CNA then reported it to the DON so the DON could begin the investigation. The Administrator stated it looked like none of this process occurred. The Administrator reported since Staff C, CNA possibly identified he/she would have been talked to and have had him/her describe the situation. Also would have been informed about allegations of abuse and suspended without pay pending investigation of the situation. Then at that time once information gathered would send a report to DIA with in 24 hours. If everything was done accordingly as needed to be felt could have had a report in to DIA by the 24 hour timeframe. During an interview on 8/4/16 at 10:45 a.m., Resident #4 stated he/she thinks it was towards evening time, not sure when and not sure if happened in February. The resident reported back sometime, toward evening a girl, thinks she was an Aide, don't remember her name. It hurt, don't remember where but it hurt. I don't want to turn anyone in. It hurt and she gave me a bruise, that's all I remember. I told someone but I don't remember who, but it wasn't you (referring to the Surveyor). During a re-interview of Staff B on 8/4/16 at 1:32 p.m., Staff B reported taking the required Mandatory Abuse Training per the facility when first hired and completed the course on 12/3/13. Staff B stated had talked to the DON by phone about the situation on Resident #4, but never documented it. Staff B reported Staff D, CNA told him/her that the resident stated they were rough to him/her when putting him/her to bed. Staff B explained did go and look at the resident and assess him/her, anything done would be reported to the next Shift Nurse. Staff C was gone from the facility at the time Staff D reported the bruise to the best of my knowledge, Staff C worked the 2:00 p.m. to 10:00 p.m. shift. Staff B stated what he/she was saying is the night he/she looked at the resident there was no bruise, but maybe wrong. Staff B then stated took this to the DON when he/she came on and Staff B was leaving around 7:00 a.m Apparently did not start a Skin Sheet. Staff B stated if Staff D had come to him/her earlier when Staff C still working, would have ensured Staff C was separated from the resident and contacted management.

Based on record review, staff and resident interviews the facility failed to investigate and report a possible physical abuse for 1 of 9 residents reviewed (Resident #4), and also failed to complete appropriate corrective action by separating the resident from the possible staff involved. The facility reported a census of 72 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) Assessment tool dated 2/3/16 revealed Resident #4 had [DIAGNOSES REDACTED]. Also documenting the resident with a score of 7 out of 15 for the Brief Interview for Mental Status (BIMS) indicating the resident had moderate loss of cognitive skills. The resident required extensive assistance of one staff with transfers, dressing, toileting, and hygiene. The Care Plan initiated on 9/30/14 showed the resident had potential for skin impairment. Interventions for this potential problem included for staff to attempt to assess and document skin integrity weekly, inspect skin with partials and baths, reporting to the nurse any red, open areas or bruises. The nursing staff also directed to approach the resident warmly and positively. An Incident/Accident Report dated 2/23/16 reported to the Assistant Director of Nursing (ADON), noted a bruise found on the resident's right forearm and had informed the nurse on duty on 2/23/16. Further review of the report noted the ADON to complete the form on 2//24/16. The report documented the resident to be alert and oriented. Review of the Progress Notes/Nurse's Notes for 2/23/16 shown no documentation in regards to the resident's bruise from Staff B, the Registered Nurse (RN) on duty that night. Review of Nurse's Note dated 2/24/16, reveals notes by the ADON, that reported a Certified Nursing Aide (CNA) informed this nurse the resident had a bruise on the right forearm. The ADON observed the resident with a 4.7 centimeter (cm) by 6.7 cm dark purple bruise on the resident's right forearm. When asked the resident 'what happened', the resident smiled and did not want to to say anything but replied 'you're going to yell at her, right?' The ADON explained the importance of knowing what happened. The resident reported a staff person grabbed his/her arm and jerked it, and stated this occurred yesterday before supper. Review of the CNA-Staff- Resident-Visitor Statement Form dated 2/24/16 at 2:30 p.m. noted to be completed by the ADON. The form states a Certified Nurse Aide (CNA) reported a resident (#4) to have a new bruise to the right forearm. The CNA also reported this to the Charge Nurse, Staff B on 2/23/16. The CNA reported felt dismissed and then reported this bruise to the ADON. The ADON reported looked through skin sheets and Nurse's Notes and found no notations on the bruise. The ADON documented a condition report and incident report prepared by him/her. Review of the Non-Pressure Skin Condition Report noted the report initiated on 2/24/16 per the ADON. The entry documented a 4.7 cm X 6.7 cm dark purple bruise with the anatomical picture of the body marked on the posterior right forearm to indicate the area bruised. Review of the CNA-Staff- Resident-Visitor Statement Form dated 2/24/16 at 3:02 p.m. noted to be completed by Staff D, CNA. The form documents reported an unusual mark to Resident #4 to the charge Nurse and felt that it was dismissed. Staff D then reported the incident to the ADON. Review of the facility's undated Abuse Prevention and Reporting Policy under the Reporting and Investigation Procedures sections directs the staff on the proper techniques to implement if an abuse situation is suspected. The policy states that all employees of this facility are Mandatory Reporters and as such are required by law to report incidents of suspected abuse. Any employee that witnesses an incident that might be considered abuse shall verbally report the incident immediately to the Charge Nurse, Nurse on-call, or Director if Nursing and will also be required to complete the Suspected Dependent Adult Abuser Report immediately. The Nurse or Department Head to whom the incident had been reported will immediately take steps to: a. Remove the alleged suspect from contact with the resident immediately. This separation my be maintained by suspending an accused employee from employment without pay pending the resolution of the investigation, or reassigning an accused employee to a shift or area of the facility so that no contact is made between the accused employee and the affected resident. b. Perform a physical assessment of the resident and determine need for emergency medical services or trauma evaluation, taking actions as necessary, including notification to the physician. c. Determine possible etiologies for injuries of unknown etiology (e.g. bruising compatible with the hook of a Hoyer lift chain or other equipment). d. Wounds related to suspected or alleged abuse shall be photographed and labeled per resident name, date, area of the body and the name of the photographer. e. Gather any evidence or immediate information surrounding the incident that might be destroyed or distorted over time. The Administrator, Operations Manager, and Owners will be notified immediately and will notify the resident's responsible party and the Department Of Inspections and Appeals (DIA) as appropriate within 24 hours of receiving the report. Review of the facility schedule for the days of 2/20/16 to 3/18/16 noted Staff C, CNA worked his/her regularly scheduled days on the 2:00 p.m. to 10:00 p.m. shift with no interruption. A notation on the schedule indicated Staff C went to an as needed status (PRN) on 3/11/16, until called in on 3/13/16 with no more hours of work on the schedule. During an interview on 8/2/16 at 5:15 p.m., the ADON reported on 2/24/16 that Staff D, CNA came to him/her and reported that Resident #4 had a bruise on his/her right arm. Staff D stated had reported this to the Nurse on the PM shift 2/23/16 but felt dismissed. The ADON reassured Staff D he/she would look into it. When talking to the resident he/she began to cry and described the person as the girl with short dark hair and glasses. The resident stated she had jerked on her arms to roll her in bed. The resident didn't want to get anyone in trouble and was reason for crying. The ADON reported the CNA (Staff C) thought to be involved was wrote up, but Staff C refused to sign the write up nor admit to anything. The ADON reported Staff C continued to work the same hall where Resident #4 resided and worked with the resident as the 2:00 p.m. to 10:00 p.m. CNA and resigned a couple months later. The ADON stated did not report this incident to DIA because the resident did not have a change in status and the facility knew how it happened. The ADON stated initially an Incident Report was not completed by the nurse that it was reported to, that he/she filled out one. The ADON also reported that Staff D, CNA who first reported the bruise on Resident #4 no longer worked at the facility. When asked how often staff are trained on abuse the ADON reported once every 5 years and can access through a computer program CE Solutions that the facility utilizes for trainings. During an interview on 8/2/16 at 5:50 p.m., Staff B, RN reported that on 2/23/16, Staff D, reported to him/her that a resident (#4) had a bruise on his/her arm. Staff B stated assessed Resident #4, questioned the resident and notified management. When assessing the wound also measured the bruise size and did range of motion. Staff B asked the resident if remembered how he/she got the bruise. Resident #4 stated the one who put me to bed was rough with him/her. Staff B couldn't remember exactly what the resident told him/her, stated in would be in the Nurse's Notes. Staff B explained there would also have been a Witness Statement completed by the person who actually found the bruise and reported it. Staff B questioned on who he/she notified and reported the DON or ADON, since works 3rd shift (6:00 p.m. - 6:00 a.m.) it is usually a note or email. Staff B reported it was probably 10:30 p.m. or 11:00 p.m. when the CNA came to him/her to report the bruise. Stated the resident vague in his/her recollection of the incident, stated they were rough with me, and didn't describe anyone person to Staff B. During an interview on 8/4/16 at 10:27 a.m., the Administrator reported was aware of Resident #4's situation but the previous DON had explained it away and we felt it wasn't a reportable situation as the resident bruises easy and had a BIMS of only 7 at the time. The resident did say she/he didn't want to get anybody in trouble. The Administrator reported that the resident when a new bruise is noted will poo-poo what happened, and not answer till someone pressures her more to talk. The bruise from 2/24/16 we took as it happened when the resident assisted, he/she is thin skinned and it happens, he/she seemed to not want to make a big deal of this. The Administrator did admit talking to the resident but never wrote that up, and now knows needs to probably do that and document when talked to residents. The Administrator stated the resident not able to describe anybody, just said that girl. The Administrator did not talk to Staff C, CNA personally, but thought the previous DON had but with him/her gone cannot find any paperwork or documentation on the interview or disciplinary paperwork on Staff C. There is nothing else that can be found on this situation, but the documentation the ADON completed, he/she began the investigation. The Administrator reported would have expected the resident would have been red from the CNA caring for him/her that would be told to Staff B, RN, and Staff B would have assessed the skin and began a skin sheet, talked to Staff C, the CNA then reported it to the DON so the DON could begin the investigation. The Administrator stated it looked like none of this process occurred. The Administrator reported since Staff C, CNA possibly identified he/she would have been talked to and have had him/her describe the situation. Also would have been informed about allegations of abuse and suspended without pay pending investigation of the situation. Then at that time once information gathered would send a report to DIA with in 24 hours. If everything was done accordingly as needed to be felt could have had a report in to DIA by the 24 hour timeframe. During an interview on 8/4/16 at 10:45 a.m., Resident #4 stated he/she thinks it was towards evening time, not sure when and not sure if happened in February. The resident reported back sometime, toward evening a girl, thinks she was an Aide, don't remember her name. It hurt, don't remember where but it hurt. I don't want to turn anyone in. It hurt and she gave me a bruise, that's all I remember. I told someone but I don't remember who, but it wasn't you (referring to the Surveyor). During a re-interview of Staff B on 8/4/16 at 1:32 p.m., Staff B reported taking the required Mandatory Abuse Training per the facility when first hired and completed the course on 12/3/13. Staff B stated had talked to the DON by phone about the situation on Resident #4, but never documented it. Staff B reported Staff D, CNA told him/her that the resident stated they were rough to him/her when putting him/her to bed. Staff B explained did go and look at the resident and assess him/her, anything done would be reported to the next Shift Nurse. Staff C was gone from the facility at the time Staff D reported the bruise to the best of my knowledge, Staff C worked the 2:00 p.m. to 10:00 p.m. shift. Staff B stated what he/she was saying is the night he/she looked at the resident there was no bruise, but maybe wrong. Staff B then stated took this to the DON when he/she came on and Staff B was leaving around 7:00 a.m Apparently did not start a Skin Sheet. Staff B stated if Staff D had come to him/her earlier when Staff C still working, would have ensured Staff C was separated from the resident and contacted management. Staff B reported since the incident with Resident #4, no one ever approached him/her to re-educate on proper identification of possible Abuse and how to report that. To the best of Staff B's knowledge, there has not been any extra education for all staff in regards to possible Abuse and reporting. During an interview on 8/4/16 at 1:55 p.m., the Administrative Assistant reported trainings are done on the computer with all staff and recorded. This process just started in may 2016 and now have a schedule for the rest of the year. The Administrative Assistant presented the schedule for the year and noted Identifying Elder Abuse and Neglect was to be completed by all staff on the computer for May 2016. Noted in a report that Staff B completed the course on 5/28/2016.

Based on observation, clinical record review and staff and resident interviews, the facility failed to ensure one of four residents received adequate supervision to prevent accidents and the health service supervisor failed to ensure the staff was aware of the resident ' s needs by an understanding of the abbreviations used (Resident #2). The facility reported a census of 65 residents. Findings include: 1. Resident #2 had an MDS (Minimum Data Set) assessment with a reference date of 11/18/13 which revealed the resident had intact cognitive skills for daily decision making, required limited assistance of one staff to transfer from one level to another and ambulate. The MDS reflected the resident had [DIAGNOSES REDACTED]. The MDS reported the resident had no falls since admission or the prior assessment. On 11/15/2013 the Care Plan identified Resident #2 had impaired physical mobility related to pain, musculoskeletal impairment, weakness, impaired range of motion and decreased tolerance for activity. The Care Plan instructed staff to assist the resident with a gait belt and wheeled walker. On 11/25/2013 the Care Plan added, except to toilet during daytime hours. On 11/25/2013 the staff added an intervention to the Care Plan that included, moderate independence with wheeled walker to toilet during daytime hours, may use urinal at night independently, continue to monitor and assist with ADL's, (Activities of Daily Living), he/she needs assistance to use "tools". The Daily Skilled Nurse's Notes reflected the following: On 11/25/2013 at 4:50 pm: Resident continues to work with OT/PT (Occupational and Physical Therapy) for gait training, strengthening and endurance. Today resident made mod (moderate) independence in room for toileting and able to stand at bedside leaning up against bed to use urinal, resident and wife aware. On 11/25/2013 at 6 pm to 6 am: patient alert and oriented, able to make needs known and in good spirits. Resident completed his/her own HS (night time) cares with supervision well. On11/26/2-13 at 3:35 pm: Increased contact guard assistance, wheeled walker and gait belt, gait steady, balance good. Working with OT/PT for strengthening, endurance, working on using tools for ADL's. Resident mod (moderate) independent in room for toileting. The Nurse ' s Notes continued: On 11/26/2013 at 10:15 pm a CNA (Certified Nursing Assistant) called the nurse (Staff F) to the resident ' s room and reported the resident fell back and she/he failed to catch self. Staff F observed the resident on his/her back by the bathroom door. The resident had shoes on and a walker in place. The resident reported he/she fell backward and lost his/her balance. Staff F observed the resident had a right wrist deformity and skin tears to the right upper extremity. The resident's spouse took the resident to the emergency room . At 11:30 pm the facility received a telephone call from hospital staff. The hospital staff confirmed the resident had a right wrist fracture and right hip fracture. Appointment made with orthopedic surgeon for 11/27/2013 at 9:45 am. At midnight the resident returned to the facility with spouse and pain rated at 10 out of 10. Pain medication administered. On 11/27/2013 the resident's spouse took the resident to the orthopedic appointment at 8:40 am, and did not return by 5:15 pm, after having surgery for [REDACTED]. The Nurse's Notes on 11/27/2013 from 6:00 pm to 6:00 am verified the resident returned with new orders and rated his/her pain at 10 on a scale of 1-10. The resident required extensive assistance of two staff to transfer and for bed mobility. On 12/13/2013, the facility notified the physician via facsimile that Resident #2 had a recently identified non-displaced fracture of the greater trochanter of the right hip and TTWB (toe touch weight bearing) of the right lower extremity. The facsimile reflected the facility needed clarification on allowable exercises and level of care for right hip and lower extremity. The physician ordered no active assistive or passive exercise to right lower extremity until evaluated by orthopedic. The Radiology Report dated 11/26/2013 revealed Resident #2 sustained a comminuted and impacted fracture of the distal right radius with radial and dorsal angulation at the fracture site and intra-articular extension. The right hip report revealed the resident had postsurgical changes of the right total hip arthroplasty, and cannot exclude acute fracture of the proximal femur. Correlate with clinical symptoms and onset, comparison to previous films would be helpful. The portable pelvis x-ray dated 11/30/2013 revealed no fractures seen. The final radiology report of the right femur revealed right hip prosthesis without evidence of complication, an equivocal non-displaced fracture through the greater trochanter right hip superior to the neck of the prosthesis, adjacent smoothly margined calcification which appears to be chronic, no other fracture identified. The weekly Medicare meeting documentation dated 11/22/2013, revealed physical and occupational therapy noted Resident #2 had weight bearing as tolerated (WBAT) status, transferred with stand by assist (SBA) to CGA (Contact Guard Assist), and increased activity tolerance and strength; focusing on balance and decreased level of activity in room. The weekly Medicare meeting documentation dated 11/29/2013 revealed occupational therapy directed staff to provide mod assist to transfer to the toilet; significant change due to right wrist fracture (dominant side). The Communication Sheet from Staff G and OT to staff dated 11/25/2013 regarding Resident #2 included: MI with FWW to toilet during daytime hrs. May use urinal at night EOB I'ly Continue to monitor with assist with ADL's, needs assist with tools. During an interview on 12/17/2013 at 11:30 a.m., Staff G. was questioned what MI meant. Staff G responded that MI meant modified independence with assistive device and allow extra time. Staff G was asked what EOB meant. Staff G stated it meant the resident may use urinal at the edge of the bed. Staff G was asked what I'ly means? Staff G stated it meant independently. During daytime hours the resident could ambulate independently in the room with the wheeled walker. Staff G was asked what would be meant by daytime hours. Staff G answered any time before bed. During the night, the resident needed to use the call light. Staff G stated the resident knew the instructions, and he/she had permission to go to the toilet only. Staff G heard when the resident fell , he/she had been in the dresser getting clothes out, unattended. At the time, the resident required assist of one staff person. The aide needed to be with the resident with a gait belt, unless he/she used the toilet only. Staff G stated the DON (Director of Nursing) asked her to put an abbreviation sheet in the communication book. On 11/27/2013 Staff G provided the abbreviations with meanings. A review of that sheet revealed no definition for 'MI'. On 12/17/2013 at 10:30 a.m., during an interview with Resident #2, with spouse present, the resident said he/she came to the facility after hip surgery for [REDACTED]. A couple of days later he/she returned to the hospital due to excessive bleeding and spent some time there. The day before he/she returned to the facility, they did an x-ray and found a crack in the bone above the replaced hip. The doctor said the break appeared perfectly aligned, showed healing, and they did not know when it occurred. The fall occurred when he/she stood between the bed and dresser, and like a bolt of lightning fell backwards. He/she had the walker and thought he/she hit a nearby metal chair on the way down. The resident indicated he/she had approval to be up in the room independently at the time of the fall. Staff H, in the room with the resident turned to put something in the bathroom. The resident's spouse thought staff needed to be with the resident, but with so many changes, it became difficult to remember. On 12/17/2013 at 10:20 a.m., observation revealed two staff transfer the resident from the wheel chair to lift chair with a gait belt, walker and pivot disc. During an interview with the DON on 12/17/2013 at 8:50 a.m., he/she indicated Resident #2 came to the facility after a hip replacement for rehabilitation. The resident got up to get something out of the dresser, the CNA walked with the resident without a gait belt, turned to put the urinal down and the resident fell backwards. The resident went to the emergency room and returned with an arm splint, diagnosed with [REDACTED]. At the time of the fall, the aide needed to have a hand on the resident. Therapy instructed staff to use stand by assistance with a gait belt and a walker. The resident could stand at the bedside to use the urinal independently. During an interview on 12/19/2013 at 11:00, the DON stated Staff H should have used a gait belt when the fall occurred. Daytime hours ended when second shift arrived for work at 6 pm. "MI" meant the resident had permission to be up in room with supervision, to the bathroom with a walker and supervision only. The Administrator now ordered therapy staff to stop using abbreviations; it caused confusion. During an interview on 12/17/2013 at 2:50 p.m., Staff H, CNA reported that on 11/26/2013 at approximately 10:30 pm, Resident #2 used the call light and asked to go to bed (with assistance). The resident told Staff H that therapy gave him/her approval to do everything independently with staff observation. During report from second shift, Staff H heard therapy switched Resident #2's status to Stand by Assist. Staff needed to observe the resident while the resident performed tasks in the room. Staff H failed to read the communication book until after the fall since the resident's call light came on soon after the shift started. When Staff H read the book, he/she had confusion with the documentation from therapy. The therapy communication read Moderately Independent with wheeled walker. The resident got up from the chair, used the walker to go to the dresser and Staff H turned towards the bathroom. Staff H heard a "ping" as if something hit the metal chair in the room. The resident's walker went down with the resident. Staff H was questioned what does stand by assist mean? Staff H responded: Only to watch, and provide help if needed. Staff H was questioned what did "MI" mean? Staff H responded: it means moderately independent, to move about with little help unless necessary. During an interview on 12/18/2013 at 10:00 am, Staff J, CNA reported working from 2 to 10 pm on 11/26/2013. When Resident #2 fell , Staff J sat at the nurse's station completing paper work. Second shift received report from the day shift. The day shift informed second shift that Resident #2 required modified independence with a walker to the toilet. Staff J, confused about the instructions, asked for clarification. Staff J stated the staff needed to watch the resident transfer and ambulate to the toilet and closet, but needed to assist the resident to the dresser. Staff G informed staff after they questioned the instructions. Staff G also informed them the resident required assistance with a gait belt if ambulating to the dresser. During an interview on 12/18/2013 at 10:55 am, Staff F, LPN (Licensed Practical Nurse) reported working on 11/26/2013 from 6 pm until 6 am on 11/27/2013. When asked what "MI with front wheeled walker to toilet during daytime" meant, Staff F reported being unsure. Therapy placed the abbreviations communication in the CNA book and therefore Staff F had never seen it and never signed it. During an interview on 12/17/2013 at 4:15 pm, Staff D, CNA reported Resident #2 recently had a communication sheet in the room from therapy with directions. Staff D stated "MI" meant mostly independent, but not for sure. The resident can do most things independently. According to the instructions, Resident #2 could toilet per self, but nothing else. The resident could use the urinal at night, but Staff D failed to know the meaning of "EOB". During an interview on 12/17/2013 at 1:50 pm, Staff I, CNA reported working the day shift from 6 am to 6 pm, and worked at the facility since 2009. Staff I reported never seeing the abbreviation "MI" and had no idea what it meant. Staff I stated Modified Independence meant staff needed to be in the room with the resident. Staff I had no idea what the abbreviation "EOB" meant. Staff I observed the abbreviation communication sheet and stated the sheet failed to include "MI", and "EOB" meant edge of bed. Staff I stated she assumed Modified Independence indicated the resident required minimal assist, but staff needed to be there with a gait belt.