Every finding on record at Kahl Home for the Aged & Infirmed

Based on observations, facility policy review, cleaning schedules, and staff interviews, the facility failed to label and date opened food items, clean equipment in the kitchen, and clean flooring in kitchen and dining areas to help prevent contamination and foodborne illness. The facility reported a census of 105 residents. Findings include:1. The following revealed during a continuous observation on 03/9/2026 from 9:45 AM to 10:30 AM: a. Walk-in refrigerator: 1. Open 5 oz (ounce) container of blue cheese crumbles2. Open bag of parmesan cheese.3. Open, undated green 5-gallon bucket of pickles. b. Stand-alone Freezer1. Open, undated bag of chicken tenders2. Open, undated bag of tater tots.c. The inside of a Victory stand-alone freezer had area of residue build up, and spilled items on the bottom shelf. Spilled items included a chicken tender, French fries and tater tots. d. Three large trays of breadsticks sat uncovered on a kitchen table.e. The outside of the fryer noted to have a buildup of a sticky grease-like substance. f. The outside of the microwave had a build up of dirt/food particles. g. The large mixer with a heavy buildup of residue. h. The bottom shelf of the prep table had buildup of residue and dried lettuce shreds. i. The inside of a Victory stand alone freezer had heavy buildup of residue, and on the bottom of the freezer there were a unpacked chicken tender, French fries and tater tots. j. The inside of the Cambro (a brand name of a heated transport cart) had a buildup of a sticky residue. 2. An observation conduced on 3/9/26 started at 10:10 AM of the 2nd floor dining room and the kitchenette between the 2 South Hall and 2 North Hall revealed:a. A spilled substance under steam table and on the shelf under the table top.b. A dried brown substance on the outside of the steam table.c. The floors in serving area had noticeable debris and a sticky red substance on the floor area in front of the steam table. d. The lower shelf of the refrigerator had spills of a sticky substance. 3. During observations of the 3rd floor kitchen the floor noted to cause shoes to stick to the floor on 3/10/26 @ 7:25 AM and on 3/12/26 at 7:36 AM. During an interview on 3/11/26 at 11:00 AM, the Dietary Manager (DM) asked about the unmarked food items and the overall cleanliness of the kitchen, stated the facility has had a lot of turn over and they are working on making changes. The DM stated it is the expectation that all opened food items are labeled and dated. The DM stated typically there are cleaning charts posted but the charts are in the process of being updated so they are not currently posted. During an interview on 03/12/2026 at 10:11 AM, Staff A, Dietary Aide stated there is a cleaning schedule for the kitchen, however they were taken about two weeks and had yet to be replaced. Staff A stated she worked day shift and cleaned the countertops, table, steam tables, toaster, coffee pots, tables, and wiped down refrigerators. She explained the kitchen staff are responsible for cleaning the floors in the kitchen, and Housekeeping staff clean the floors in the dining rooms. During an interview on 3/12/26 7:38 AM, Staff B, Dietary Aide stated first and second shits are responsible for keeping the kitchen clean. Staff B explained the floors are cleaned daily. Staff B confirmed the floors felt sticky when walked upon and she noticed the sound of sticking shoes made. Review of the policy titled Food Receiving and Storage, revised July 2014 revealed a Policy statement which declared Foods shall be received and stored in a manner that complies with safe food handling practices. The Policy Interpretation and Implementation section directed, in part:a. Food Services, or other designated staff, will maintain clean food storage areas at all times.b. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date).Review of the Dietary [NAME] job description, dated 2023 included, in part the following Assigned Task:a. Assists/directs daily cleaning duties in accordance to established policies and procedures. Review of the Dietary Aide job description, dated 2023 included, in part the following Assigned Task:a. Assists in daily cleaning duties as assigned to include work tables, meat blocks, and refrigerators/freezers in accordance to established policies and procedures. Review of a Dietary Cleaning Schedule indicated the following task assigned to Dietary Aides:Daily: Food Carts - thoroughly clean; Dishwasher - wipe clean after each use; Steamer - clean; Storage shelves - wipe clean; Sink & Drain - three times/day; Utility Carts - wipe clean after each use; Floors - Sweep & Mop; Refrigerator - wipe cleanWeekly: Range Hood - Thorough cleaning; Dining Room Tables & Chairs - clean with soap & water; Stock - put it awayReview of the Daily Cleaning Schedule checklist included, in part, the following tasks to be completed: Wash & Sanitize Mixer; Wash & Sanitize Prep Tables/Countertops; Sweep & Mop Kitchen Floor; Sweep & Mop Dining Room; Clean Microwave Oven; and Clean Food Carts.

Based on clinical record review, policy review, and staff interview, the facility failed to offer updated pneumococcal vaccinations (given to protect against infections which can cause pneumonia, a serious lung infection) for 4 of 5 residents reviewed for immunizations (Residents #3, #10, #12, and #32). The facility reported a census of 105 residents.Findings:1. Resident #3's admission Record listed an admission date of 5/22/22. The record listed her age as 94.The resident's Immunization Report documented she received the Pneumovax 23 (a type of pneumococcal vaccine) on 11/3/14 and the Prevnar 13 (a type of pneumococcal vaccine) on 11/10/15. A 5/2/22 Information/Permission form asked if the resident wished to receive the Pneumovax vaccine if there was no record of previous immunizations of Prevnar 13 and Pneumovax 23. The form indicated the resident previously received Prevnar 13 and Pneumovax 23. The form did not include information regarding updating the resident's pneumococcal vaccinations per current Centers for Disease Control and Prevention (CDC) guidelines. The form lacked information/education regarding additional pneumococcal vaccines available such as PCV20 and PCV21.2. Resident #10's admission Record listed an admission date of 8/14/24. The record listed her age as 88. Resident #10's Immunizations report documented she received the Prevnar 13 vaccination on 2/3/16.A 2/28/24 Information/Permission form asked if the resident wished to receive the Pneumovax vaccine if there was no record of previous immunizations of Prevnar 13 and Pneumovax 23. The form indicated the resident previously received Prevnar 13 and Pneumovax 23. The form did not include information regarding updating the resident's pneumococcal vaccinations per current CDC guidelines. The form lacked information/education regarding additional pneumococcal vaccines available such as PCV20 and PCV21.3. Resident #12's admission Record listed an admission date of 11/20/24. The record listed his age as 72. The resident's Immunization Summary documented he received the Prevnar 13 vaccine on 10/25/18 and the Pneumovax 23 on 11/12/19.A 8/14/24 Information/Permission form asked if the resident wished to receive the Pneumovax vaccine if there was no record of previous immunizations of Prevnar 13 and Pneumovax 23. The form indicated the resident previously received Prevnar 13 and Pneumovax 23. The form did not include information regarding updating the resident's pneumococcal vaccinations per current CDC guidelines. The form lacked information/education regarding additional pneumococcal vaccines available such as PCV20 and PCV21.4. Resident #32's admission Record listed an admission date of 12/30/25. The record listed her age as 79. The resident's Immunization report documented she received the Prevnar 13 vaccine on 2/5/15 and the Pneumovax 23 on 12/10/13.A 12/30/25 Information/Permission form asked if the resident wished to receive the Pneumovax vaccine if there was no record of previous immunizations of Prevnar 13 and Pneumovax 23. The form indicated the resident previously received Prevnar 13 and Pneumovax 23. The form did not include information regarding updating the resident's pneumococcal vaccinations per current CDC guidelines. The form lacked information/education regarding additional pneumococcal vaccines available such as PCV20 and PCV21.The facility policy Infection Control: Influenza and Pneumococcal Immunizations, dated 8/25/21, stated the facility followed the recommendations from the CDC as individualized by the resident's health care provider's professional judgement to determine appropriate vaccinations for residents. The CDC's Pneumococcal Vaccine Timing for Adults, retrieved from https://www.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf included the following directives:A. For adults over age [AGE] who had Prevnar 13 at any age and Pneumovax 23 at age [AGE] or older, vaccine providers may choose to administer PCV20 or PCV21.B. For adults over age [AGE] who had Prevnar 13 only, PCV20 or PCV21 was recommended.On 3/12/26 at 4:22 p.m., the Director of Nursing (DON) stated that they worked with the pharmacy to set up vaccination clinics. She stated she expected residents to be up to date on their vaccinations. She stated they could not locate any additional records of vaccines for the residents. She stated they would offer the vaccines in the near future.

Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to follow dietician recommendations and weigh a resident at least monthly for 1 of 11 reviewed for nutrition (Resident #112). The facility reported a census of 106 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 did not have a Brief Interview for Mental Status (BIMS) exam completed due to resident rarely or never understood. The MDS indicated resident required set up or clean up assistance with eating. The list of diagnoses included non-Alzheimer's dementia and depression. The MDS indicated no known weight loss of more than 5% in a month and the need for a mechanically altered diet. The Care Plan revealed a Focus area, revised on 10/20/25, to address at risk for malnutrition due to weight loss related to energy needs greater than energy intake related to difficulty chewing, holding food in mouth, possibly being a vegetarian diet for 5 months, dementia, depression as evidenced by 9 pounds weight loss in 4 months. Interventions included, in part:a. 8 ounces of Ensure (brand name of a nutritional supplement) 250 to 350 kcal (calories) and 9-13 gm (grams) of protein and 30 ml (milliliters) Active Protein Liquid (15 gm protein and 60 kcal) for at risk of malnutrition. Start date: 10/20/25.b. Weigh per policy. Start date: 10/10/25. Review of the electronic health record (EHR) revealed the following Physician Orders:a. Ensure daily 8 ounces. Ordered 10/12/25b. Active (protein liquid) 30 ml daily. Ordered 10/12/25c. Regular diet, Mechanical Soft with Ground Meat texture, thin consistency for diet requested per daughter. Ordered 1/22/26Review of a Progress Note dated 12/23/25 at 8:47 AM revealed the Nutrition Comprehensive Assessment Completed Nutrition diagnosis: underweight related to inadequate energy intake as evidenced by body mass index (BMI) of 19 with poor oral intakes. RD (Registered Dietician) recommendations: Increase supplements due to poor oral intakes. Offer Ensure three times a day (TID) and active 30 ml daily. Encourage oral intakes greater than 50%, assist as needed. RD will monitor oral intakes/weight trends. Notify of significant changes/concerns .The Progress Notes signed by the Nurse Practitioner (no date identified). The EHR Weight Summary Report revealed a weight of 107.5 Lbs (pounds) on 12/5/25, and on 2/1/26 a weight of 99.6 Lbs. This represents a weight loss of 7.35%. No weights recorded for the month of January 2026. During an observation on 3/10/26 at 12:35 PM, Resident #112 independently ate broccoli, ground meat, white rice, and a piece of bread. During an interview on 3/11/26 at 2:54 PM, Staff D, former Registered Dietician (RD) explained she has returned to the facility to assist with training Staff E, RD. Staff D stated dietician recommendations go to the provider to be signed, and then the Director of Nursing (DON) put the orders in the electronic system. During an interview 3/11/26 at 2:57 PM, Staff E, RD stated Staff D, former RD had recommended Resident #112 receive three times a day and Active liquid protein daily and to encourage resident to eat more. During an interview on 3/11/26 at 3:00 PM- Staff D, former RD confirmed the order for Resident Ensure is daily. Staff D explained she did not work at the facility in December 2025 and another RD covered during that time. Staff D explained that no weights were documented in January 2026 for Resident #112 thus there was not a weight loss triggered on the EHR dashboard for the dietician. During an interview on 3/12/26 at 12:08 PM, Staff F, RD stated Dietician asked about Resident #112 weight and Staff F stated another dietician who worked remotely put in the recommendations in December. Staff F stated sometimes working remotely things can fall through the cracks and in this case that could have been what happened. Staff F stated if she would have noticed Resident #112 not being weighed in January, she would have told the facility to get the weight, but she did not notice the missed January weights. During an interview on 3/12/26 at 2:49 PM, Staff G, Registered Nurse (RN) Unit Manager queried on who completed the weights and Staff G stated everyone was responsible for weights. Staff G stated the system flagged for weights to be completed every 30 days and the Certified Nurse Assistants (CNA) usually did them, but the nurses could obtain the weights too. Staff G stated she was just looking at Resident #112 file and the facility had safety precautions in place to prevent weights from getting missed but the new system rollout allowed staff to complete an assessment without all the documentation completed. Staff G stated the facility's system failed. Staff G stated Resident #112 went to the hospital during that time and the facility didn't know if Resident #112 lost weight during the hospital admission or at the facility. Staff G confirmed a readmission weight did not get obtained. During an interview on 3/12/26 at 3:17 PM, the DON queried on Resident #112 weights and dietician recommendations to increase supplements and the DON confirmed the TID Ensure order was missed. The DON stated all the recommendations went through her and the DON would have signed the recommendation. The DON stated all the residents were ordered monthly weights and the DON didn't know if the weight loss happened at the hospital or the facility. Review of the undated facility policy titled Weight Monitoring Policy revealed, in part: a. A weight monitoring schedule will be developed upon admission for all residents:1. Weights should be recorded at the time obtained.2. Residents with weight loss- monitor weight weekly.Review of the undated facility policy titled, Nutritional Management revealed, in part:a. Monitoring/revision:1. Nutritional recommendations may be made by the dietician based on the resident's preferences, goals, clinical condition or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. 2. Dietary orders may be written or modified by the qualified dietician or other clinically qualified nutrition professional if the resident's attending physician/practitioner delegates the task, dependent upon state law or facility policy.

Based on observations, clinical record review, and staff interviews, the facility failed to cover clean laundry during transport to resident rooms during 2 out of 2 observations, failed to keep a urinary drainage bag off the floor and failed to keep the graduated cylinder used to empty urine form a catheter collection bag off the floor for 1 out of 1 resident reviewed (Resident#35). The facility reported a census of 105 residents.Finding include:1. During an observation on 03/09/2026 at 1:09 PM, Staff I, Laundry Aide pushed an uncovered laundry cart, which contained hung clean laundry, from North 210 to North 203. 2. During an observation on 03/11/2026 at 11:42 AM, Staff J, Laundry Aide pushed an open hanging cart, half full of clean clothes on hangers, past three residents in the lounge on the South 3rd floor. Staff J left the cart open while she delivered clothing to five resident rooms. 3. Review of the Minimum Data Set (MDS) assessment for Resident #35, dated 2/11/26, list of diagnoses included of stoke, obstructive uropathy ( blockage in the urinary system that prevents urine from flowing freely), and dementia. The MDS identified Resident#35 with severe cognitive impairment base on a Brief Interview for Mental Status (BIMS) score of 2 out of 15. The MDS reflected Resident#35 dependent for toileting hygiene. The Care Plan for Resident #35 dated 8/8/25, identified an indwelling suprapubic catheter (flexible tube inserted through the lower abdominal wall directly into the bladder to drain urine). The Care Plan revised on 2/24/26 directed Resident#35 will not develop a urinary infection through review date. Review of a Progress Notes dated 3/1/26 at 3:10 PM, reflected Resident#35 took antibiotic for a urinary tract infection (UTI).During an continuous observation on 03/11/2026 which started at 1:11 PM , Resident #35 sat at a table in the dining room. At 1:14 PM, Staff H, Certified Nurse Assistant (CNA) pushed Resident#35 out of the dining room. At 1:16 PM, Staff H stood in the room while Resident #35 lay on the bed. Staff H reported she needed to empty Resident #35's drainage bag. Staff H put on the required personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP). Staff H gathered her supplies and placed them on the bed, the catheter drainage bag sat on the floor in the left side of the bed. Staff H explained what she was doing to Resident #35. Staff H set graduated cylinder directly on the floor on the left side of the bed. Staff H obtained a paper towel and placed it under the graduated cylinder. Staff H sat Resident#35 up on side of the bed. At 1:20 PM, Staff H opened the catheter drainage spout, drained the urine into the graduated cylinder, closed the drainage spout and cleaned it with an alcohols swab. Staff H unhooked the leg bag, used an alcohol swab to clean the connections, swabbed to the drainage bag connection and hooked it to the catheter. At 1:22 PM, with Resident #35 urinary catheter drainage bag on the floor, Staff H removed her gloves and washed her hands. Staff H placed new gloves on and dumped the urine into the toilet. Staff H rinsed out the graduate with water and stored the graduate in a plastic bag. Staff H removed her gloves and washed her hands. At 1:24 PM Staff H picked catheter bag up off the floor and hung on the side of the bed. Staff H covered Resident#35 and the movement of the bed shifted the catheter bag the bottom 1 inch of the catheter bag sat on the floor. During an interview on 3/12/2026 at 4:05 PM, Staff K, CNA stated staff needed to place the graduated cylinder on a paper towel on the floor when the catheter is emptied. Staff K said the catheter bag should not be placed on the floor. During an interview on 03/12/2026 at 4:15 PM, Staff M, Registered Nurse (RN) stated staff needed to place the graduated cylinder on a paper towel on the floor when the catheter is emptied. Staff K said the catheter bag should not to be placed of the floor.During an interview on 3/16/26 at 11:46 AM the Infection Preventionist (IP) reported the laundry should be covered while being transported throughout the facility and when distributed onto a units. The IP reported catheter bags are to be covered, and need be hung below the bladder, not resting on the floor. The IP said if a graduate cylinder is used, it should be placed on a floor barrier. Review of the facility policy, titled Binder Basics Infection Control dated 2025, identified the presence of invasive medical devices such as urinary catheters or central lines provide a site for pathogen to enter the body. These devices and medical conditions are associated with a greater risk of infection. The Binder directed clean linen must be transported by a methods that ensure cleanliness and protect from dust and soil during transport.

Based on observation, clinical record review and staff interviews, the facility failed to implement a physician order given after a low lab result for 1 of 5 residents (Resident #1) in the sample. The facility reported a census of 104 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS list of diagnoses included malignant neoplasm of the colon (colon cancer), arthritis and aphasia (difficulty speaking). The MDS indicated Resident #1 required substantial/maximal staff assistance with toileting, partial/moderate assistance with showers, dressing, putting on and removing footwear and repositioning.Review of the electronic health record (EMR) revealed an admission Record which indicated Resident #1 admitted to the facility on [DATE] and discharged on 12/19/25.Review of a 12/8/25 Progress note -routine written by a Nurse Practitioner (NP) revealed a 12/5/25 lab result of K+ (potassium) result of 3.2 - L (low). The Assessment & Plan section included.Hypokalemia (low potassium) Will start potassium chloride 10-mEq (milliequivalents) daily. Repeat BMP (Basic Metabolic Panel - a lab order that includes potassium level) in 1 week. Review of the EMR revealed a Health Status Note entered on 12/8/25 at 10:33AM, [Name of NP redacted] noted labs with no new orders.Review of the December 2025 Medication Administration Record (MAR) revealed a lack of an order for /administration of Potassium Chloride 10 mEq daily. A review of the lab reports revealed no reports after 12/8/25 results.During an interview on 12/23/25 at 7:32 AM, Staff D, Registered Nurse (RN) reported if a Nurse Practitioner writes a new order, she will leave the order with the floor nurse. Staff D explained the floor nurse would document this on a progress note and send the order to the pharmacy. The new order should be recorded on the physician order summary. Staff D stated the NP does not dictate the notes the day of rounds and a nurse may not see then for a week. During an interview on 12/23/25 at 2:35 PM, the NP reported she recalled she had written an order for Resident #1 on 12/8/25 for the potassium chloride 10 mEq daily. She stated she expected orders to be carried out within 24 hours.During an interview on 12/30/25 at 11:28 AM, the Director of Nursing reported when a NP writes a new order, it is placed on physician order sheet and should give it to the floor nurse or Unit Manager, either one is responsible for processing new orders. The Unit Manager is responsible for running a report to review for new orders on a daily basis. The order written 12/8/25 for potassium chloride for Resident #1 should have been processed and transcribed to the MAR within 24 hours of 12/8/25. Review of the facility policy, titled Verbal Orders dated 4/17/24 revealed the Policy statement Physician orders may be received by telephone, by a licensed nurse or registered health care specialist who is legally authorized to do so. The Policy Explanation and Compliance Guidelines directed, in part:1. Repeat any prescribed orders back to the physician or health care provider.2. Use clarification questions to avoid misunderstandings.3. Enter the order into the electronic medical record.4. The T.O. (telephone order) or V.O. (verbal order) must include: date, time, name of the resident, the complete order with form, dosage, route, frequency and indication, the name of the physician or health care provider and nurse sign off of the electronic order as per the software system guidelines. 5. The physician or provider will authenticate the order within the time limit set by state regulations.6. Preferred method for provider signatures: Physician or provider should authenticate the order within Point Click Care's order portal.7. If necessary, the order may be printed out for the physician or provider to sign in wet ink within state identified time limit. If the order is signed in this manner, the actual signed order should be scanned into Point Click Care, and the order should be marked as 'signed in wet ink' in the orders portal as soon as reasonably able to be completed.8. Follow through with orders by making appropriate contact or notification (e.g., lab or pharmacy).

Based on observation, clinical record review and staff interviews, the facility failed to utilize isolation gowns when providing resident care that require the use of Enhanced Barrier Precautions (EBP) for 1 of 3 residents (Resident #3) in the sample. The facility reported a census of 104 residents.Findings include:Review of the Minimum Data Set (MDS), dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS list of diagnoses included pressure ulcer to the sacral region. The MDS indicated Resident #3 dependent on staff for assistance with toileting and transfers in and out of bed/chair, and required substantial/maximal assistance with showers.Review of Resident #3 Care Plan, dated 2/12/25, the Care Plan revealed a Problem to address The resident requires enhanced barrier precautions (EBP) to reduce the spread or potential spread of multi-drug resistant organisms R/T (related to) a pressure injury. Interventions included, in part:a. Nursing staff to wear gown and gloves during wound cares. Date Initiated: 2/12/25.b. Staff are to wear gown and gloves with ADL (activities of daily living) cares such as: dressing, bathing/showering, catheter or ostomy cares, and toileting tasks including changing briefs, and toileting hygiene. Date Initiated: 2/12/25.During an observation on 12/23/25 at 1:22 PM, an Enhanced Barrier Precautions sign posted on the room of Resident #3 door. During an observation on 12/29/25 at 11:25 AM, Staff G, Licensed Practical Nurse (LPN) and Staff H, Registered Nurse (RN) each wore isolation gown and gloves while they assisted Resident #3 with toileting. Staff F, CNA entered the bathroom wearing gloves but did not wear a gown. During an interview on 12/29/25 at 1:46 PM, Staff F, CNA reported when providing cares to Resident #3, staff should be wearing a gown and gloves. She admitted she gave Resident #3 a shower earlier and took the isolation gown off afterward and forgot to put another one when she dried her back.During an interview on 12/29/25 at 2:03 PM, Staff G, LPN reported before staff provide care for Resident #3, they should wear an isolation gown and gloves as she is on EBP. Staff G stated Staff F, CNA should have worn an isolation gown during cares today.During an interview on 12/30/25 at 11:28 AM, the Director of Nursing reported she would expect staff to wear an isolation gown and gloves prior to providing care to Resident #3 as she is in EBP. Review of the facility policy titled, Enhanced Barrier Precautions Policy dated 3/27/25 included, in part:a. Policy statement: It is the policy of this home to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. b. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.c. Policy Explanation and Compliance Guidelines section: 3. Implementation of Enhanced Barrier Precautions b. PPE (Personal Protective Equipment, i.e gloves and gowns) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact care activities include: Dressing, Bathing, Transferring Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters), Wound care: any skin opening requiring a dressing

Based on clinical record review, facility policy review and staff interviews, the facility failed to intervene and inform the provider a pressure ulcer worsened which resulted in a hospitalization for treatment for 1 of 3 (Resident #1) residents reviewed for pressure ulcers. The facility reported census was 106. Findings include: The MDS (Minimum Data Set) assessment definition of pressure ulcers included the following: 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 (dead tissue, usually cream or yellow in color). 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 (dry, black, hard necrotic tissue), may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Review of the Minimum Data Set (MDS), dated [DATE], for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS list of diagnoses included peripheral vascular disease, renal insufficiency, diabetes mellitus, paraplegia, pressure-induced deep tissue damage of other site, and malnutrition. The MDS indicated Resident #1 dependent for transfers and mobility. The MDS identified Resident #1 at risk for developing pressure ulcers, and documented Resident #1 with 1 unstageable pressure ulcer/injury at the time of the assessment. Review of the Care Plan, dated 5/8/25 revealed a Focus area to address The resident has unstageable area to left buttock r/t (related to) Hx (history) of pressure injuries, bowel incontinence and immobility. Present upon readmission from hospital. Interventions included, in part: Assess/record/monitor wound healing weekly and PRN (as needed). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvements and declines to the MD (medical doctor). Revision Date: 5/8/25. Review of the electronic health record (HER) revealed the following: a. Health Status Note entered on 4/17/25 at 5:20 PM documented Resident returned from hospital via transporter in wheelchair at 17:05 (5:05 PM). b. Health Status Note entered on 4/18/25 at 5:35 AM documented Wound Care Buttock Fold. Prior to hospitalization Care to buttock and coccyx skin was for house barrier Cream BID (twice daily). admission skin assessment on 4/17/25 found two open areas, slits, bleeding, to the buttock skin fold. Two wound forms completed. Wrote new wound care order until seen by Wound Nurse. c. Physician/Nurse Practitioner/Physician Assistant note entered on 4/21/25 at 4:36 PM documented, in part .Chief Complaint: FOLLOW UP ON HOSPITALIZATION for right foot osteomyelitis .INTEGUMENTARY (skin): .Exam: Findings: see nsg (nursing) documentation on skin assessment. documented left and right heel wounds. protective boots in place. Buttocks wound. PLANS: Buttocks wound not addressed. d. Physician/Nurse Practitioner/Physician Assistant note entered 4/22/25 at 2:39 PM documented, in part .Reason for visit: Routine .Skin: Several wounds followed by wound dr, healing ulcer on right dorsum (back or upper surface) 2nd digit (finger or toe). Assessment/Plan: No new orders. e. Structured Progress Note entered on 4/23/25 at 9:27 AM documented [name redacted] wounds were evaluated. Resident has Four wounds. Locations/Left Heal Right Heal Left Buttock Sacral Refer to weekly wound form. 1. Weekly Wound Documentation, dated 4/23/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Stage 3. Length: 2.5 cm. Width: 1.5 cm. Depth: 0.1 cm. Granulation tissue 100%, pink/red 100%; Exudate amount: light (less than 10% on dressing), serosanguineous (combination of body fluid and blood, which appears light pink to red in color). Wound odor: Not applicable. Wound Progress: New. f. Physician/Nurse Practitioner/Physician Assistant note entered on 4/28/25 at 5:02 PM documented, in part .Chief Complaint: FOLLOW UP ON HOSPITALIZATION for right foot osteomyelitis .INTEGUMENTARY (skin): .Exam: Finding see nsg documentation on skin assessment .buttocks wound. PLANS: Buttocks wound not addressed. g. Structured Progress Note entered on 4/30/25 at 11:33 AM documented [name redacted] wounds were evaluated. Resident has Four wounds. Locations/Left Heal Right Heal Left Buttock Sacral Refer to weekly wound form. 1. Weekly Wound Documentation, dated 4/30/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Stage 3. Length: 4.0 cm. Width: 3.0 cm. Depth: 0.1 cm. Granulation tissue 50%, pink/red 100%; Slough: 50%, white, adherent. Exudate amount: Moderate (50% on dressing), serous (straw colored body fluid). Wound odor: Not applicable. Wound Progress: Worse. 2. Review of the EHR from 4/30/25 to 5/6/25 lacked documentation the facility notified the MD Resident #1's pressure ulcer worsened. h. Structured Progress Note entered on 5/7/25 at 11:53 AM documented [name redacted] wounds were evaluated. Resident has Three wounds. Locations/Left Heal Right Heal Left Buttock Refer to weekly wound form. 1. Weekly Wound Documentation, dated 5/7/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Stage 3. Length: 2.5 cm. Width: 3.0 cm. Depth: 0.1 cm. Granulation tissue 10%, pink/red 10%; Slough 90%, white and adherent. Exudate amount: moderate (50% on dressing), serous. Wound odor: Not applicable. Wound Progress: Worse 2. Review of the EHR from 5/7/25 to 5/13/25 lacked documentation the facility notified the MD Resident #1's pressure ulcer worsened. i. Structured Progress Note entered on 5/14/25 at 10:09 AM documented [name redacted] wounds were evaluated. Resident has Three wounds. Locations/Left Heal Right Heal Left Buttock Refer to weekly wound form. 1. Weekly Wound Documentation, dated 5/14/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Stage 3. Length: 2.5 cm. Width: 4.0 cm. Depth: 0.1 cm. Granulation tissue 5%; Slough 95%, white, tan and adherent. Exudate amount: moderate (50% on dressing), serous. Wound odor: Not applicable. Wound Progress: Worse 2. Review of the EHR from 5/14/25 to 5/20/25 lacked documentation the facility notified the MD Resident #1's pressure ulcer worsened. j. Structured Progress Note entered on 5/21/25 at 9:27 AM documented [name redacted] wounds were evaluated. Resident has Three wounds. Locations/Left Heal Right Heal Left Buttock Refer to weekly wound form. 1. Weekly Wound Documentation, dated 5/21/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Stage 3. Length: 2.5 cm. Width: 3.5 cm. Depth: 0.1 cm. Slough 100%, white, adherent. Exudate amount: Light (less than 10% on dressing), serous. Wound odor: Not applicable. Wound Progress: Stable/No change. k. Structured Progress Note entered on 5/28/25 at 11:52 AM documented [name redacted] wounds were evaluated. Resident has Four wounds. Locations/Left Heal Right Heal Left Buttock Sacrum Refer to weekly wound form. 1. Weekly Wound Documentation, dated 5/28/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Unstageable. Length: 6.5 cm. Width: 3.5 cm. Depth: 0.1 cm. Eschar 100%, black, adherent, soft. Exudate amount: Moderate (50% on dressing), serous. Wound odor: Not applicable. Wound Progress: Not documented. 2. Health Status Note entered on 5/28/25 at 9:30 PM documented pt wound care done tonight left buttock wound is necrotic was cleaned and dried and a clesan [clean] dry dressing was applied and covered with triad gel, sacrum was clean and a clean dry dressing was applied she tolerated her treatment well. 3. Review of the EHR from 5/28/25 to 6/3/25 lacked documentation the facility notified the MD Resident #1's pressure ulcer worsened. l. Structured Progress Note entered on 6/4/25 at 7:04 AM documented [name redacted] wounds were evaluated. Resident has Four wounds. Locations/Left Heal Right Heal Left Buttock Sacrum Refer to weekly wound form. 1. Weekly Wound Documentation, dated 6/4/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Unstageable. Length: 4.0 cm. Width: 2.0 cm. Depth: 0.1 cm. Eschar 100%, black, adherent, soft, boggy. Exudate amount: Light (less than 10% on dressing), serous. Wound odor: Not applicable. Wound Progress: Worse. 2. Review of the EHR from 6/4/25 to 6/10/25 lacked documentation the facility notified the MD Resident #1's pressure ulcer worsened. m. Health Status Note entered on 6/5/25 at 5:59 PM documented Treatment with [provider name, clinic name. address, and phone number redacted] June 16th 2025 13:30 (1:30 PM) and June 26th 2025 at 14:00 (2:00 PM). n. Structured Progress Note entered on 6/11/25 at 12:51 PM documented [name redacted] wounds were evaluated. Resident has Three wounds. Locations/Left Heal Right Heal Left Buttock Refer to weekly wound form. 1. Weekly Wound Documentation, dated 6/11/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Unstageable. Length: 4.0 cm. Width: 2.0 cm. Depth: 0.1 cm. Eschar 100%, black, adherent, soft, boggy. Exudate amount: Light (less than 10% on dressing), serous. Wound odor: Not applicable. Wound Progress: Worse. 2. Health Status Note entered on 6/16/25 at 10:47 PM documented, in part .treatment done to buttock foul smelling small amount of drainage. The lacked documentation the MD notified of foul smell noted during the treatment. 3. Review of the EHR from 6/11/25 to 6/17/25 lacked documentation the facility notified the MD Resident #1's pressure ulcer worsened. o. Physician/Nurse Practitioner/Physician Assistant note entered on 6/17/25 at 2:20 PM documented, in part .Reason for Visit: Routine. Patient complaints: None .Skin: Several wounds followed by wound dr .Assessment/Plan: No new orders. p. Structured Progress Note entered on 6/18/25 at 2:58 PM documented [name redacted] wounds were evaluated. Resident has Three wounds. Locations/Left Heal Right Heal Left Buttock Refer to weekly wound form. 1. Weekly Wound Documentation, dated 6/18/25, in part: Wound Three. Anatomical Location: Left buttock. Type of Altered Skin Integrity: Pressure Injury. Pressure Injury Stages: Unstageable. Length: 7.5 cm. Width: 4.4 cm. Depth: 1.5 cm. Eschar 100%, black, adherent, soft, boggy. Exudate amount: Light (less than 10% on dressing), serous. Wound odor: Foul. Wound Progress: Worse. 2. Review of the EHR from 6/18/25 to 6/24/25 lacked documentation the facility notified the MD Resident #1's pressure ulcer worsened. q. Physician/Nurse Practitioner/Physician Assistant note entered on 6/19/25 at 3:14 PM documented, in part .Encounter Type: Comprehensive Progress Note .INTEGUMENTARY: .Exam: Finding: see nsg documentation on skin assessment .buttocks wound. Plan: stable. next wound clinic appt on 6/26/25 please schedule weekly visits with wound clinic for now per their recommendations. Continue offloading measures. r. Health Status Note entered on 6/24/25 at 5:12 PM documented This nursing supervisor received a call from the wound clinic notifying that the resident is being transferred to the ER (emergency room) for the ischium (a paired bone forming the lower and back part of the hip bone) wound . Review of the Provider Progress Note, Service: Wound Care dated 6/24/25 at 2:30 PM revealed the following Wound Assessment for Pressure Injury Left Ischium Unstageable (active): Site Assessment: Necrotic; Eschar. Length: 7.5 cm. Width: 7 cm. Depth: 1.3 cm. Drainage Amount: Small. Wound Drainage Description: Malodorous (unpleasant smell); Serosanguineous. The Provider Progress Note Assessment included, in part: a. Complicated wound infection verses cellulitis (bacterial infection of skin and underlying tissues) to her left ischium, patient sent to [hospital name redacted] emergency room in [name of town redacted]. b. Unstageable pressure ulcer to left ischium with no subcutaneous tissue exposed covered with slough/necrosis, nonhealing with evidence of infection. During an interview on 7/1/25 at 1:30 PM Staff I, Registered Nurse (RN), facility wound nurse, stated Resident #1 pressure ulcer started as two open slits that started during a hospital stay (4/17/25) and grew a little over the next two months. Staff I stated Resident #1 was eventually referred to the wound clinic when they felt they needed help treating the wound. Staff I noted Resident #1 had heel wounds [diabetic ulcer] which the wound clinic managed, but she had not been referred to the wound clinic for her buttocks until 6/5/25. Staff I stated she last saw Resident #1's buttocks wound on 6/18/25 and at that time she changed the order to include Dakin's (name brand of a topic antiseptic used for wound care) to help dry out the wound. Staff I stated she relies on her staff to inform her of a wound worsening or getting infected. During an interview on 7/3/25 at 11:40 AM, the Director of Nursing (DON) stated the hospital wound clinic had been involved with Resident #1's buttocks wound prior to her April hospitalization and was to resume care after her hospitalization. The DON stated she believed it was the resident or family that said something about Resident #1's buttock wound on 6/5/25. The DON stated the wound clinic chose not to look at it at that time and instead scheduled a routine visit on 6/16/25. The DON stated Resident #1 was seen by her primary care physician (PCP)on 6/17/25 and the NP (Nurse Practitioner) on 6/19/25. The DON was not sure whether the PCP looked at the buttocks wound. The DON stated the reason for a referral to a wound clinic or hospital is to get a higher level of expertise when treating wounds, but noted they have successfully treated wounds much worse than Resident #1's. The DON stated she knew of no one at the facility that was in contact with the wound clinic or who sought out a higher expertise during the time the buttocks wound continued to deteriorate and the time she was admitted with an infected wound and sepsis. Review of ED (Emergency Department) Provider Notes, dated 6/24/25 at 4:47 PM revealed Chief Complaint: Wound Check .Physical Examination: Skin: Comments: Erythema (redness) extensively over sacral coccyx with pressure ulcer over the left ischial tuberosity. Wound is malodorous, with drainage Summary/Medical Decision Making: Differential Diagnoses: Infected pressure ulcer, osteomyelitis, sepsis . Review of a hospital Infectious Disease Progress note, dated 7/1/25 revealed the following Assessment/Plan, in part: a. Patient is s/p (status post, meaning after) surgical debridement of left ischial wound on 6/29[2025] with [physician name redacted]. b. Wound culture from 6/24[2025] of left ischial wound positive for pseudomonas (type of bacteria). Review of the policy titled, Wound and Skin Care-Pressure Injury Prevention and Management, dated 5/31/23 revealed a Policy statement which declared This home is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The Definitions section of the policy included: Avoidable means that the resident developed a pressure ulcer/injury and that the home did not do one or more of the following: evaluate the residents clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The Policy Explanation and Compliance Guidelines sections of the policy included, in part: 5. Monitoring b. The attending physician will be notified of: i. The presence of a new pressure injury upon identification ii. The progression towards healing, or lack of healing, of any pressure injuries weekly and as needed. iii. Any complications (such as infection, development of a sinus tract, etc) as needed.

Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure two staff transferred a resident with a mechanical lift and positioned the resident appropriately in a Broda chair resulting in an injury for 1 of 2 residents (Resident #2) reviewed for safety. The facility reported census was 106. Findings include: Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had a Brief Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS indicated Resident #2 required maximal to dependent assistance with transfers and mobility. The MDS list of diagnoses included Non-Alzheimer's dementia, congestive heart failure, and arthritis. During an interview on 7/1/25 at 4:50 PM Staff J, Certified Nurse Aide (CNA), queried regarding a transfer of Resident #2 on 5/13/25, stated they were busy because the day shift did not get their showers completed. At around 5:00 PM he and his partner, Staff N, Registered Nurse (RN) were getting residents up for supper. Resident #2 was one of the last to get up. Staff J stated he went into her room and placed the mechanical lift sling under her and attached it to the lift on his own. After waiting some time for his partner, he decided to lift Resident #2 by himself. While she was lifted, Staff J stated he had a hold of her right foot and was attempting to unfold the foot rest on the Broda chair (a brand name of a specialized wheelchair), when he accidentally dropped her foot on the foot rest, resulting in the cut to her right 5th toe. Staff J stated he reported the incident to his nurse, Staff M, RN Unit Manager. Review of the Non-Pressure Skin Condition Record, dated 5/13/25, completed by Staff N, RN Resident #2 had a 3 centimeter by 1 centimeter by 0.1 centimeter skin tear to her right 5th toe. During an interview on 7/2/25 at 11:37 AM, Staff O, CNA, stated she knew of Resident #2's right foot injury on 5/13/25. Staff O stated they were very busy on the night of 5/13/25 and she was giving a resident a shower when the incident occurred. Staff O stated Resident #2 was a full body mechanical lift and required two staff to transfer residents safely. She assumed Staff J, CNA transferred her by himself. Staff O stated she first heard of the incident during supper, when Staff J whispered that Resident #2 had a cut toe that occurred while he was attempting to adjust her feet during a transfer. Staff O stated Staff J was upset. Staff O stated Resident #2 often had lower extremity swelling. During an interview on 7/2/25 at 12:22 PM, Staff P, Licensed Practical Nurse (LPN), queried about Resident #2's right foot injury on 5/13/25. Staff P recalled it was supper time and she was in the nurse's station charting when Staff J, CNA approached her and said Resident #2's toe was bleeding. Staff J stated she went to look at her toe and she was in her Broad chair. Her right 5th toe was bleeding slightly and there was a slit on the bottom joint of her toe. Staff IP stated she cleaned it and wrapped it gauze. After supper it seemed to start bleeding more. Staff IP, LP stated she cleaned it, added an antibiotic ointment and wrapped it more firmly in Kerlix (an umbrella brand name used to for a gauze like bandage roll). Staff P stated Staff J told her he had hit her foot on the Broda chair foot rest. Staff P stated she notified family, physician and supervisors of the incident. Staff P stated she was not aware that Staff J had transferred Resident #2 using the full body mechanical lift by himself. During an interview on 7/2/25 at 7:57 AM, the Hospice Case Manager (HCM) queried regarding Resident #2's foot injury on 5/13/25, stated the facility notified them (hospice) of an incident resulting in a laceration of Resident #2 ' s right toe. The facility stated they were trying to move her and dropped her foot. Hospice sent out a nurse who assessed the wound noting a small, but deep laceration on her right small toe. The whole foot was swollen. The HCM stated the following day she assessed the right foot and stated it was black and blue, the big toe swollen and black. During an interview on 7/2/25 at 9:30 AM, the Director of Nursing (DON) queried what she knew of Resident #2's right foot injury on 5/13/25, stated Staff J, CNA had Resident #2 sitting in her Broda chair and her foot rest was not flipped open. According to Staff J, he lifted her foot to open up the foot rest and dropped her right foot striking the foot rest and resulting in the lacerated right 5th toe. In a follow up interview on 7/3/25 at 11:40 AM, the DON queried regarding the injury of Resident #2. The DON stated she was aware that Staff J, CNA had transferred Resident #2 using a mechanical lift from her bed into her Broda chair by himself. The DON stated the transfer was successful and it was the positioning the resident after the transfer when the injury occurred. Review of the policy titled, Resident Care-Safe Resident Handling/Transfer, dated 9/12/2024 revealed a Policy statement which declared, It is the policy of this home to ensure residents are handled and transferred safely to prevent or minimize the risk for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The Compliance Guidelines section, directed staff, in part: #10 Two staff members must be utilized when transferring residents with a mechanical lift. Review of facility staff training documentation revealed: a. An In Service Sign In sheet, dated 5/14/25, Topic: All Staff Mechanical Lift Requires assist x 2. The Sign In sheets had a total of 54 facility staff signatures. b. An In Service Sign In sheet, dated 5/15/25, Topic: Proper Placement of feet in W/C (wheelchair) and Broda. The Sign In sheets had a total of 55 facility staff signatures.

Based on observation, record review and staff interview, the facility failed to utilize Enhanced Barrier Precautions for 4 of 6 residents observed (Residents #12, #41, #68 and #89) and failed to keep the tubing of indwelling catheter tubing off the floor for one of two residents observed (Resident #68). The facility reported a census of 104 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #12 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: fractures/multiple trauma, pneumonia and a urinary tract infection. The MDS indicated the resident dependent on staff for toileting and showers, repositioning and required substantial/maximal staff assist with transfers, lower body dressing and putting on footwear. The MDS also identified Resident #12 had an unhealed Stage IV pressure ulcer, A review of the Physician Orders revealed the following orders: a. 10/29/24 Enhanced Barrier Precautions b. 11/12/24 for Sacral Stage 4 (wound): Apply wet-to-dry using dakins. Cover with super-absorbent. Then apply dry protective dressing twice daily and prn (as needed). every day and evening shift and every 1 hours as needed for soiled or displaced dressing. c. 12/3/24 Foley Catheter Diagnosis: Stage 4 sacral wound Catheter Size: 16 Fr (French)/10 mL (milliliter) balloon. Original Insertion Date: 12/1/24, Place Foley catheter drainage bag in privacy bag On 12/6/24, the Care Plan identified the resident with the problem of Stage 4 pressure injury to sacrum. Interventions did not direct the use of Enhanced Barrier Precautions (EBP) during wound care. On 2/11/25, the Care Plan identified the resident with the problem of an indwelling Foley catheter. Interventions did direct the use of EBP during catheter care. During an observation on 2/11/25 at 7:44 AM, Staff I, Registered Nurse (RN), and Staff L, Certified Nursing Assistant (CNA) entered Resident #12's room. Both Staff I and Staff L washed their hands and donned gloves. Neither one had donned isolation gown for EBP prior to wound care. The door and/or room did not have an indication of the need to use EBP for wound or catheter care, and isolation gowns were not immediately available to the staff. 2. The MDS dated [DATE] identified Resident #41 as cognitively impaired with a BIMS of 05 and had the following diagnoses: atherosclerotic heart disease, peripheral vascular disease and arthritis. It also identified Resident #41 was totally dependent on staff for assistance with toileting, showers, lower body dressing and putting on footwear and required substantial/maximal assist with the remainder of activities of daily living. The MDS also identified Resident #41 with a Stage III pressure ulcer. On 12/5/24, the Care Plan identified Resident #41 with the problem of a Stage III pressure injury to the coccyx. Interventions did direct the use of EBP during wound care. A review of the Physician Orders revealed an order dated 1/22/25 to cleanse the coccyx with Wound Wash, apply Triad paste and cover with a dry protective dressing three times daily and as needed. The orders did not include placing the resident in Enhanced Barrier Precautions. During an observation of cares on 2/11/25 at 11:26 AM, Staff J, Licensed Practical Nurse (LPN) and Staff S, RN PN entered Resident #41's room. Staff J, and Staff S, washed their hands and donned gloves. Neither nurse donned gowns. Staff J proceeded to provide wound care. After wound care, both nurses removed their gloves and washed their hands. The door and/or room did not have an indication of the need to use EBP for wound or catheter care, and isolation gowns were not immediately available to the staff. During an interview on 2/12/25 at 8:51 AM, Staff G, LPN stated EBP should be in place for any resident with COVID or infectious disease. And when providing cares to a resident in Enhanced Barrier Precautions, staff should wear an isolation gown, gloves and a mask. During an interview on 2/12/25 at 9:17 AM, Staff H, CNA stated residents that should be placed in EBP if they have with catheters, COVID, flu, C-diff (a bacterium that can cause inflammation of the colon). When providing cares to a resident in EBP staff should wear a gown, gloves, mask and goggles if she would anticipate splashing. 3. The MDS dated [DATE] identified Resident #68 as cognitively intact with a BIMS of 14 and had the following diagnoses: cancer, atrial fibrillation (an abnormal heart rhythm) and peripheral vascular disease. The MDS also identified Resident #68 as totally dependent on staff for assistance with toileting and lower body dressing and putting on footwear. The MDS also identified Resident #68 had an indwelling urinary catheter. A review of the Physician Orders revealed the following: a. 12/3/24 Foley catheter 16 Fr 10ml balloon b. 2/12/25 Enhanced Barrier Precautions On 12/4/24, the Care Plan identified Resident #68 with the problem of an indwelling urinary catheter. Interventions did direct the use of EBP during catheter care. During an observation on 2/10/25 that started at 11:06 AM, Resident #368 noted to be in sitting in a wheelchair, with the tubing to his indewelling catheter on the floor The tubing drug on the floor while the resident self propelled down a hallway. At 2/10/25 at 11:09 AM, Resident #368 self propelled to the end of the hallway as Staff L, CNA walked beside him. Staff L did not reposition the catheter tubing off the floor. At 2/10/25 at 12:24 PM, the resident in his wheelchair while in the main dining room. The catheter tubing remained on the floor. At 2/10/25 at 2:26 PM, Resident #368 self propelled himself from the main dining room to the hallway as the DON (Director of Nursing) beside him. The DON did not reposition the catheter tubing. During on obsevation on 2/11/25 at 8:13 AM Staff O, CNA and Staff L, CNA both entered Resident #68's room wearing masks. Both aides washed their hands and donned gloves, however, neither one donned an isolation gown. Staff L completed catheter care. The door and/or room did not have an indication of the need to use EBP for catheter care, and isolation gowns were not immediately available to the staff. During an interiveiw on 2/12/25 at 10:13 AM, Staff L, CNA reported when a resident has an indwelling catheter, the tubing should never be on the floor. During an interview on 2/12/25 at 10:09 AM, the DON stated she would expect the nursing staff to pick up the Foley tubing off the floor if they would see it on the floor. A review of the undated facility policy titled: Catheter Care did not direct staff to maintain the indwelling catheter tubing off the floor. 4. The MDS dated [DATE] identified Resident #89 as cognitively intact with a BIMS of 14 and had the following diagnoses: stroke, cancer and coronary artery disease. It also identified Resident #89 required partial/moderate assistance with most activities of daily living and had a feeding tube. A review of the Physician Orders revealed an order, dated 11/20/24 Aspiration precautions: keep head of bed elevated above 30 degrees at all times. Check tube for correct placement and patency before administration medication, administration of feeding and tube flushes. Enhanced Barrier Precautions. On 11/21/24, the Care Plan identified Resident #89 with the problem of requiring a tube feeding. Interventions did direct the use of EBP during catheter care. During an observation of gastric tube cares on 2/11/25 at 10:26 AM Staff J, LPN entered Resident #89's room Staff J washed her hands and donned gloves, but did not don isolation gown. Staff J used the proper technique to for gastric tube care. The door and/or room did not have an indication of the need to use EBP for gastric tube care, and isolation gowns were not immediately available to the staff. During an interview on 2/12/25 at 9:36 AM, Staff J, LPN reported she had never been informed that Resident #89 was supposed to be placed in Enhanced Barrier Precautions. She also reported that residents that required Enhanced Barrier Precautions were residents who had catheters, colostomy, any kind of wounds that have drainage. During an interview on 2/12/25 at 10:09 AM, the DON stated Resident #89 should be on EBP as he has the feeding tube. She stated she did believe the EBP precaution sign was posted, or PPE available outside of the room. A review of the facility policy dated as last revised March 2024 and titled: Enhanced Barrier Precautions had documentation of the following: INITIATION OF ENHANCED BARRIER PRECAUTIONS a. Residents will be reviewed upon admission and/or change of condition for the need of EBP by the Director of Nursing/Designee. b. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with MDRO (Multi-Drug Resistant Organisms) that is not currently targeted by the CDC (Center for Disease Control). c. An order for Enhanced Barrier Precautions will be obtained for residents for any of the following: aa. Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with an MDRO bb. Infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply. IMPLEMENTATION OF ENHANCED BARRIER PRECAUTIONS a. Make gown and gloves available immediately near our outside the resident's room. b. Enhanced Barrier Precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observations, facility policy review, and staff interviews, the facility failed to ensure the disposal of expired food items, and food items in a resident refrigerator were labeled with the name of the food item, date placed in refrigerator and the date item needed to be disposed in an effort to prevent the potential for foodborne illness. The facility reported a census of 104 residents. Findings include: 1. During the initial tour of the kitchen and dry storage room on [DATE] at 9:58 AM, the following food times were found to be expired: a. 1- Chocolate Cake Mix expired [DATE]. b. 12- Apricot Nectar cans expired [DATE]. c. 1 - Baking Powder container expired [DATE] and 2 additional cans expired [DATE]. d. 1 - Poultry Seasoning canister expired [DATE]. e. 2 - Ground Mustard canisters - 1 expired [DATE], the other expired [DATE]. f. 11 - Cornbread Mix boxes - 4 expired [DATE], 7 expired [DATE]. g. 1 - Whole Sesame Seeds canister expired [DATE]. h. 1 - Nutmeg canister expired [DATE]. i. 8 - Lemon Juice bottle- 1 expired [DATE] and 7 expired [DATE]. j. 1 - Ground Sage canister expired [DATE]. k. 1- Red Hot Seasoning canister expired [DATE]. l. 2- Thyme canisters - 1 expired [DATE] and 1 expired [DATE]. m. 3 - Lasagna noodles boxes expired [DATE]. n. 1 - Balsamic Vinegar bottle did not have an expiration date or open date, the top was crushed, and the liquid inside appeared separated and lumpy. During an interview after the initial tour, Staff A, Certified Dietary Manager (CDM) stated she expected the cooks of disposal of expired items. During an observation on [DATE] at 2:31 PM, the 1st floor north unit refrigerator contained an individual cup of open, undated applesauce; an open, undated container of apple juice; an undated sandwich in plastic wrap; and a plastic grocery bag with a staff member's meal inside. Staff B, Dietician, and Staff A, CDM stated everything in the refrigerator must have a label with the name of the product, the date item placed in the refrigerator, and the date item needs to be disposed of (three days from in date), and the refrigerator was for resident food only. A sign which indicated these expectations observed on the refrigerator door. Staff A stated she expected dietary staff to check the unit refrigerators when they delivered food and drinks for dates and expired items daily. During an interview on [DATE] at 9:47 AM Staff C, Dietician, confirmed she was aware of the expired food items. She stated they had to work on a better schedule to check those things. A policy titled Dietary Storage Guidelines revised [DATE] documented all non-perishable and perishable items would be stored in the proper areas at proper temperatures and in a safe manner. All items were put away in the first in first out method and rotated to assure the use of older products first and avoid the use of outdated products. All opened items (such as refrigerated leftovers) would be dated and labeled with a specific label which contained the date of preparation or opening and the product name if needed.

Based on observation, clinical record review, facility policy review, staff, family and resident interviews, the facility failed to answer call lights within 15 minutes to meet resident needs for 1 of 3 residents reviewed (Residents #5). The facility reported a census of 104 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated moderate cognitive impairment. The MDS documented the resident admitted [DATE] and needed substantial to maximal assistance with toileting hygiene, toilet transfers, and lower body dressing. The Care Plan, initiated 1/8/25 documented the resident required 1:1 staff for toileting. During an interview on 02/10/25 at 12:56 PM Resident #5 shared that some call lights took a longer time to answer, maybe 15-20 minutes. He stated he knew staff were busy but he needed help to go to the bathroom. On 2/11/25 at 8:58 AM during a hallway observation the resident's call light was noted to be on. At 9:14 AM two therapy staff and a CNA walked by the resident's room and did not ask what Resident #5 needed. At 9:19 AM, 21 minutes after activated, staff entered his room with the vitals cart and asked why his light was on. The resident stated he was waiting to go to the bathroom. During an interview on 02/11/25 at 09:27 AM Staff R, Certified Nursing Aide (CNA) reported call lights could be seen at the resident's door and on a screen by the nurses station. Staff were able to tell if the light was from the bathroom or their regular room light. Staff R stated they could also hear the sound the system made in the spa room and in linen and laundry, and that included lights for the whole floor. When asked about the time frame for answering lights, she confirmed staff are trained they should answer them in 15 minutes or less. While in the resident's room for a follow up interview on 02/11/25 at 02:50 PM Resident #5 indicated that he had long call lights that morning and the evening before. A family visitor stated the long lights did not happen every day, but at least every other day since he arrived. During an interview on 02/12/25 at 09:11 AM, Staff E, Licensed Practical Nurse (LPN) stated they tried to answer call lights promptly and stated any staff could answer them to see what a resident needed. They tried to get to everyone in 15 minutes but acknowledged it sometimes took longer, especially in the skilled area. During an interview with the Director of Nursing on 2/13/25 at 8:26 AM she stated call lights were always a factor. She expected everyone to stop and ask what the resident needed, and reported call light expectations were an ongoing topic of staff education. At 8:54 AM on 2/13/25 the Administrator sent an email documenting that the facility did not have a report that printed out call light response, and they had not completed any call light audits. She further reported the unit managers, nurses, and DON were responsible for monitoring call light answering. She wrote the 'box' that made the sound for a call light was at the nurses station to get the call light handled as soon as possible. A policy titled Call Lights: Accessibility and Timely Response implemented 10/21/24 noted call lights would directly relay to a staff member or centralized location to ensure appropriate response. Compliance guidelines included staff education on the proper use of the call system and ensuring resident access to the call light, resident education, and resident evaluation for unique needs and preferences. It further documented all staff members who see or hear an activated call light were responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on record review, family and staff interview, and policy review, the facility failed to safely transfer one of three residents reviewed with a mechanical lift (Resident #1). The facility reported a census of 99 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS of 13 out of 15, and had the following diagnoses: Heart Failure, Peripheral Vascular Disease and Renal Insufficiency (Kidney Failure). The MDS also identified Resident #1 was totally dependent on staff for assistance with toileting hygiene, upper and lower body dressing, help with footwear, and transfers. On 4/6/18, the Care Plan identified Resident #1 with the problem of having an ADL (Activities of Daily Living) self-care performance deficit related to Parkinson's with dementia and directed staff to have two staff assist with toileting with the Hoyer Lift to the Shower Chair. A review of the incident report dated 3/29/24 at 11:12 AM had documentation of the following: Resident #1 fell during a transfer in the resident's bathroom. Resident #1 was laying on her back with the aide holding the back of her head. There was a small to moderate amount of bleeding from the back of her head. She is alert and verbally responsive. Her legs are on the base of the Hoyer lift with the lift sling still attached to the lift. Resident #1's only complaint is a headache. Three staff members utilized a full sized sling and Hoyer lift to transfer her from the floor to her bed. After notification of her physician and family she was transferred to the hospital. The resident reported she slid out of the Hoyer sling and struck the back of her head on the toilet riser. A review of the undated written witness statement by Staff B, CNA revealed the following: She entered Resident #1's room to assist her with going to the bathroom. Staff B brought in the Hoyer lift and put the Hoyer sling around Resident #1 and went to get assistance. When Staff B and Staff D, CNA returned, they connected the sling straps to the hooks on the Hoyer. After they transferred her to the bathroom, they began to lower Resident 1's pants. Resident #1 then slipped out back first hitting her head on the toilet. A review of the undated written witness statement by Staff D, CNA revealed the following: Staff B, CNA asked for help to transfer Resident #1 from her chair to the toilet. Resident #1 was already hooked up in the sling and ready to be lifted. Both aides hooked the leg straps into the machine. She operated the lift while the other aide held the back of the sling correctly. After they got her into the bathroom, they both started to pull Resident #1's pants down, then Resident #1 slid out of the sling before they could catch her. Her head slid out and hit part of the toilet while her legs were still in the air, All the straps were hooked on correctly. In an interview on 5/28/24 at 1:57 PM, Resident #1's power of attorney reported Staff C, Unit Clerk/CNA/CMA had informed her sister that the staff did not secure the sling to the lift properly. In an interview on 5/29/24 at 10:03 AM, Staff B, CNA reported the following: a. When using a mechanical lift to transfer a resident, there should be two staff to transfer. b. Before she transfers a resident she would make sure everything is hooked up correctly and in there comfortably. c. She was trained by another CNA on the use of mechanical lifts. When she transferred Resident #1 on 3/29/24, it was her first time to use the Hoyer lift after her 2 day training. d. Resident #1 was care planned to be transferred with use of the Hoyer lift. e. Both Staff B and Staff D, CNAs were in the room when Resident #1 fell . f. When asked how the sling was connected to the resident and to the lift, she reported she put the sling behind the resident and wrapped it around her. She would need to make sure the buckles to the middle and across the chest are buckled. The sling should be near the top of the head. Make sure the sling is underneath the legs and cannot be criss-crossed. Then we put the loops from the sling and hook it up to the Hoyer. I think there are 2 in the middle and 2 on top. g. When Staff B and Staff D transferred Resident #1 to the bathroom, she was first in her wheelchair and they moved her from wheelchair to toilet. They put the sling underneath her and connected it to the lift. Staff B operated the lift and Staff D connected the sling to the lift and guided her body during the transfer into the bathroom. h. As Staff B and Staff D pulled Resident 1's pants down, Staff D held on to the back of the sling holding on to the handle and Resident #1's shoulder. As they both lowered Resident #1's pants, she began to lean backwards and pushed her weight on the lift and she slipped out of the lift. Everything was secure. i. Staff D went to have the DON (Director of Nursing) assess Resident #1 as Staff B stayed with her. The DON looked at everything and said everything was connected the way it should have been. The DON felt Resident #1 kept leaning backwards and caused her to slip out of the sling. j. If they had helped her to stay upright and have one person stand behind her as the other one pulled her pants down, this might have prevented the fall. In an interview on 5/29/24 at 8:31 AM, Resident #1's other family member reported on 3/29/24 Resident #1 called her and said they wanted to send her to the ER. She said she fell out of the Hoyer lift and hit her head. The family member then spoke to Staff C, Unit Clerk who informed her that Resident #1 was in the Hoyer lift which was not fastened correctly, she fell out and hit her head on the toilet riser and it bled. Then they sent Resident #1 to the hospital. In an interview on 5/29/24 at 10:30 AM, Staff C, Unit Clerk/CNA/CMA reported she was not in the room when Resident #1 fell on [DATE] was told that there was an incident where the girls transferred her with the Hoyer lift and she hit her head. In an interview on 5/29/24 at 12:59 PM, Staff D, CNA reported the following: a. When using a mechanical lift to transfer a resident, there should be 2 staff to transfer. b. When transferring a resident using a mechanical lift, she would first check the care plan. Get another worker in the room with her. We would make sure to put the sling underneath the resident. There are two long straps that go under the legs and go up. There are clips under each side of the resident's ears and by the ribs that need to be clipped together. Then attach the straps to the lift. One person would operate the lift and the 2nd person should be behind the resident. She would hold on to the strap behind the sling. c. Resident #1 had Staff B as her primary aide for her aide that day. She was brand new and only had 2 days of training. d. Resident #1 was care planned to be transferred with use of the Hoyer before she fell on [DATE]. e. Before she entered Resident #1's room, Staff B had already put the sling on her and said all she needed help with was transferring. She could not recall if the sling was placed properly or not. f. When Staff B and Staff D transferred her to the bathroom, Staff D operated the lift. Staff B stood behind Resident #1. Staff B was not holding on to the strap attached to back of the sling. When Resident #1 was up in the air, she started to complain her arm was hurting. Staff B and D tried to pull her pants down before sitting her on the toilet. Then Resident #1 started to slip out of the bottom of the sling and hit her head on the front of the toilet seat. After that she fell down to the floor and hit her head on the floor. Her legs were still up in the sling but then they eventually slid out. Staff B held Resident #1's head up and held pressure to the back of her head where it was bleeding. Staff B stayed with Resident #1 while Staff D went to get Staff D, LPN. After Staff D assessed her, they transferred her back to bed. Staff D could not see where anything had snapped, broke, tore or ripped. g. When asked if the fall could have been prevented, she said she couldn't say. She reported she did not know Staff B had transferred anyone using a Hoyer before that. She only had two days of training before this fall. There is no checklist that is to be completed before new aides are allowed to start working on the floor. In an interview on 5/29/24 at 1:35 PM, the Director of Nursing (DON) reported the following: a. When using a mechanical lift to transfer a resident, she would expect two staff members to transfer the resident. b. The procedure she would expect staff to to follow when transferring with a mechanical lift: Tell the resident what they're doing. Make sure all the straps are under the armpits and they are clipped under the arm and then clipped to the Hoyer. The straps used for the transfer on 3/29/24 was the toilet sling so the straps underneath the legs went straight up and hooked up to the lower part of the Hoyer. The toilet sling does not cover the resident below the thighs. The one aide should stand in front of the lift and would be operating the lift. The 2nd person should be standing behind the resident holding on to a handle which is on the back of the sling to keep the resident from swinging. c. When new CNAs are hired, they receive a 3 day orientation which should include the use of mechanical lifts with a return demonstration. d. The staff contacted the DON immediately after Resident #1 fell on [DATE]. When she arrived to her room, Resident #1 was on the floor with her head on the floor beside the toilet. She had a shower chair riser over the toilet and she bumped her head on that when she slid out of the Hoyer and fell approximately 2 feet from the lift to the floor. She had the blue sling. Everything looked like everything was hooked correctly. They said they had her clipped right. e. When Resident #1 fell out of the sling, the aides were trying to pull her pants off and she leaned too far back. f. When asked how the fall could have been prevented, she reported the aides should have used a full body sling. g. Resident #1 was later transferred to the hospital where she had multiple scans and everything was negative. While at the hospital, she had an anaphylactic reaction to the Lidocaine which she thought they used before they treated the laceration. She was later intubated and sent to a critical illness recovery hospital. A review of the undated facility form titled: Mechanical Lifts Competency had documentation of the following: When transferring a resident with a lift, it must always be from surface to surface. The surfaces should be directly next to each other. Never transfer a resident from a bed or recliner to the restroom using the lift. The residents should not be wheeled while in the lift throughout the room. The resident is to be transferred to a wheelchair or toilet chair and then taken into the bathroom.

Based on record review, resident and staff interview, and policy review, the facility failed to document the review of the bed hold policy prior to residents being transferred to the hospital for three of four residents reviewed (Residents #1, #4, and #5). The facility reported a census of 99 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS score of 13 out of 15, and had the following diagnoses: Heart Failure, Peripheral Vascular Disease, and Renal Insufficiency (Kidney Failure). The MDS also identified Resident #1 was totally dependent on staff for assistance with toileting hygiene, upper and lower body dressing, help with footwear, and transfers. A review of the Progress Notes revealed the following: 3/29/24 at 11:33 AM This nurse was summoned to the Resident #1's room by the assigned aide. Resident #1 was laying on her back on the floor of the restroom with her head being held by the aide. The aide reported they were transferring her from the wheelchair to the toilet when she slid from the Hoyer sling and bumped her head. There was a moderate amount of blood from this wound where her head hit the toilet riser. The injury was a laceration which measured 2.5 cm (centimeters) long. Resident #1 was assisted off the floor using a full body sling by 2 to 3 staff. 3/29/24 11:53 AM several attempts made to contact the resident's daughters and son without any response. The physician was called and provided orders to transfer to the ER if family wishes. 3/29/24 12:38 PM Resident #1 had the nurse call her daughter from her personal cell phone. The nurse informed her daughter of the incident and gave permission to take her to the hospital. The Progress Notes did not have any documentation to show the Bed Hold Policy had been reviewed with the resident/family. In an interview on 5/28/24 at 1:57 PM, Resident #1's family member reported she did not receive any information on the Bed Hold Policy until 4/6/24 informing her she had 10 days to respond after she had been transferred to the hospital on 3/29/24. 2. The MDS dated [DATE] identified Resident #4 as cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 9 and had the following diagnoses: Renal Insufficiency (Kidney Failure), Cerebrovascular Accident (Stroke), and Diabetes Mellitus. The MDS also identified Resident #4 required substantial/maximal staff assistance with toileting, showers, putting on and taking off footwear, and transfers. A review of the Progress Notes revealed the following: 5/10/24 at 9:56 AM Resident noted to have dark brown emesis. Resident #4 is currently on Eliquis (a blood thinner). Nurse Practitioner notified of possible GI bleed and orders received to send to the emergency room for evaluation and treatment. 5/10/24 at 10:05 AM Medics transported Resident #4 to the ER. 5/13/24 at 9:40 PM returned from the hospital via ambulance. The Progress Notes did not have any documentation to show the resident's family had been informed of the Bed Hold Policy. 3. The MDS dated [DATE] identified Resident #5 as cognitively intact with a BIMS score of 15. The MDS also identified Resident #5 required substantial/maximal staff assistance with showers. The MDS also identified Resident #5 to be dependent on staff for assistance with toileting hygiene, lower body dressing, putting on and taking off footwear, and transfers. A review of the Progress Notes revealed the following: 3/2/24 at 1:19 PM Medics arrived at about 1:05 PM to transport Resident #5 to the emergency room . 3/6/24 at 4:12 PM Resident returned from the hospital with a diagnosis of Pulmonary Embolism (blood clot) and cellulitis to the left thigh. The Progress Notes did not have any documentation to show the resident's family had been informed of the Bed Hold Policy. In an interview on 5/29/24 at 10:30 AM, Staff C, Unit Clerk/CNA/CMA reported the following: a. When asked who was responsible for reviewing the Bed Hold Policy with residents/family when they are transferred to the hospital, she stated the Social Worker has always done it. b. The review of the Bed Hold Policy with residents/families are usually documented in the electronic medical record. c. She did now know what the time frame was to complete the review and documentation of the Bed Hold Policy with residents/families after the resident had been transferred to the hospital. In an interview on 5/29/24 at 1:35 PM, the Director of Nursing reported the following: a. When asked who is responsible for reviewing the Bed Hold Policy with residents/family when they are transferred to the hospital, she stated the Social Worker. b. In the case of Resident #1, the Administrator followed up with the family and told them the facility would hold her bed because she had lived here for so long. The Administrator had explained that the facility would waive the bed hold charge and we would keep her bed for her until she returned. c. She did not know where the review of the Bed Hold Policy is documented. d. The time frame is 14 days to complete and review and documentation of the Bed Hold Policy with residents/families after the resident had been transferred to the hospital. In an interview on 5/29/24 at 2:51 PM, the Administrator reported the following: a. When asked who is responsible for reviewing the Bed Hold Policy before residents are sent out to the hospital, she stated the Social Worker. b. The time frame to review and document the review of the Bed Hold Policy is within 10 days. c. The review of the Bed Hold Policy should be documented in the Progress Notes in the electronic medical record. d. Regarding Resident #1's transfer to the hospital on 3/29/24, she spoke to Resident #1's daughter about keeping her bed and that the facility would keep it open for her for as long as they needed to. She had documented in an e-mail that she would not give her bed up. In an interview on 5/30/24 at 8:30 AM, Staff G, LPN/Unit Manager reported she looked through the Social Worker's office (as the Social Worker was on medical leave) to locate any paperwork regarding the review of the Bed Hold Policy for Residents #1, #4, and #5. A review of the facility policy titled: Bed Hold Process Facility Policy with the effective date of 2/28/23 had documentation of the following procedure: a. The Nurse will obtain the Bed Hold Policy and Return to Facility Notice and provide the notice to the resident and their representative at the time of transfer or leave of absence. b. In cases of an emergency transfer, notice at the time of transfer means the facility will send the notice along with the necessary paperwork to the receiving setting and the resident representative will receive a notice sent within 24 hours of transfer. If the facility is unsuccessful in contacting the resident representative, all attempts must be documented. c. The nurse will ensure that a copy of the notice accompanies the resident as the resident leaves the facility. d. The nurse will inform the resident representative on the telephone, if necessary, about the Bed Hold and Return to Facility Policy and ask how best to provide a copy of the notice to the representative. aa. The nurse will inform the representative that the notice accompanied the resident at the time the resident left the facility. bb. The nurse will document the provision of the Bed Hold Policy and Return to Facility Policy to the resident, and information given to the representative in the resident's record.

Based on interviews, record review, and facility policy review, the facility failed to ensure consistent documentation of code status for 1 of 8 resident reviewed for advanced directives (Resident #232). Documentation for Cardiopulmonary Resuscitation (CPR) found in the electronic record, a form in the chart directed Do Not Resuscitate (DNR) and another form in the chart directed CPR both signed by the provider on the same day. The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #232 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, indicating cognition intact. Diagnoses for Resident #232 included debility, cardio-respiratory conditions, heart failure, renal disease, pneumonia, diabetes, and pulmonary disease. The Care Plan focus initiated [DATE] documented Resident #232 had chosen specific advance directives, noted as Full Code. A document titled, Full Code Form, located in the chart for Resident #232 check marked, attempt resuscitation, cardiopulmonary resuscitation. The resident signed on [DATE], the provider signed on [DATE]. A document titled Iowa Physician Orders for Scope of Treatment (IPOST) located in chart for Resident #232, check marked, Do Not Attempt Resuscitation (DNR), signed by the provider, Advanced Registered Nurse Practitioner (ARNP) on [DATE], signed by the resident, with no date. The electronic Clinical Resident Profile sheet documented code status: Full Code. Interview on [DATE] at 1:50 PM with Staff B, Licensed Practical nurse (LPN) regarding resident code status. Relayed would look in the resident chart for direction. Questioned about the two forms, one directing CPR and one directing DNR with the same date. Staff B responded, I would have to check with my manager. I would expect direction to be the same. Interview on [DATE] at 02:31 PM Staff B Registered Nurse (RN) relayed they could not say for certain if resident choice was DNR as per the IPOST or CPR since admitting form stated CPR and are signed same date by the provider. Explained process is resident is asked upon admission reflected by the form designating CPR. The IPOST form is done following that and gives additional details, both are signed by the medical provider. Relayed the IPOST is usually the go to. Acknowledge, should not be conflicting information on forms and in the electronic record. Policy titled Cardio Pulmonary Resuscitation (CPR), revised [DATE] documented nurses and other care staff as identified are educated to initiate CPR as recommended by the American Heart Association, unless a valid DNR order is in place. Responders should be able to identify where to look to locate the resident code status and verbalize what actions will follow.

Based on record review, staff interview, and facility policy review the facility failed to follow physician orders to provide notification of elevated blood sugars for 1 of 5 residents reviewed for medications (Resident #72). The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 12/14/23, listed diagnoses for Resident #72 that included diabetes mellitus, heart disease, renal disease, anxiety, and depression. The Care Plan initiated 10/20/23 stated the resident would not have any complications related to diabetes. Staff to give medication as ordered by the doctor and to monitor, document for side effects and effectiveness. Review of the March 2024 Medication Administration Record (MAR) revealed the following: 1. 3/5/24 at 12:00 PM blood sugar result of 394 mg/dl 2. 3/14/24 at 12:00 PM blood sugar result of 384 mg/dl The Medication Administration Record (MAR) for March 2024 reflected a physician order (PO) started 3/6/24 that directed staff to administer extra units of Humalog insulin based on blood sugar, it directed if blood sugar is 301-350 administer 8 units, if blood sugar is 351-400 administer 10 units and directed if blood sugar is over three hundred fifty (350) to notify the Medical Doctor (MD). The resident's record lacked documentation of physician notification as directed for hyperglycemia (high blood sugar). In an interview with the Director of Nursing (DON) on 3/28/24 at 10:45 AM revealed no evidence could be located regarding physician notification of blood sugars over 350 for date and times reviewed on the March MAR. The DON acknowledged the expectation is to follow physician orders. Facility policy titled Physician Orders implemented 3/20/24 documented staff direction for ensuring physician orders, included physician orders are those given to the nurse by the physician, staff directed to use clarification questions to avoid misunderstood, included entering the order in the medical record, the physician to authenticate the order, noted to follow through with orders by making appropriate contact or notification.

Based on observations, interview, record review and policy review the facility failed to ensure that the kitchen was maintained in a sanitary manner for 84 out of 84 residents. Specifically, food items in the kitchen and bistro refrigerators and storage areas were unlabeled or expired, dietary equipment had a white residue and dietary staff was removing the clean dishes from the dishwasher while wearing the same gloves that were used to load the soiled dishes in the dishwasher. Findings include: Review of the facility's policy titled, Food Receiving and Storage dated 2019, revealed, Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by' date). Such foods will be rotated using a first in - first out system .All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by' date) .Refrigerated foods must be stored below 4 l degrees F unless otherwise specified by law c. Refrigerators must have working thermometers and be monitored for temperature. Review of the facility's policy titled, Refrigerated and Frozen Food Storage Units revised [DATE], revealed, All refrigerators and freezers in the [NAME] Home will have thermometers in the warmest area of each unit .Temperature of refrigerators are to be within the 35 to 38 range .Temperature of freezers are to be within the 0 or below range .If equipment temperatures are not in the required range, temperatures of food are taken and steps are taken. Review of the facility's policy titled, Sanitization revised ,d+[DATE], revealed, .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . The initial kitchen inspection was conducted on [DATE] from 9:12 AM through 10:33 AM with the Food Service Director (FSD). The following concerns were noted: Three black, plastic three tier rolling carts were noted to be coated with a white, filmy residue. The FSD stated they are cleaned according to the cleaning schedule, generally once a week. In the Produce Cooler was a plastic, rectangular container of undated, unlabeled cut up vegetables. The FSD stated they are mushrooms and that the staff are responsible for the labeling. A 25-pound box of green peppers, delivery date of ,d+[DATE] was opened, and peppers were observed to look wrinkled and dented. An opened case of 16-ounce cartons of strawberries, delivery date of [DATE]. In two cartons, a gray, furry mold was noted on several strawberries. The FSD stated that the staff goes through the containers and discards any funky ones. An open case of buttermilk pancake batter with an expiration date of [DATE]. In the Dry Storage area, the following observations were made: 1. A square, clear plastic container containing pasta was unlabeled, and dated ,d+[DATE]. 2. An opened, six pack of hot dog buns, with one bun missing was not labeled or dated. -The buns felt hard to the touch. 3. A second opened, six pack of hot dog buns was also not labeled or dated. -The FSD stated the packages should have been dated. 4. An opened bag of cinnamon raisin bagels were dated [DATE]. -The bagels felt hard to the touch. 5. An opened 25-pound bulk bag of chocolate chips with loose dried cranberries noted on top of the bag, was dated [DATE]. -The FSD says the staff just open stuff and the cranberries must have dropped in the other box, he stated that this is potential for cross contamination/food allergy complications. In the walk-in refrigerator the following observations were made 1. An unlabeled clear, rectangular, plastic container containing a liquid substance dated ,d+[DATE]. - The FSD stated, it looks like vegetable soup. It should be labeled. 2. A clear plastic container containing a thick brown viscous substance was dated ,d+[DATE]. - The FSD stated that it's probably chili. 3. An unlabeled plastic container of vegetables dated ,d+[DATE]. - The FSD stated it was probably wax beans. 4. An unlabeled full tray of a casserole dated ,d+[DATE]. - The FSD stated that it was macaroni and cheese. 5. An unlabeled container of vegetables dated ,d+[DATE]. - The FSD stated it was probably brussels sprouts. 6. An unlabeled container of a white food item dated ,d+[DATE]. - The FSD stated it was leftover mashed potatoes. The reach in freezer contained an undated, unlabeled frozen round item with a tear in it. - The FSD stated a box probably dropped on it. A tour of the Unit Pantry refrigerators, which was where the residents could store their food from outside, was conducted on [DATE] at 10:55 AM with the FSD. The following observations were made: The 1st floor North refrigerator temperature was observed to be 47 degrees Fahrenheit (F). The 2nd floor North refrigerator temperature was observed to be 42 degrees F. The 2nd floor South refrigerator temperature was observed to be 43 degrees F. The FSD stated that the temperature should be under 41 degrees F. Temperature logs were obtained from the 1st Floor North and 2nd Floor South refrigerators. Several temperature entries were missing from each log. The FSD stated it should be both departments (dietary and nursing's) responsibility to check the pantry refrigerators temperatures. During a follow-up kitchen observation on [DATE] at 9:15 AM observed the following concerns: In the produce cooler the 25-pound box of green peppers, delivery date of ,d+[DATE] was still in the cooler in a box. An odor of decomposing vegetables was noted. A five-pound bag of shredded carrots was found with two approximately one-inch circular areas of mold noted inside the package. There was an unlabeled container of unidentified items, dated ,d+[DATE]. The FSD stated they are chopped onions. The reach in fridge contained an unlabeled shallow container of white food items dated ,d+[DATE]. The FSD stated that it was cream of wheat. The reach in freezer contained an unlabeled bag of breaded items, dated ,d+[DATE]. The FSD stated that they are chicken patties. The FSD confirmed that all of the dates on the items observed only included the month and day. Observation on [DATE] at 09:28 AM of the 3rd Floor kitchen dishwasher revealed the Dietary Aide (DA) did not wear gloves upon arrival to the area. She rinsed off dirty dishes and prepared them for the dishwasher. Without completing hand hygiene, the DA put the dishes in the dishwasher, removed the clean dishes from the dishwasher, and then put the clean dishes on a rack to air dry. The DA then prepped the next group of dishes. She again put the rack with dirty dishes in the dishwasher and proceeded to wipe down the dirty side with a rag. She then walked around the kitchen area and returned to remove the clean dishes with the dirty rag still in her left hand. She also placed the clean wet dish rack on top of the previously cleaned rack of dishes. The FSD stated she should not have put the wet rack above the drying rack. The FSD stated that she should have worn gloves and washed her hands between handling the dirty and clean dishes. Interviewed on [DATE] at 9:28 AM, the DA reported that she usually wears gloves, removes them, and then washes her hands before taking the clean dishes out of the dishwasher. The DA stated it slipped her mind that day.

Based on record review, review of facility policy, and interview, the facility failed to ensure the Care Plan was revised and updated to reflect care of indwelling urinary catheters for one resident (R)3 of two sampled residents with catheters. Findings include: Review of the facility's policy titled, Interdisciplinary Comprehensive Care Plan with an effective date 6/1/18 revealed, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Review of R3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS documented the resident has an indwelling urinary catheter to promote continence. R3's Physicians' Orders listed an order dated 12/29/22 for a urinary catheter size 16 French with 10 milliliter (mL) balloon for neurogenic bladder secondary to Cerebral Vascular Accident (CVA). R3's Care Plan revised on 12/28/22 and did not include the resident's use of an indwelling urinary catheter. On 2/22/23 at 12:12 PM, Licensed Practical Nurse (LPN)1 stated that the Unit Manager and the MDS nurses are responsible for the development and revision of the residents' Care Plans. LPN1 confirmed that R3's Care Plan did not include the use of the resident's indwelling urinary catheter. On 2/23/23 at 11:25 AM, the MDS RN stated that the MDS staff was responsible for the development of the initial Care Plan. Care plans are reviewed and revised with quarterly and comprehensive assessment. Care plans can be revised and updated by any department (i.e. nursing staff) as needed. The Care Plan for R3's indwelling urinary catheter should have been revised with the quarterly assessment. During an Interview on 2/23/23 at 12:15 PM, with the South 200 Hall Unit Managers and Director of Nursing (DON), the DON stated that Care Plans are revised and updated by the MDS staff not the nurses.

Based on observation, interview, and record review, the facility failed to provide proper positioning and drainage of the indwelling urinary catheter bag. In addition the facility failed to provide appropriate incontinence and urinary catheter care for one (Resident (R)3) of two sampled residents with an indwelling urinary catheter. The failure to position the urinary catheter bag lower than the resident's bladder and the failure to provide appropriate incontinence and catheter care could contribute to possible urinary tract infections (UTIs). Findings include: During the initial tour on 2/21/23 at 9:12 AM, observed R3 in her wheelchair with the urinary drainage bag on the floor. On 2/21/23 at 3:14 PM, observed R3 seated in the wheelchair with the urinary drainage bag strapped underneath the seat of the wheelchair with the urinary drainage bag tubing resting on the floor. On 2/22/23 at 1:45 PM, witnessed R3's urinary drainage bag was flat on the floor. Observation of incontinence and catheter care on 2/22/23 at 4:26 PM revealed two Certified Nursing Assistants (CNAs) (CNA2 and CNA5) transferred R3 from the wheelchair to the bed. Once the resident was placed in bed the drainage bag was positioned beside the resident in bed. Both of the CNAs donned gloves to remove the resident's adult brief. The resident wore a catheter strap and had a moderate amount of soft brown stool. The CNAs provided incontinence care by first cleaning the soft brown stool from the resident's rectal area. Without hand hygiene, the CNAs repositioned R3 to clean her vaginal area. The CNAs cleansed the vaginal area by wiping from the rectal area upward towards the vaginal area. This motion was done three times. The CNAs did not separate the labia area to clean or clean the catheter tubing in the vaginal area. R3's electronic medical record (EMR) under the section labeled diagnosis indicated R3 was readmitted to the facility on [DATE] with diagnosis of cerebrovascular infarct (CVA) with right sided hemiplegia. On 12/20/22 the diagnosis of neuromuscular dysfunction of the bladder was added to the diagnoses list. R3's Physicians' Orders listed an order dated 12/29/22 for a urinary catheter size 16 French with 10 milliliter (mL) balloon for neurogenic bladder secondary to Cerebral Vascular Accident (CVA). Observation and interview with Registered Nurse (RN)1 on 2/22/23 at 3:32 PM, RN1 confirmed the urinary drainage bag sat on the floor. RN1 verified that improper placement and positioning of the drainage bag could contribute to recurring UTIs. When questioned about the placement of the urinary drainage bag while a resident laid in bed on 2/22/23 at 4:26 PM, CNA5 responded that the drainage bag should be positioned below the resident's bladder and not in the bed with the resident. CNA2 and CNA5 said the nurse was responsible for performing catheter care for the resident. When questioned about the observation on how they performed incontinent care by wiping from the rectal area towards the vaginal area, both CNAs admitted the care was performed incorrectly. They explained that they should have cleaned the labia folds and wiped in a downward motion cleaning front to back. During an interview on 2/22/23 at 4:40 PM, RN1 confirmed that the CNAs had performed the incontinence care incorrectly and that both CNAs have been trained to perform catheter care.

Based on clinical record review, observation, staff interviews, and facility policy review, the facility failed to update a Care Plan when a resident's mobility status changed and pressure injury resolved for one of four residents reviewed for falls and skin impairment (Resident #2). The facility reported a census of 78 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident required extensive assistance of two or more staff for bed mobility, transfers, walking, and toilet use. The resident's Brief Interview for Mental Status (BIMS) test scored 3 indicating severe cognitive impairment. The current Care Plan documented Resident #2 had a self-care deficit related to weakness and [CONDITION(S)] on 6/6/19 with approaches: a. Mobility: Uses wheelchair for long distance mobility or when feeling weak. Requires assist of one staff, gait belt, and walker to toilet, revised 4/19/21. b. Toilet use: Assist of one person, gait belt, and walker for toileting. Ambulate (walk) with the resident three times a day to/from the toilet, revised 10/22/20. c. Transfer: Requires assist of one person using a gait belt and walker, revised 12/23/19. The current Care Plan also addressed a problem of limited physical mobility on 6/1/20 with approaches: a. Ambulation: Requires stand by assistance of one staff to walk with a walker a minimum of three times a day. Encourage to walk to the closet for clothing and to the bathroom for toileting, revised 6/1/20. b. Locomotion: Walker for locomotion, dated 6/1/20. The current Care Plan noted a problem of a Stage III pressure injury to Resident #2's intergluteal cleft (inner buttocks/coccyx area), revision date 8/31/21. Review of Resident #2's facility Progress Notes revealed the following documentation: a. 8/20/21 3:06 p.m. Resident #2 uses the Sara lift (mechanical sit to stand lift) during transfers. b. 8/21/21 1:11 a.m. The resident transfers with the Sara lift at night and uses a wheelchair propelled by staff. c. 8/21/21 12:14 p.m. Resident #2 is assisted by two staff with the Sara lift. d. 8/31/21 8:41 p.m. Resident #2's wounds have all healed on her coccyx; there are no longer any open areas. An observation on 10/13/21 at 8:02 a.m. revealed staff pushing Resident #2 in her Broda (reclining wheelchair) chair to the dining room. At 8:45 a.m., staff brought the resident back from the dining room in her Broda chair. On 10/13/21 at 12:00 p.m., staff pushed the resident to the dining room in her Broda chair and brought the resident back to the common area at 12:48 p.m. in the Broda chair. On 10/13/21 at 1:05 p.m., Staff A, Certified Nurse Aide (CNA) and Staff B, CNA, brought Resident #2 to her room in the Broda chair and transferred her with a mechanical, sit-to-stand, lift and assist of two staff to the toilet and then to a recliner. Observation revealed no pressure injuries to the buttocks or coccyx area. On 10/13/21 at 1:50 p.m., Staff B stated Resident #2 no longer walks to the bathroom. The resident uses the mechanical lift for transfers. On 10/19/21 at 1:50 p.m., Staff H, CNA, stated staff have utilized the mechanical sit-to-stand lift with Resident #2 for over a month and not walked with the resident. The facility policy titled Care Planning - Interdisciplinary Team dated 8/18/09 documented the care plan is revised or modified on an ongoing basis to reflect changes in the resident and the care the resident is receiving. On 10/20/21 at 11:45 a.m., Staff J, Licensed Practical Nurse/ MDS Coordinator, stated she updates care plans when MDS assessments are completed and occasionally in between if something is going on, such as the resident falling. On 10/20/21 at 12:28 p.m., the Director of Nursing stated staff are expected to update care plans as changes occur, for example if a resident changes from needing assistance of one staff to two or changes the type of mechanical lift needed.

Based on clinical record review, staff interview, observation, and facility policy review, facility staff failed to provide incontinence care to a resident for seven hours for one of three residents reviewed for incontinence (Resident #4) and failed to provide routine repositioning for two of three dependent residents (Residents #2 and #4). The facility reported a census of 78 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident required extensive assistance of two or more staff for bed mobility, transfers, and toilet use and had frequent bladder incontinence. The resident's Brief Interview for Mental Status (BIMS) test scored 3 indicating severe cognitive impairment. The current Care Plan documented Resident #2 needed reminding/assistance to turn/reposition at least every two hours, more often as needed or requested on 6/21/21. Constant observations on 10/13/21 from 6:35 am to 9:50 a.m. and 10:05 a.m. to 1:05 p.m. revealed the following mobility/positioning of Resident #2: a. An 6:35 a.m. Resident #2 sat, fully dressed, in a Broda chair (reclining wheelchair) in a common area in front of the TV, asleep. b. At 8:02 a.m. staff pushed the resident in her Broda chair to the dining room. c. At 8:45 a.m., staff brought the resident back from the dining room to the common area. Staff reclined the Broda chair back about 20 degrees, placed a pillow behind the resident's head, and covered the resident with a blanket. d. At 10:50 a.m., Resident #4 remained in the exact same position with tilt of chair, pillow, and blanket in same positions as at 8:45 a.m. e. At 12:11 p.m., staff pushed the resident to the dining room in her Broda chair, and at 12:48 p.m. brought the resident back to the common area. f. At 1:05 p.m., Staff A, Certified Nurse Aide (CNA) and Staff B, CNA, brought the resident to her room and transferred her with a mechanical lift and assistance of two staff to the toilet and then to a recliner. 2. The MDS assessment dated [DATE] listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident required extensive assistance of two or more staff for bed mobility, transfers, hygiene, and toileting. The MDS documented Resident #4 had two Stage II pressure ulcers and received pressure ulcer care. The resident had frequent incontinence of bowels and always experienced incontinence of bladder. The resident's BIMS scored 11 indicating moderate cognitive impairment. Resident #4's current Care Plan documented on 7/15/21 the resident needed encouragement and assistance with turning and repositioning every two hours and as needed and to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/21 at 7:30 a.m., Staff A and Staff B provided resident incontinent cares in bed. The observation revealed Resident #4 had two open wounds on the right buttock and one on the left. Staff A and Staff B transferred the resident with a Hoyer lift (non-weight bearing mechanical lift) to the recliner in her room. Continuous observation on 10/13/21 from 7:30 a.m. to 9:50 a.m. and 10:05 a.m. to 2:40 p.m. revealed no major position changes. Resident #4 sat in her recliner, feet hanging down with pillow between the recliner and her calves. Her bed remained stripped of sheets. On 10/13/21 at 2:40 p.m., Staff E, CNA, and Staff F, CNA, transferred the resident to bed with a Hoyer lift and provided incontinent care. Urine and stool saturated the resident's incontinent brief. The facility's Incontinent Care policy dated 11/15/05 documented the expectation for the facility to provide consistent incontinent care to all residents according to the guidelines set forth in the Iowa CNA course. The facility's Skin Care Protocol dated 11/2/09 documented staff should turn residents and/or encourage the residents to reposition themselves every two hours if at low risk for skin breakdown. If at moderate or high risk for skin breakdown, staff should supplement with small shifts in resident's position or encourage the resident to reposition. Staff should reposition chair or wheel chair-bound residents every hour. On 10/13/21 at 1:30 p.m., Staff A stated staff reposition and toilet or provide incontinent cares for dependent residents every two hours. Night shift gets Resident #2 up before day shift arrives at 6:00 a.m., and day shift assists the resident to the bathroom after breakfast and before lunch. They took the resident to the bathroom today between 10:00 a.m. and 10:30 a.m. Resident #4 is scared of the Hoyer lift so transfers are limited. Resident #4 he does not sit on the toilet, but staff provide incontinent cares in bed. Staff A stated she checked the resident for incontinence in her recliner at lunchtime and found her to be dry. Maintenance is aware her recliner's footrest has not been elevating today. On 10/13/21 at 1:50 p.m., Staff B reported she normally repositions and provides incontinent cares for dependent residents every two hours but did not have a normal routine today due to not working with a staff member she usually works with. Resident #4 usually stays in bed until after breakfast. On 10/14/21 at 11:25 a.m., the Director of Nursing stated she expects staff to check incontinent residents every two hours. The DON also stated the expectation that staff to complete repositioning every two hours for residents unable to position themselves.

Based on observation, staff interview and record review the facility failed to provide adequate supervision for 1 of 3 residents reviewed and resulted in an elopement from the facility (Resident #1). The facility identified a census of 91 residents. Findings include: 1. A Minimum Data Set (MDS) Assessment for Resident #1, dated 6/4/20, showed the resident with [DIAGNOSES REDACTED]. The resident had a Brief Interview of Mental Status (BIMS) of 5 indicated the resident with severe cognitive impairment. The resident required supervision with transfers, ambulation, bed mobility, dressing and toilet use. The MDS did not indicate the presence of wandering or the use of an assistive device for the resident. A Care Plan for Resident #1, dated 9/9/19 showed the resident as an elopement risk/wanderer related to disorientation to place, impaired safety awareness, and behavior of wandering aimlessly. Interventions on the Care Plan dated 9/9/19 were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and book. Also an intervention to identify a pattern of wandering and intervene as appropriate. Another intervention included provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of the Nurse Progress Note dated 12/5/19 at 2:25 a.m. showed a staff member found the resident walking down the stair way. The resident located on a different floor in the facility with their coat on. The staff were able to redirect the resident back to their room. The facility did not provide an incident report for this date. An intervention added to the Care Plan for the resident, dated 12/9/19, for placement of a wander guard on the resident's ankle. The intervention included the resident frequently removed the wander guard bracelet. A Progress Note dated 12/11/19 at 1:13 p.m., documented the resident changed rooms due to wandering behavior and resident safety. Review of the Order Summary Report showed orders, dated 1/5/20 to check the wander guard function every Friday morning and to check the placement of the wander guard every shift. The Care Plan showed an intervention, dated 7/4/20, of a one to one sitter provided on the 2 p.m.-10 p.m. shift and the 10 p.m.-6 a.m. shift, urine dip, and lab evaluation. A Progress note dated 7/4/20 at 3:12 a.m. showed Staff A, Licensed Practical Nurse (LPN), informed at 1:14 a.m. by staff the door alarm sounded and the resident could not be located in the stair way or their room. The resident was brought back to the facility at 1:55 a.m. after found sitting on a bench at a car dealership. The Wandering/Elopement Assessment, dated 9/3/19 showed the resident at moderate risk for wandering and the resident had a history of [REDACTED]. The Wandering/Elopement Assessments, dated 12/1/19, 3/1/20, and 5/31/20 showed the resident at moderate risk for wandering. The Wandering/Elopement Assessment, dated 7/9/20, revealed the resident at moderate risk for wandering. The assessment also showed the resident wandered on the unit to exit seek despite staff attempts to redirect. The wander guard in place but the resident often removed. The facility investigation included: The Occurrence Report, dated 7/4/20 at 4:37 a.m. completed by Staff A, LPN, revealed on 7/4/20 at 1:14 a.m. she received a call from a Certified Nurse Assistant (CNA), while caring for another resident the door alarm to the Dementia Unit had sounded. The CNA checked the stairway and the resident rooms and were unable to locate Resident #1. Two facility staff found the resident sitting on a bench at a car dealership at 1:55 a.m. The resident was brought back to the facility by the staff members. Staff completed a body check and there were no injuries identified. The resident's knees were slightly red but blanchable, the resident did not have complaints of pain or discomfort and range of motion within normal limits. A Per MAR indicated [REDACTED]. The Incident Report showed Staff B, CNA, heard the door alarm sound on the Dementia Unit while Staff B attended to another resident. The staff were unable to locate the resident. At 1:16 a.m. the Security Staff saw on the camera the resident walked out the south stairwell door and down to the parking lot on the backside of the facility. At approximately 1:55 a.m. Staff C, Certified Medication Tech, and Staff D, Registered Nurse (RN), found the resident sitting on a bench at a car dealership approximately 1/2 to 1 mile east of the facility at the corner of 2 four lane streets. At 2:01 a.m. Staff C and Staff D brought the resident back to the facility by car. The Follow Up Report, dated 7/6/20, completed by the Administrator, revealed the facility completed a urinalysis and lab work for the resident. The facility incorporated a sitter with the resident from 2 p.m. until 6 a.m. each day. The root cause of the incident determined as due to resident action or internal risk factors. An observation of the resident on 7/9/20 at 2:06 p.m. showed the resident sat on the side of the bed. The resident had a wander guard bracelet secured to the right ankle. Observed the resident on 7/13/20 at 1:45 p.m. showed the resident rested in bed. An observation on 7/13/20 at 2:08 p.m. showed the resident sat on the edge of the bed with a sitter located in the room with the resident. A demonstration of how the resident exited the facility conducted on 7/9/20 at 2:35 p.m. by the Administrator and Staff E, LPN, Unit Manager, showed the resident exited the stairwell 4 exit door on the Dementia Unit. The resident traveled down the stairs and left the building through the first floor exit door on the backside of the facility. The resident walked down a hill to the back parking lot and followed the parking lot to 4 lane road and turned left. The resident crossed the 4 lane road with a speed limit of 45 miles per hour. Facility staff found the resident sat on a bench in front of a car dealership located approximately 0.6 miles from the facility as per The state Climatologist reported in Davenport on 7/4/20 at 2:00 a.m. a temperature of 67 degrees and 87 percent humidity. Review of the Facility Staff Schedule, dated 7/3/20, showed one CNA on the Dementia Unit and one nurse for the two units on the floor of the facility. During an interview on 7/9/20 at 12:35 p.m., the Administrator reported on the night of the incident the CNA on the Dementia Unit heard the door alarm go off so the CNA checked the front exit door and did not see anything then realized the alarm came from the back exit door. She reported the CNA went down the back stairwell and after a room check the staff identified the missing resident to be Resident #1. The Administrator reported the facility conducted a perimeter search and could not locate the resident. The Administrator reported she had been contacted approximately 30 minutes after the incident and instructed the staff to contact the police. She explained that the facility staff were able to locate the resident at a car dealership down the road and the staff brought the resident back to the facility. The Administrator reported the facility implemented a sitter with the resident from 2 p.m. until 6 a.m. An interview on 7/9/20 at 1:21 p.m. the Plant Operations Director explained the first floor exit doors require a badge swipe to enter the facility. He reported the first floor exit doors did not alarm when the doors open to exit the facility. An interview on 7/13/20 at 11:15 a.m. Staff F, Scheduler, reported the usual staffing pattern for the facility on the night shift is one nurse per floor and two CNA per unit. An interview on 7/13/20 at 11:45 a.m. Staff F, reported the night of the incident a staff member notified the facility they would be late to work. She reported one of the two CNA's scheduled on the Dementia Unit had moved to another unit and left one CNA on the Dementia Unit. An interview on 7/13/20 at 12:04 p.m. Staff B, CNA, reported the night of the incident the resident wanted to go downstairs to meet their daughter. Staff B reported she sat and talked with the resident and explained it was late and the resident's daughter was asleep. Staff B reported the resident decided to go into their room so she waited to ensure the resident would not come back out of their room before she started the unit rounds. She reported the resident declined to take their jacket and shoes off when they returned to their room. Staff B could not recall who the other staff were that were scheduled to work on the Dementia Unit with her that night. She explained the normal staffing for the night shift is one nurse for the floor and 2 CNA for the unit. Staff B reported while providing care to another resident on the unit she heard the door alarm sound. She reported she exited the resident's room and went to the front exit door of the unit but realized the alarm sounded at a different exit. She reported she sprinted to the back exit as it went to an outside exit door. She reported she went down two or three stairs and did not hear or see anyone. Staff B remarked the last time she observed the resident approximately 40 to 45 minutes prior to the incident. Staff B reported she placed a call to Staff D, RN and Staff A, LPN and they came to the unit. Staff B explained a search of the unit along with the facility conducted. She reported staff were able to find the resident down the street at a car dealership. She reported the resident returned to the facility and had no injury. During an interview on 7/13/20 at 1:58 p.m. Staff G, CNA, reported the resident moved up to the front of the Dementia Unit after the first elopement attempt. She reported the resident's first attempt to elope happened during the night as well. During an interview on 7/13/20 at 2:28 p.m. Staff H, CNA, explained a staff from the agency hired to sit with the resident had reported the resident talked of plotting it again. Staff H could not recall if she reported the conversation to anyone at the facility. During an interview on 7/14/20 at 5:43 a.m. Staff I, Per MAR indicated [REDACTED]. Staff I reported she had not seen a resident on the floor and continued to watch the video camera. Staff I explained when a stairwell door alarm sounds she is not able to hear it at the reception desk on the first floor. Staff I remarked facility staff thought the resident may have gone outside so she went back and reviewed the video footage and found the resident exited the facility at 1:16 a.m. Staff I reported she did not see the resident leave the building on the camera at the time the incident occurred. Staff I explained the Police arrived to the facility at 2:01 a.m. just prior to the staff and the resident. An interview on 7/14/20 at 6:15 a.m. Staff J, RN, reported she observed a previous incident when the resident looked around the corner and then the resident ran to the bathroom at the front of the Dementia Unit near the dining room. She reported the resident leaned on the door to keep the staff from going into the bathroom. She reported the incident happened more than one time and a staff member had to sit outside of the resident room. An interview with the Director of Nursing (DON), RN, on 7/14/20 at 7:10 a.m. reported the resident had previously left home and the reason the resident had been placed in the facility. She explained the resident previously had been a runner and is fast. She reported the resident had a wander guard placed shortly after admission and the resident had a history of [REDACTED]. The DON reported no knowledge of resident attempt to leave the facility prior to the night of the incident. The DON explained the expectation for the night shift staffing in the facility is to have 1 nurse cover two units and 2 CNA cover each unit. During an interview on 7/14/20 at 8:34 a.m. Staff D, RN reported she received a call from Staff B who explained they thought one of the resident's had left the floor. Staff D reported she went up the stairs and started searching the stairwells. She reported Staff B, CNA completed a search of the resident rooms on the floor. Staff D explained the other staff in the facility checked the other floors for the resident. When the resident could not be found in the facility Staff D remarked she searched outside of the facility. She explained another staff member and herself drove through the dealership parking lot and when they drove out of the parking lot they observed the resident sat on a bench. Staff D reported she checked the resident over and the staff brought the resident back to the facility in the car. Staff D explained the night of the incident the Dementia Unit only had one CNA. She reported the Supervisor is in charge and determined the staff work assignment when the facility had a call off. An interview on 7/14/20 at 9:52 a.m. the Administrator reported the Dementia Unit had the capability to house 23 residents. She explained the night of the incident the census on the Dementia Unit had been 21 residents. She remarked the resident had left home and is the reason the facility placed a wander guard on the resident. The Administrator reported no awareness of the resident ever found in the facility stair well. The Administrator explained the staffing pattern in the facility is based on the facility size. She remarked the night shift staffing is 1 nurse per floor and 2 CNA per unit. She reported if there had been a call off one CNA will overlap between units. The Administrator confirmed the night of the incident the Dementia Unit had been staffed with one CNA. During an interview on 7/14/20 at 10:36 a.m. Staff A, LPN reported Staff B, CNA had called her due to the door alarm sounding and a possible missing resident. She reported at the time of the call she had another incident she needed to attend to and could not leave to go to the Dementia Unit. Staff A remarked it took her approximately 10 to 15 minutes to respond to the dementia unit. She explained when she arrived to the unit Staff B completed a room check as they were the only staff member on the dementia unit and could not leave. She explained other facility staff searched the rest of the facility. She explained Staff D and Staff C found the resident at a car dealership up the road. When the staff brought the resident back to the facility Staff A explained she completed a body check and the resident had no injuries. She remarked the resident's knees were slightly red but blanchable. She reported the redness subsided within 20 minutes. Staff A explained the resident had reported they ducked down when cars passed by. Staff A reported the facility tried to put 2 CNA on each unit but due to a call off that evening the staffing ended up with one CNA on the dementia unit. She explained when the facility had call off the supervisor made changes to staff assignments and on the night of the incident she had been the supervisor. Staff A reported she could have probably done something different related to the staff assignments the night of the incident. An interview on 7/14/20 at 10:59 a.m. the Administrator reported the facility does not have a policy for facility staffing. During an interview on 7/15/20 at 8:45 a.m. the Administrator reported she looked into the incident and the Nurse Supervisor made an error in judgement. She explained Staff A should have looked at the acuity of the resident's when she determined the staff assignments for the night of the incident. Review of the Facility Assessment, updated October 28, 2019, showed the ratio for night shift CNA's as 1:10. Review of the Elopement Prevention Policy, revised 2/1/4, revealed the policy is to identify residents who have a high risk for elopement, to put interventions into place to prevent elopement of residents and to ensure that the facility's specific interventions are effective. Additionally the policy provided for a system by which the Interdisciplinary Care Plan Team would be alerted to the resident's potential for wandering and elopement. The Risk Assessment Procedure portion of the policy showed: 9. Any staff member observing a confused resident or previously identified wandering resident attempting to leave the premises shall intervene to prevent departure. Should the intervention fail, the staff member shall obtain assistance of other staff members in the immediate vicinity. The Risk Assessment Procedure also noted the staff member should remain with the resident if the resident's safety is in question. Review of the Door Alarm Check Policy, revised 6/24/17, showed all door alarms are checked every third week by Maintenance Supervisor. A 24 hour a day monitored Infinias System by front desk personnel. The procedure section of the policy revealed doors are monitored 24 hours a day at front desk reception through the Infinias door lock system. The incident detailed above resulted in determination of Immediate Jeopardy for the facility and notified of such on 7/14/20 at 3:45 p.m The Facility Staff abated the Immediate Jeopardy situation on 7/14/20 through the following actions: a. All staff in-serviced beginning 7/14/20 to include the operating instructions to the new (temporary) alarm system on the four doors leading to the stairwell. b Also the Nursing Supervisors in-serviced on the staffing policy and 24 hour 1-1 (uninterrupted) supervision of a resident/s as required to ensure safety. The call light will be signaled and answered before a sitter can be dismissed for any reason. c. A temporary alarm system on the four doors leading to the stairwells on 7/14/20 with a follow-up by the alarm company to install a permanent door alarm system on 7//15/20. After installation, staff will receive in-service training on the new system as well. Based on the results of the corrective measures taken by the facility lowered the scope and severity of the deficiency from a J level to a D level.

Based on observation, record review, staff, resident and family member interviews, the facility failed to prevent a significant medication error that required transfer to the hospital emergency room (ER) for treatment and hospitalization for Resident #1. The facility reported a census of 107 residents. Findings include: The 12/31/19 Minimum Data Set (MDS) Assessment tool revealed Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Noted cognitive assessment not completed, and required assistance of 1 staff to reposition in bed, transfer to and from bed and chair, ambulation, toileting and personal hygiene. Physician orders [REDACTED]. 1. [MEDICATION NAME] (a [MEDICATION NAME][MEDICATION NAME]) 2.5 milligrams (mg) in 3 milliliter (ml) solution via nebulizer inhalation every 4 hours as needed. 2. [MEDICATION NAME] (a [MEDICATION NAME] inhibitor used for [MEDICAL CONDITION] treatment) 5 mg oral daily. 3. Aspirin 81 mg tablet oral daily. 4. [MEDICATION NAME] (corticosteroid used for asthma) 2 puffs inhaled orally twice daily. 5. [MEDICATION NAME] ([MEDICATION NAME]) 50 mg administered oral daily at bedtime for [MEDICAL CONDITION]. 6. [MEDICATION NAME] [MEDICATION] for asthma treatment) 10 mg administered oral daily. 7. [MEDICATION NAME] (steroid) 10 mg administered oral daily as needed for asthma. 8. [MEDICATION NAME] ([MEDICATION NAME] medication for asthma) 2 puffs inhaled oral daily. 9. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg ([MEDICATION NAME], a strong narcotic [MEDICATION NAME]) 1 tablet administered oral every 4 hours as needed. Vital signs recorded at 9:20 p.m. upon the resident's 12/30/19 admission were blood pressure 135/75 millimeters mercury (mmHg), pulse 88 and respirations 18 per minute, oxygen saturation of 94 percent with oxygen administered at 2 liters per minute per nasal cannula. A Medication Error Report form dated 12/31/19 stated Resident #1 received medications ordered and intended for another resident (Resident #2), that included blood pressure medications and [MEDICATION NAME], identified as an allergy. The nurse, Staff A, Licensed Practical Nurse (LPN), administered the following medications in error: 1. Atorvastatin (medication that decreases cholesterol) 40 mg tablet. 2. [MEDICATION NAME] ER (extended release medication that prevents [MEDICAL CONDITION]) 60 mg tablet. 3. Magnesium Oxide (magnesium supplement) 400 tablet. 4. [MEDICATION NAME] (blood thinner) 3 mg tablet. 5. Metroprolol (beta-blocker that reduces blood pressure) 50 mg tablet. 6. Senna Plus 8.6/50 mg (stool softener) 1 tablet. 7. [MEDICATION NAME] (beta-blocker that reduces blood pressure) 40 mg tablet. 8. [MEDICATION NAME] 100 mg tablet. A Nurse's Note transcribed at 10:53 a.m. on 12/31/19 revealed blood pressure 88/50 mmHg, the nurse practitioner notified and ordered the resident's transfer to the ER, the next entry at 11:08 a.m. revealed the resident transferred to the hospital via ambulance. A hospital ER Progress Note dated 12/31/19 revealed the resident treated for [REDACTED]. The facility's Medication Administration Policy, dated as last reviewed 10/25/19, directed: 1. The individual administering medications must verify the resident's identity before giving the resident his/her medication. 2. Methods of identifying the resident included checking the photograph attached to the medication record, calling the resident by name, and utilizing other staff to assist in the identification of the resident. Staff interviews revealed: 1/6/20 at 2:31 p.m., Staff A, LPN, stated she worked the day shift (6:00 a.m. to 2:00 p.m.) on 12/31/19, and a chaotic day. There were several new residents, the 2 Certified Nursing Assistants (CNA's) assigned to the unit new and unfamiliar with resident routines and she had multiple interruptions when she administered morning medications to the residents assigned to her that day. Both Resident #1 and Resident #2 admitted the evening before and neither had a photo on their Medication Administration Record [REDACTED]. Between 8:00 a.m. and 8:30 a.m., Resident #1 seated in a wheel chair in her room, the resident's name observed on the nameplate in the hall by her door. Staff A prepared Resident #2's medications, walked into Resident #1's room, called the resident by Resident #2's name, Resident #1 said yes, she administered the medications to the resident who did not say anything else, and she documented Resident #2's medications were administered on the MAR. Staff A stated between 9:00 a.m. and 9:15 a.m., as she prepared Resident #1's medications, she realized she had made the mistake, contacted the Nurse Practitioner and the Director of Nursing (DON) right away, assessed the resident's blood pressure noting to be low and completed the actions required to transfer the resident to the hospital. Staff A reported being a nurse [AGE] years and never made a medication error until this. 1/6/20 at 4:38 p.m., Staff B, LPN, stated she worked on an as needed basis. When she administered medications, she asked the resident's name, she has asked other staff on duty to help her identify residents, looked for residents in their room and if in doubt would call the Nursing Supervisor. 1/7/20 at 7:40 a.m., Staff C, Certified Medication Aide (CMA), stated if there was a new resident she would identify them by the photo, ask the resident their name if able to say it, and ask other staff to identify the resident. 1/7/20 at 8:06 a.m., Staff D, LPN, stated if a new resident he would check their photo, although sometimes there was not one, would ask the resident their name if able to say it. Also, ask other staff if they could identify the resident and look for the resident in their room when he completed medication administration for new residents. 1/7/20 at 8:36 a.m., Staff E, Registered Nurse (RN), stated if administering medications to a new resident she would ask the resident their name, check the photo although sometimes there was not a photo if the resident admitted the day before. Also, ask other staff if they knew the resident, check for the resident in their room, and knows the other residents well enough that she would recognize a new face. Staff [NAME] reported could also ask the Unit Manager for assistance to identify a resident. 1/6/20 at 9:55 a.m., the Director of Nursing (DON), stated when staff administered medications, she expected them to look at the resident's photo on the MAR, check the name on the resident's door, and ask other staff to assist to identify the correct resident. All nursing staff educated after the error occurred. 1/7/20 at 11:10 a.m., the DON and Administrator stated in the future if multiple admissions on the same day, they would not put them in neighboring rooms. They recognized that on the day the error occurred, the Unit Manager was off, the two CNA's were not familiar with the residents or the routine on that unit and they would have approached Staff A with all questions and caused frequent interruptions. They also reported going to educate staff not to interrupt the nurse when at the medication cart or in process of medication administration. On 1/6/20, the resident's family member and responsible party stated the facility notified them of the medication error, the ER had to contact a poison control center in order to treat one of the medications that the resident received in error, and the hospital transferred the resident to another facility on 1/3/20.

Based on clinical record review and resident, family member, staff, pharmacist and physician interviews, the facility failed to ensure that each resident remained free from undesired side effects from medications identified as allergens that resulted in pain, nausea, weight loss, overall decline and hospitalization for one of six residents reviewed (Resident #3). The facility reported a census of 119 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated [DATE] recorded Resident #3 had [DIAGNOSES REDACTED]. Resident #3 required the assistance of one to two staff for transfers to and from bed, dressing, toilet use, bathing and personal hygiene. The resident did not walk during the assessment lookback period. A hospital discharge summary dated [DATE] detailed the resident's hospitalization and treatment for [REDACTED]. Chronic medical conditions included [MEDICAL CONDITION] with surgical correction in 2012, and ulcerative [MEDICAL CONDITION]. A hospital universal transfer form dated [DATE] directed to transfer Resident #3 to the facility and medication administration that included [MEDICATION NAME] (a combination of [MEDICATION NAME] and Sulfa antibiotic medication, labeled as an anti-[MEDICAL CONDITION] medication for ulcerative [MEDICAL CONDITION]) 1000 milligrams (mg) administered orally three times daily. The [DATE] universal transfer form also listed the following medication allergies and reactions: a. [MEDICATION NAME] (a component of aspirin) - abdominal pain. b. Bactrim (a sulfa-based antibiotic) - rash. c. Sulfa drugs - nausea. d. Aspirin - no reaction listed. A warning/alert message on [DATE] at 7:40 p.m. in the electronic record, addressed to Staff A, registered nurse (RN) and author of the order entry the system identified a possible drug allergy for the following order: [MEDICATION NAME] 500 mg tablet, give 2 tablets by mouth 3 times a day for bowel health. The resident's Medication Administration Record, (MAR) listed allergies that included Sulfa antibiotics, [MEDICATION NAME] and aspirin and documented Resident #3 received [MEDICATION NAME] 3 times a day as ordered from [DATE] through [DATE] with the following omissions: a. [DATE] refused at 8:00 a.m. b. [DATE] refused at 8:00 a.m. c. [DATE] at 12:00 p.m. when hospitalized . d. [DATE] at 8:00 p.m. through [DATE] at 8:00 p.m., when a physician ordered staff to withhold the medication pending review by the primary care physician. e. [DATE] refused at 8:00 a.m. f. [DATE] out of facility at 12:00 p.m. g. [DATE] refused all doses. h. [DATE] refused at 8:00 p.m. A Nurse's Note (NN) transcribed by Staff B, RN (Registered Nurse) on [DATE] at 6:35 p.m. recorded Resident #3 stated he had not felt good since the day before, with nausea, upset stomach, loose stools, and felt like he had the flu. A physician order [REDACTED]. The MAR recorded staff administered [MEDICATION NAME] on [DATE] at 4:04 p.m., [DATE] at 10:55 a.m. and [DATE] at 9:02 a.m. On [DATE] at 11:40 a.m., a nurse practitioner assessed the resident, concerned about continued nausea, dizziness and headaches with movement, and ordered the resident's transfer to the emergency room (ER). The [DATE] ER record described the resident treated for [REDACTED]. Abdominal X-rays obtained then did not reveal any gastric or abdominal abnormalities. A [DATE] NN transcribed at 6:06 p.m. by Staff C, licensed practical nurse (LPN), documented Resident #3 had continued nausea with poor appetite. On [DATE] at 11:45 a.m., the [MEDICATION NAME] order was increased to 8 mg administered orally every 6 hours as needed for nausea or vomiting. The MAR recorded staff administered [MEDICATION NAME] 8 mg on [DATE] at 12:32 p.m., [DATE] at 8:49 p.m. and [DATE] at 10:59 a.m. A [DATE] visit note transcribed by the NP recorded the resident had continued bouts of nausea, directed staff to continue to administer [MEDICATION NAME] as needed and added an order for [REDACTED]. A NN transcribed on [DATE] at 6:45 p.m. by Staff B reported the resident's stomach upset and poor appetite. A NN transcribed on [DATE] at 3:44 p.m. by Staff C documented continued nausea with a poor appetite. A visit note transcribed by the NP on [DATE] described continued nausea with temporary relief from [MEDICATION NAME], his oral intake impacted by nausea, the resident had continued loose stools without abdominal pain, and directed staff to schedule an appointment with the resident's [MEDICATION NAME] for follow-up. A NN transcribed by Staff C on [DATE] at 3:49 p.m. described the resident's continued nausea with poor appetite. A NN transcribed by Staff D, LPN, on [DATE] at 1:36 p.m., documented Resident #3 had continued nausea. When she administered his noon medications she noticed the resident's listed Sulfa allergy on the MAR and his prescribed [MEDICATION NAME]. The resident reported stomach upset was one of the symptoms of the allergy and he had been nauseated for a few weeks. She contacted the on-call physician and obtained an order to hold the [MEDICATION NAME] until his primary care physician could evaluate the resident. A visit note transcribed by the NP on [DATE] recorded Resident #3 stated he felt a little bit better that day, with a continued poor appetite but food intake slightly increased, no complaints of abdominal pain, and directed staff to resume administration of [MEDICATION NAME]. A computed tomography (CT) scan of the abdomen performed [DATE] revealed the test ordered for the resident's abdominal pain with diarrhea and bloating symptoms for about a month. The scan did not reveal any current abnormalities of concern related to the abdomen or stomach. A facsimile (fax) document addressed to the physician on [DATE] requested discontinuation of [MEDICATION NAME] due to constant daily refusals, and listed allergies that included Sulfa antibiotics, [MEDICATION NAME] and aspirin. The returned fax on [DATE] ordered the medication discontinued. A NN transcribed on [DATE] at 7:10 p.m., described the resident as pulseless, breathless, cardiopulmonary resuscitation (CPR) initiated, 911 activated and the resident transferred to the ER. Recorded resident weights included: [DATE] 227.0 pounds (#) [DATE] 227.7# [DATE] 227.5# [DATE] 226.8# [DATE] 210.6# [DATE] 210.4# [DATE] 214.0# [DATE] 214.8# [DATE] 213.0# [DATE] 213.8# [DATE] 213.0# [DATE] 213.8# [DATE] 211.9# [DATE] 212.0# [DATE] 213.0# [DATE] 213.6# [DATE] 214.2# [DATE] 213.8# [DATE] 213.5# [DATE] 213.5# [DATE] 210.8# [DATE] 211.6# [DATE] 211.0# [DATE] 211.9# [DATE] 210.6# [DATE] 207.4# [DATE] 208.0# [DATE] 208.0# On [DATE] at 1:01 p.m., the resident's [MEDICATION NAME] stated in the past, he prescribed [MEDICATION NAME] but discontinued the medication due to the resident's Sulfa allergy. Resident #3 complained of abdominal pain and nausea, had been prescribed Apriso then (an anti-[MEDICAL CONDITION] medication for the treatment of [REDACTED]. One or the other medication should be prescribed to treat the targeted symptoms, but not both. On [DATE] at 1:46 p.m., a pharmacist at the resident's retail pharmacy (utilized before hospitalization and admission to the facility) stated Resident #3 had not refilled the [MEDICATION NAME] medication since March, (YEAR) and Sulfa was not listed as an allergy. During a second interview on [DATE] at 8:55 a.m., a pharmacist confirmed a Sulfa allergy was not listed and stated someone allergic to Sulfa should not take [MEDICATION NAME]. On [DATE] at 12:44 p.m., the facility's NP stated she reviewed admission referrals with medication orders for residents admitted to the facility's Medical Director. She could make changes to the medication regimen, meet with the resident and/or family, clarify conditions and allergies at that time, but Resident #3 was under the care of a different physician group who would have had that responsibility. Upon request on [DATE], staff could not locate the resident's admission orders [REDACTED]. The document would list allergies, medical conditions, medications, treatments ordered, and physician signature mandated for admissions to facilities for skilled level of care. On [DATE] at 2:31 p.m., Staff A, RN and evening supervisor, stated when pharmacy identified a medication conflict or allergy, the nurse or pharmacy could resolve that with the provider. He had not contacted the provider when he was alerted of the potential [MEDICATION NAME] allergy on [DATE], the pharmacy took care of it and if the nurse clarified the order they would document that in the NN. On [DATE] at 12:10 p.m., Staff I, LPN, stated if a nurse received notice of potential medication allergies in the resident's electronic record, they should review and clarify it with the provider, then document the action in the NN. On [DATE] at 12:25 p.m., Staff F, LPN and unit manager, stated the nurse was notified of a potential medication allergy in the electronic record. She normally clarified it with the provider, sometimes made a note about it, and the facility NP verified orders. In a subsequent interview on [DATE] at 12:32 p.m., Staff F stated their NP signed all physician order [REDACTED]. On [DATE] at 2:10 p.m., Staff C, LPN, stated the nurse should contact the provider to clarify if alerted of a medication allergy by the pharmacy, and document that in the NN. Resident #3 had a lot of gastrointestinal issues, lots of nausea, went to the ER a few times and always came back with nothing; the [MEDICATION NAME] didn't help, nothing helped. Staff C stated she went through his medication list with his spouse, she said he was allergic to the [MEDICATION NAME] so they discontinued it. On [DATE] at 1:58 p.m., the Director of Nursing (DON) stated she wasn't sure what staff did to clarify orders if there was a conflict or potential drug allergy. The DON expected staff to clarify it with the provider but didn't think they wrote an order about it. At 2:44 p.m. the DON stated she spoke with the nurses and if they identified an allergy, they consulted with the provider and documented in the NN, they would write an order only if it changed the original order. On [DATE] at 1:32 p.m., the facility's consultant pharmacist stated staff are alerted of potential medication allergies through the electronic record after medication orders were entered, nursing staff were supposed to clarify the matter with the physician and the pharmacy was not involved in that process. The Medication Regimen & Review policy, dated [DATE] and without approval signatures, recorded a drug regimen review is conducted upon admission and throughout the stay. When potential clinically significant medication issues are identified the facility will address the issue in a timely manner. The admission nurse was responsible for medication reconciliation and identification of potential clinically significant medication issues upon the resident's admission. The Medication Allergy Identification and Procedure policy, without signatures, dated [DATE] and provided on [DATE] at 12:40 p.m., recorded that a drug regimen review is conducted upon admission and throughout the resident's stay. Potential drug allergies will be addressed with the physician/NP. Orders will be obtained if it is determined the medication has potential risks and should be discontinued. The initial time the allergy warning appears on the MAR the nurse administering will consult with the physician/NP, if not done before. The nurse will document the results of the conversation in the medical record. The facility's policy and procedure manuals provided on [DATE] at 1:11 p.m., contained the following documents: a. A nursing Administering Medications policy, dated and signed by the previous administrator on [DATE], which directed nursing staff to verify medication allergies prior to medication administration, and if a medication was withheld, staff were to document the event with rationale in the NN and notify physician. b. A Nursing Service: Medication Reconciliation policy, dated and signed by the previous administrator and current DON on [DATE], directed that each resident's drug regimen was free from unnecessary drugs that included the presence of adverse consequences which indicated the dose should be reduced or discontinued, clinically significant adverse consequences would be minimized, and the potential contribution of the medication regimen to an unanticipated decline or newly emerged or worsened symptom would be recognized and evaluated, and the regimen modified when appropriate. Nurses were to document physician notification and verification of admission orders [REDACTED]. b. A nursing Medication Regimen & Review policy, dated and signed by the current administrator and DON [DATE], directed the consultant pharmacist's monthly review of resident medication regimens that included the medical record, and written reports required and directed to the physician, facility medical director and DON, for any irregularity that required action. The written report was to detail the relevant medication irregularity. If the identified irregularity required urgent action, the consultant pharmacist would report the irregularity to the DON and attending physician by phone, with a separate written report to the physician, medical director and DON. The physician was required to document any follow up action necessary in the resident record within 10 days of the report. On [DATE] at 8:46 a.m., Staff J, responsible for mission integration, and Staff K, responsible for infection control and QAPI, (Quality Assurance and Performance Improvement), stated facility policies and procedures were reviewed at least annually, revised when appropriate, dated when reviewed, signed by the administrator and located in manuals accessible to staff. They had not seen the unsigned policies before and Staff J questioned where they came from. On [DATE] at 5:53 p.m., Staff E, RN, stated the policy and procedure manuals were in the inservice director's office, nurses had access to them in the office and they were not located on the nursing units or electronically on the computer. On [DATE] at 1:31 p.m., Staff D, LPN, stated she worked on [DATE]. She prepared his ordered medications, Resident #3 asked what they were, he said he was allergic to the medication, she asked what his symptoms were and he said it made him nauseous and upset his stomach. She was informed in report that day that he'd been nauseous and had received antiemetic medications almost as long as he had been there. She called the on-call physician and obtained an order to hold the [MEDICATION NAME]. On [DATE] at 11:25 a.m., Staff H, LPN and unit manager, stated Staff D was not familiar with the resident's physician group, obtained the order to hold the [MEDICATION NAME] from the wrong physician, and one of the NP's in the resident's physician group said to disregard the order since it wasn't made through their provider group. On [DATE] at 2:04 p.m., the facility's consultant pharmacist stated he reviewed the resident's medical records, medication orders and allergies when he performed the medication regimen review on [DATE]. [MEDICATION NAME] was listed as a home medication, the resident had been at the facility for 4 days, staff didn't identify any particular problems when he asked, at that point there wasn't an indication to modify the order, the facility didn't document medication allergy verses intolerance, and many medications cause nausea. His note would have addressed the allergy if there was a concern at the time. On [DATE] at 8:30 a.m., the resident's family member stated the [MEDICATION NAME] put Resident #3 on Apriso and took him off the [MEDICATION NAME] because he was allergic to Sulfa. Facility staff didn't tell the resident what medications they gave, informed he was on Anoro and [MEDICATION NAME] when she asked, and she told staff he was allergic to both medications. The resident was nauseous, had stomach pain and didn't feel good during every visit.

Based on record review and interviews with staff and resident, the facility failed to provide adequate supervision and an assistive device in order to mitigate the risk of an accident (Resident #1). The sample consisted of 4 residents and the facility reported a census of 111 residents. Staff A directed Resident #1 to stand and grab the bar. Staff A did not apply the gait belt to prevent a fall and turned to check the wheelchair. The resident fell , fracturing the left hip and left shoulder. The resident required hip surgery to repair the fractured hip and the left shoulder required an immobilizer device. Findings include: 1. According to the Admission Record dated 3/15/17, Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 2/16/17. The MDS identified the resident had no cognitive impairments and required extensive assistance of 1 staff member with transfers and toilet use. The Minimum Data Set assessment dated [DATE] revealed Resident #5 had no cognitive impairments. Resident #1 required extensive assistance of one staff member with transfers, walking in room and corridor, personal hygiene and toilet use. The MDS indicated the resident had problems with balance during transitions and walking and only able to stabilize with staff assistance. The Care Plan Summary dated 12/15/16 directed the staff to provide assistance of one (staff person) with a gait belt and a hemi walker for all transfers. The Incident/Accident Report dated 3/2/17 at 8:30 p.m. identified Staff A observed Resident #1 fall. Resident #1 reported I fell . I was holding onto the bar. Resident #1 had two skin tears on the left arm and a hematoma to the forehead and the back of the head. The report indicated Staff A received directed about the need for a gait belt and to be used at all times. The Progress Notes dated 3/2/17 at 11:22 p.m. indicated at 8:25 p.m., the certified nursing assistant approached the registered nurse and they went to the resident's room. The resident laid on floor with arm under body. The blood pooled onto the floor from the resident's face. The nurse cleansed the wounds. The nursing assistant had been getting resident ready for bed at the time of the incident. The resident did not have a gait belt on but did have skid slipper socks on feet. The nurse administered Tylenol (analgesic) for the pain. The staff placed the resident in the shower due to blood from hair. The resident voiced complaints of pain in left arm from the elbow to the fingers and around left knee. The resident was transferred to the hospital at 10:10 PM. According to the Intake Information sheet dated 3/7/17, the facility made a self-report on 3/3/17 at 11:46 a.m. On 3/2/17 at 8:30 p.m., the staff had Resident #1 on the toilet. The staff transferred Resident #1 off the toilet without a gait belt. The resident was admitted to the hospital for a fractured hip and shoulder. The physician's History and Physical/Discharge Consults record, dated 3/7/17) indicated the resident had discharge [DIAGNOSES REDACTED]. The Progress Notes dated 3/7/17 at 3:17 p.m. indicated the resident readmitted into the facility. On 3/16/17 at 9:10 a.m. Resident #1 was interviewed and stated the nursing assistant (Staff A) did not use a gait belt and informed her/him that she would not let the resident fall. The resident stated Staff A did not use a gait belt when she transferred her/him to the toilet either. Resident #1 stated she had her own gait belt on the back of the wheelchair. The facility provided staff training on 3/7/17 for 16 direct care staff. The training consisted of and directed staff that whenever transferring a resident, and have hands on the resident, the staff needs to use a gait belt for all transfers. The training instructed the staff to always look at the Care Plan Summary and make sure it is followed. The training informed the staff audits on transfers and gait belts would be completed. Staff A was interviewed on 3/15/17 at 4:58 p.m. Staff A stated there were 2 nursing assistants during the shift and usually have 3 aides. Staff A stated she knew she had a lot to get done. Staff A stated the incident occurred in the resident's bathroom. Staff A stated she had the resident stand up to grab the bar and the resident did not wear a gait belt. Staff A stated she turned to get the wheelchair in place and had her hand on the resident's back. The resident fell to her/his left side and hit head on the door frame. Staff A stated she saw blood and yelled for help. Staff A stated she had felt rushed with only 2 nursing assistant that night working. An interview on 4/12/17 at 12:40 p.m. the Administrator reported an expectation of staff to follow the Care Plan Summary card at all times. The Administrator stated the expectation is for all staff to use a gait belt for all hands on transfers.

Based on record review, staff and medical examiner interviews, the facility failed to ensure that each resident received adequate supervision, assistance and intervention to prevent hazards for 1 of 10 resident records reviewed (Resident #2). The findings constitute an immediate jeopardy to residents health and safety. Resident #2 with a known history for eating too fast and then choking was served dinner tray and although a staff person was present, Resident #2 was allowed to stuff the food in her/his mouth. The resident then choked and became unresponsive. The facility reported a census of 118 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 7/1/16 revealed Resident #2 had [DIAGNOSES REDACTED]. dressing, toileting, bathing and personal hygiene. The nursing care plan included a problem identified as nutritional status, and included interventions that directed staff to: 1. Serve a general diet, plate guard on plate and the resident to eat in the dining room for all meals. 2. Assist or cue for meals as needed. Set up plate, cut up meat as needed. Nurse's Notes contained the following entries: 8/8/16 at 10:33 p.m. Resident requested dinner, a sandwich offered, resident shoved more than 1/2 of sandwich in their mouth and caused them to almost vomit. Staff broke sandwich into pieces and handed to resident 1 piece at a time. 8/16/16 at 8:57 a.m. Plate guard added this morning at breakfast due to resident attempts to eat too fast. 9/3/16 at 9:02 p.m. Resident choked on food at supper in the floor dining room. Resident able to cough it up and encouraged to eat slowly and chew food completely. 9/6/16 at 1:56 p.m. Inquired about changing resident's diet to puree due to resident eating too quickly, that caused them to cough. Dietitian stated a pureed diet was not indicated at that time because the resident did not have chewing or swallowing difficulties. 9/6/16 at 10:07 p.m. Staff sat with resident during dinner, monitored eating, continued to place large amounts in their mouth and attempted another large amount prior to swallowing. Staff encouraged the resident to finish chewing, swallowing and to take smaller bites. 9/7/16 at 5:10 p.m. Fax (facsimile) received from physician related to eating behavior. Recommended smaller portion sizes and small pieces. (The fax was dated 9/5/16 when sent to the physician). 9/7/16 at 6:25 p.m. Staff called nurse to room, stated resident was choking on some of their food. Resident stood and held their walker, appeared to have shallow breaths. Attempted to perform Heimlich Maneuver at that time, the resident became unresponsive and collapsed, then placed in wheel chair with further Heimlich attempts. Agonal (gasping respiration) breaths noted at that time. Supervisor arrived to assist, abdominal thrusts performed by both supervisor and this nurse without results. Thrusts continued until no pulse was noted. During an interview on 9/22/16 at 4:04 p.m., Staff F, certified nursing assistant (CNA) stated on 9/7/16, another CNA, Staff G, asked her to take a dinner tray into the resident's room, stay in the room to supervise and resident could feed themselves. Staff F stated the resident was seated on the side of the bed, received sausage that was sliced, bun, creamed cabbage and potatoes, she cut the sausage into smaller pieces as the resident started to eat really fast and directed the resident to stop, the resident continued to put the food in their mouth, then resident put the bun in their mouth and started coughing. She directed the resident to take a drink, the resident did and threw up some food and drink. The resident attempted to lay down, she directed the resident to sit up and assisted the resident to a seated position, the resident gulped the juice and laid down again. Staff F stated the resident didn't look right, she sat the resident up again, went to the doorway and yelled for assistance. During an interview on 9/22/16 at 4:41 p.m., Staff G, CNA, stated on 9/7/16 she directed Staff F to stay in the resident's room as they ate, to cut the food into small pieces, watch the resident as they put to much food in their mouth and wouldn't swallow. Staff G stated the resident had a pattern of putting too much food in their mouth, the weekend before this happened he/she had put too much food in their mouth in the dining room and attempted to throw up, the nurse, Staff J, licensed practical nurse (LPN), had to push up on their abdomen and the resident coughed up an unchewed hot dog with bun. During an interview on 9/26/16 at 2:32 p.m., Staff D, LPN, stated on 9/7/16 staff alerted her the resident was choking, the resident stood near the door with Staff F, CNA, and didn't look right, didn't speak, she got behind the resident and performed the Heimlich Maneuver and as she did the resident became unconscious. Staff assisted her to place the resident in a wheel chair, they reclined the back of the wheel chair and she continued to attempt abdominal thrusts, the nursing supervisor came and also assisted with abdominal thrusts without success, the resident became pulseless and they stopped resuscitation efforts. Staff D stated the resident had started to put too much food in their mouth and wouldn't swallow, then put more food in their mouth for 1 to 2 weeks prior to this event, she had asked about a pureed diet and was instructed the resident didn't require one. Staff D stated staff had started to stay with the resident as they ate, cut food into pieces and reminded the resident to swallow and slow down. During an interview on 9/27/16 at 11:34 a.m., Staff H, LPN and nursing supervisor, stated on 9/7/16 staff called her to the floor, informed her the resident was choking, the resident was unconscious, not breathing with blue/yellow color as the nurse, Staff D, performed abdominal thrusts with the resident reclined in a wheel chair. Staff H said she assisted Staff D, they both performed abdominal thrusts without success until the resident was pulseless. Staff H stated a day or 2 prior to this Staff D had informed her that staff had to supervise the resident as they ate, gave 1 or 2 bites at a time or the resident shoved all their food in their mouth. During an interview on 9/27/16 at 3:26 p.m., Staff K, CNA, stated the resident had already choked several times, approximately 6 weeks ago the resident had fed him/herself and got up from the table, she realized they were choking, the resident walked towards Staff J, LPN, she got a basin and the resident threw up food that was not very well chewed. During an interview on 9/26/16 at 3:51 p.m., Staff J, LPN, stated on 9/2/16 she was outside the dining room, one of the CNA's said the resident was choking as they walked towards her, she got behind the resident, performed the Heimlich Maneuver, encouraged the resident to cough, and the resident was able to clear their throat without coughing. Staff J stated staff had to supervise the resident, cut food into small pieces and remind the resident to slow down as they ate. During an interview on 9/26/16 at 11:31 a.m., the facility's RDLD stated the resident ate too fast and did better if staff remained with him/her as they ate and reminded the resident to swallow and slow down. When interviewed on 9/27/16 at 12:15 p.m., the RDLD stated she spoke with the evening shift nurse, Staff D on 9/6/16, and recommended they cut the resident's food, and serve 1 item at a time with plate guard During an interview on 9/26/16 at 10:49 a.m., Staff I, CNA, stated the resident was shoveling their food too fast and staff frequently had to remind the resident to slow down, and either the day he/she choked or the day before, someone said that staff had to remain with the resident at meals. During an interview on 9/27/16 at 3:24 p.m., the Medical Examiner stated the preliminary autopsy results revealed the resident's primary cause of death was choking, with a food bolus found at the epiglottis that extended to the esophagus and larynx, and stroke complications identified as a contributing factor. The facility abated the IJ on 9/28/16 when the facility developed a new policy on interventions to be implemented when a resident had coughing/choking with food or medications. Staff were educated on the new policy on 9/29/2016. Care plans were updated on 9/28/2016 for those residents who had modified diet and risk for choking and/or swallowing problems. These actions lowered the IJ from a J severity to an D severity with the need for ongoing monitoring to ensure residents received adequate supervision with eating.

Based on observation, record review and staff and resident interviews, the facility failed to ensure that residents were free from mental abuse for 1 of 10 residents reviewed (Resident #1). The facility reported a census of 118 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. The resident's nursing care plan included a problem identified as difficulty making self understood related to dementia, with staff interventions that included ask the resident simple questions that required 1 or 2 word answers. The facility's Abuse prevention policy dated as last reviewed on 9/2/16 prohibited staff from taking or using photographs or recordings in any manner that would demean or humiliate a resident. The facility's Social Networking Policy dated 10/1/09 directed that social networking had the potential to violate Health Insurance Portability and Accountability Act (HIPAA) and such posts were prohibited by law. A copy of a post on Staff E's, certified nursing assistant (CNA), social media Internet website provided with the facility's self report showed Resident #1's hand holding a hairbrush, and a portion of the back of the resident's leg with pants on. Narrative on the post included I look up his/her ass digging in the toilet putting toilet water in their hair, talkin bout it gone hold it down, and these people too funny, stanky scalp ass. During an interview on 9/26/16 at 3:12 p.m., Staff A, CNA, stated approximately 2 or 3 weeks ago Staff E, CNA, posted inappropriate pictures and information about the resident on a social media Internet website, and she reported the information to her nurse, Staff D, the same day she saw the information on the Internet. During an interview on 9/26/16 at 2:32 p.m., Staff D, licensed practical nurse (LPN), stated a CNA from another floor showed her information posted on a social media Internet site and asked what she should do about it; Staff D reported it to the unit manager, Staff B, via e-mail. During an interview on 9/27/16 at 8:32 a.m., Staff B, unit manager, stated Staff A showed her a copy of what was posted on Staff E's social media Internet website, she contacted the director of nursing (DON) and the human resource department, and Staff E was terminated on that date (9/2/16). During an interview on 9/26/16 at 12:40 p.m., Staff E acknowledged that she posted the information on her social media Internet website when shown copies the facility provided, and stated she didn't feel she did anything wrong as she did not identify the resident by name and did not show anything in the photos that would identify the resident.

Based on observation, record review and staff interview, the facility failed to maintain adequate nutritional status by not revising nutritional interventions or offering food for extended periods of time to prevent further weight loss for one of six residents (Resident #7). Resident #7 continued to have weight loss each month with no new intervention added until April 2016 which was for staff to offer snacks throughout day and no new intervention since this time. The facility reported a census of 122 residents. Finding include: Record review of Resident #7 Minimum Data Set (MDS) assessment dated [DATE] identified [DIAGNOSES REDACTED]. The assessment identified Resident #7 had long & short term memory loss, and severely impaired cognitive skills for daily decisions making skills (rarely made decisions). The resident weight had been identified at 125 pounds, with a loss of 5% in past 30 days or 10% in past 180 days); and noted the resident not on prescribed weight loss regimen. The MDS documented Resident #7 required limited assistance of one staff to eat or drink. The care plan with a start date of 11/5/15 documented Resident #7 at risk for inadequate energy intake related to dementia [DIAGNOSES REDACTED].>surgery and decrease appetite last edited 5/11/16. The care plan indicated the resident will maintain current weight plus/minus 4 pounds this quarter (154 pounds). The care plan indicated Resident # 7 will receive a mechanical soft with ground meat, small portions, whole milk with meals for additional calorie, medpass program supplement (120 mL three times a day), provide finger foods when resident wanders during mealtimes. The care plan directed staff to assist or cue the resident for meals and weight monthly, and as needed notify the physician of significant weight changes. The activities of daily living (ADL) care plan dated 2/1/16 identified if Resident #7 chooses to remain in bed through breakfast, staff will offer continental breakfast. Care plan intervention from 4/28/16 added to encourage snacks throughout day. Record review shows dietary progress note 2/10/16 of Significant weight loss of 13.7% in past three months and 5.8% in past month. Whole milk with meals. Recommend small portions due to may be overwhelming. Decrease appetite with weight loss expected with advancing dementia. Wanders through day [MEDICAL CONDITION], but intake is poor. Resident feeds self with set up and encouragement. Fax to ARNP to increase supplement from 120 milliliters (mL) twice a day to 120 mL three times a day. Record review of dietary progress note from 3/10/16 11.2% weight loss in the past 3 months. Medpass supplement increased last month continue current supplement. Dietary progress note dated 5/11/16 noted 18.6% weight loss in past 6 months and 7.5% weight loss in the past 3 months. Continue with supplement 120 mL three times a day. Whole milk with meals. Dietary progress notes dated 4/12/16 identified significant weight loss of 9.4 % in three months. Slight weight loss from last month. Poor intake of meals. Medpass Supplement increase to TID (three times a day) in February. Continue current supplement. Dietary progress note dated 5/11/16 weight showing significant weight loss at 18.6 % x 6 months, weight loss of 7 ½ pounds x 3 months, slight weight loss from last month. Meal intakes recorded at 25 % most meals, refuses at times, 50% at times. The dietary progress notes did not identify any new interventions. Dietary progress note dated 6/14/16 16.8%, continues to receive supplement 120 ml three times a day with whole milk with meals. Dietary progress note dated 7/14/16 15.8% weight loss in past 6 months. Continue supplement 120mL three times a day. Whole milk with meals. Record review shows weight on 12/30/15 140.7 pounds and on 6/8/15 weight is 121.7# this is greater than a 10% loss in the past 180 days. Weight on 7/7/16 was documented as 118.5 pounds which indicates continued weight loss and is greater than 10% in the past 180 days. Currently diet is Mechanical soft with ground meat and small portions. Observation by surveyor on 7/25/16 noted resident #7 to be sleeping during lunch meal and no tray offered throughout rest of day. Observation by surveyor on 7/26/16 noted resident #7 to be sleeping from 6:30 A.M. to 2:15 P.M. with no breakfast or lunch tray offered. During observation on 7/25/16 slept through noon meal staff did not offer any snacks upon awakening. The surveyor had also observed the resident slept through breakfast meal and noon meal on 7/26/16 with no snacks were offered between meals. Record review of meal completion sheet shows numerous slashes and no documentation of meal completion. Staff interview with staff W Certified nursing assistant (CNA) 7/28/16 at 8:45 AM states that if meal completion not filled in or slash means that did not come down for meal. Staff were unable to provide documentation that meals or snacks were provided to resident from 7/23/16/to evening meal on 7/25/16. Interview with registered dietician 7/28/16 @ 8:00 AM states that means resident slept through meal and continental breakfast should be offered. Also stated that had thought about fortified foods as interventions for weight loss but this policy had not been implemented in the facility. Small frequent meals not being done due to snacks are available for CNA to offer resident when awake. Also does not have MD order for small portions that were implemented in February 2016. Reported that does not notify MD of small portions part of diet or obtain order. Staff interview 7/28/16 at 12:00 PM with Director of Nursing (DON) provided care plan intervention to offer snacks throughout day added on 4/28/16. The DON was not able to provide documentation that other interventions had been initiated since this date.

Based on clinical record review, staff interviews and facility policy review, the facility failed to provide adequate supervision resulting in an injury for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 123 residents. The MDS (Minimum Data Set) assessment dated [DATE] for Resident #1 revealed a BIMS (Brief Interview for Mental Status) score of 12 out of 15 that identified moderate cognitive impairment. The MDS reflected Resident #1 required extensive assist of two staff members to physically assist with transfers and assist of one staff member for other activities of daily living. The MDS documented Resident #1 used a walker and wheelchair for mobility. The MDS [DIAGNOSES REDACTED]. The MDS documented Resident #1 had a falls in the last month prior to admission/entry or reentry. The MDS documented the balance assessment that indicated Resident #1 as not steady and only able to stabilize with staff assistance. The MDS indicated the resident had no functional limitations in both upper and lower extremities and in range of motion. According to the Initial Plan of Care dated 2/13/15 Resident #1 requires assist of one staff member, a gait belt, walker and wheelchair for transfers and mobility. A gait belt and wheel chair are used for Resident #1 for all long distance mobility. Review of the Fall Assessment Tool dated 2/13/15, indicated Resident #1 to be at moderate risk for falls. Review of Resident's #1's Progress Notes dated 02/23/15 at 4:20 a.m. revealed Nurse summoned to Resident #1's room by Certified Nurse Aide (CNA) and found Resident #1 sitting on the floor between the bed and side table. Resident #1 noted with a large amount of bloody drainage on face and tee shirt. Upon entering Resident #1's room. The CNA reported Resident #1trying to stand up and wipe self after using the urinal, and CNA reported he/she went to get wipe from the bathroom and when CNA turned around Resident #1was on the floor. Resident reports hitting head on cement. resident sustained [REDACTED]. Resident #1 noted to have a 3 x 5 cm hematoma under right eye extending to bridge of nose, left hand with mild edema and unmeasured ecchymosis to thumb and index finger. At 4:30 a.m. on call physician notified and orders received at 4:31 a.m. to send Resident #1 into the ER (emergency room ). Resident #1's family notified and medic called for transport to ER. Review of the Fall Scene Investigation Report dated 2/23/15 at 4:20 a.m. revealed Resident #1 ' s feet slide out from under him/her, the area and position observed sitting on floor with feet and legs towards side of bed and head under bedside table. Resident #1 with injury of right eyebrow laceration 2 cm long by 1 cm wide, right nose laceration 1 cm by 1 cm, right eye hematoma extending to bridge of nose 5 cm long by 3 cm wide, left brow laceration 3 cm long by 1 cm wide, and left thumb and index finger ecchomotic and edematous. Location of fall in Resident #1's room, no assistive equipment in use, and Resident #1 left unattended after standing up and using urinal and resident's legs gave out. Resident #1 had gripper socks on at time of fall, Resident #1 alert and oriented to person, place, and time, Resident #1's wounds cleansed, physician notified, and resident sent to ER. Review of the Post-Fall Investigation dated 2/23/15 revealed Resident #1 reported he/she was standing up and feet fell out. The CNA in the room with Resident #1reported she thinks Resident #1trying to go to bed and fell forward. No gait belt on Resident #1 and left standing unattended. Review of Emergency Department Notes dated 2/23/15 indicated Resident #1 presented to the ER following a fall at the facility. Location of injury is to Resident #1's face and 2nd digit of hand; Resident #1 has pain and swelling of these areas. CT findings include a right orbital blowout fractures involving the floor of the right orbit as well as the medial wall of the right orbit (lamina papyracea). There is some herniation of intraorbital fat into the roof of the right maxillary sinus extending approximately 9 millimeter (mm) without entrapped or herniation of extraocular muscles. There is approximately 4 mm displacement of bone fragments inferiorly. There is an additional fracture involving the posterior aspect of the medial wall of the right orbit also containing herniated fat. Left hand x-rays (radiographs) revealed Resident #1 presents with second digit extensive swelling and bruising of the left hand, no fractures or dislocations identified. Review of the Progress Notes dated 2/23/15 at 10:35 a.m., revealed Resident #1 returned to the facility from the ER department. Review of the ED Discharge Instructions dated 2/23/15 included instructions for Resident #1 to follow-up with physician for his/her eyes on 2/24/15 and to have sutures removed in 7 to 10 days. Staff C CNA, reported to the facility on [DATE] that Resident #1 always uses his/her urinal and call light. Staff C responded to the Resident #1's call-light on the date of the fall. Staff C indicated the Resident #1 always gets up alone to use the urinal. Staff C reported she just watched Resident #1 get up and use the urinal independently. Staff C reported after Resident #1 was finished with the urinal she took it from Resident #1 and went to the bathroom to empty the urinal while Resident #1 remained standing and wiping self. Staff C reported while in the bathroom she heard a loud noise and turned around and observed Resident #1 hit the ground. Staff C reported no gait belt in use and Staff C acknowledged she should not have left Resident #1 unattended while standing. Interview on 3/18/15 at 9:46 a.m., Staff B Registered Nurse, (RN), stated she spoke with Resident #1 on 2/23/15 and Resident #1 stated he/she turned the call light on and Staff C CNA came in shortly after. Staff B stated Resident #1 reported Staff C CNA handed Resident #1 a urinal, the resident used it and handed the urinal back to Staff C CNA. Resident #1reported to Staff B that he/she started to ask Staff C CNA for a Kleenex to wipe self with and Staff C CNA turned away from him/her and went into the bathroom to empty the urinal while he/she was still standing. Staff B stated Resident #1 reported he/she started to feel a loss of balance and fell . Interview on 3/18/15 at 10:02 a.m., Staff A, RN House Supervisor, reported she was summoned to Resident's #1 room the morning of the fall. Staff A reported entering Resident #1's room and observed the resident sitting on the floor with legs and feet towards side of bed, bedside table behind Resident #1 and his/her walker not within reach. According to Staff A RN no gait belt was observed on Resident #1. Staff A stated Staff C CNA in the room and reported that she got Resident #1 to a standing position at the side of the bed, not using a gait belt. Staff A stated Staff C CNA reported Resident #1 normally does everything by his/her self. Staff A stated Staff C CNA went to empty the urinal. Staff C reported hearing the resident gasp. Staff A stated Staff C reported she came out of the bathroom and Resident #1 was on the floor. Staff C reported to Staff A that no gait belt in use or walker for Resident #1 at the time of the incident. Staff C reported to Staff A that she should have used the gait belt and walker and not leave Resident #1 standing unattended. According to Staff A ' s interview, Staff C acknowledged she failed to follow the care plan for Resident #1. Review of the facility's Gait Belt Use Policy/Procedure with effective date of 3/1/06 revealed the guidelines are established to provide for the safety of both the residents and employees. Employees will use a gait belt when the resident requires hands-on assistance to transfer or ambulate

Based on record review, staff, family and physician interviews, the facility failed to assess a condition change and contact the physician for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 132 residents. Findings include: According to Minimum Data Set (MDS) Assessment Tool dated [DATE], listed Resident #2 was admitted to the facility on [DATE]. The MDS identified Resident #2 scored a 14 out of possible 15 for the Brief Interview for Mental Status (BIMS) that identified Resident #2 as cognitively intact. The MDS indicated Resident #2 required extensive assist of two staff members for bed mobility, transfers, toilet use and bathing, and extensive assist of one staff member for locomotion and personal hygiene. The MDS documented Resident #2 had functional limitation in range of motion on upper and lower extremities to one side of the body. The MDS indicated Resident #2 used a wheelchair for mobility. The MDS listed Resident #2 had [DIAGNOSES REDACTED]. The MDS documented Resident #2 had mild pain that occurred occasionally. The MDS indicated Resident #2 experienced no falls since last assessment period. Review of the resident's Care Plan with a start date [DATE] indicated a Problem for risk for falls due to weakness and debility and use of anti-depressant and pain related to advanced age. The Care Plan Approach's directed staff to: a) Transfer Resident #2 with a mechanical lift (Sara Lift) and assist of two staff members. Date of [DATE] revealed an intervention for use of a Hoyer lift and 2 staff member assist for transfers. b) Resident #2 sleeps in the recliner. c) Encourage Resident #2 to wear appropriate foot wear and to wear gripper socks when not wearing shoes. d) Keep Resident #2's items within reach when on toilet. Grab Bars on toilet for safety. e) Monitor for fatigue, restlessness due to pain, and other risk factors for falls. f) [DATE] revaluate lift chair and staff education regarding gripper socks that are to be applied to resident. Resident owns recliner, remote to recliner to be placed in side pocket of chair for resident's safety. g) Assess pain level during medication pass and as needed using the numeric pain scale and medicate per physician's orders [REDACTED]. h) Notify the physician if pain is not relieved or if it changes in duration, type, or site or if scheduled or as needed (PRN) pain medication loses its effectiveness as stated by resident or noted through increased PRN pain medication usage. Review of the facility's Fall Scene Investigation Report dated [DATE] at 4:05 p.m. revealed Resident #2 found lying on the floor on right side, under blankets with head under bed and the recliner/lift chair in the high position. Resident #2 had been sitting in remote control recliner, reclined back, prior to fall. Staff noted a hematoma to top middle of Resident #2 ' s forehead. Resident #2 stated leaning and just fell over. Status of Resident #2 noted to be per normal, alert and oriented to person, place, and time. Call light had been in reach but not turned on. Assessed and placed in bed with positioning bars up and call light in reach. The report indicated Resident #2 accidentally hit the electric button on chair and it lifted up causing Resident #2 to slip out of chair. Immediate Interventions to prevent future falls included education for Resident #2 on use of electric chair and after Team Meeting Notes indicated staff education on regular socks and gripper socks, recliner evaluated and controls are to be kept in side pocket of recliner when not in use. Review of the facility Fall Progress Note dated [DATE], revealed Resident #2 had unwitnessed fall on [DATE] and sustained injuries that included a hematoma to the top of the forehead. All fall interventions not in place at time of fall. Staff failed to have gripper socks on Resident #2 at time of fall. Staff educated regarding gripper socks and lift recliner remote to be left in side pocket when not utilized. Review of the resident's Progress Notes dated [DATE] at 3:45 p.m. revealed Resident #2 heard yelling "help", staff responded to Resident#2 ' s room and resident found lying on the floor covered up with blankets lying on right side with head underneath the bed, lift chair/recliner extended in upward position. Resident #2 stated leaning over and fell to the floor. Staff assessed Resident #2 and complained of right hip pain and noted to have a 3 cm (centimeters) hematoma to top of forehead, no complaints of headache. Resident #2 assisted with mechanical lift to bed, Tylenol administered for discomfort, and call light in reach. Resident #2's physician and family notified of fall. The progress notes dated [DATE] at 5:00 p.m. revealed staff documented received a call from the resident #2's physician instructed to continue to monitor and if Resident #2 complains of bad headache to send to the emergency room for further evaluation and treatment. Review of Resident #2's Progress Notes dated [DATE] at 8:00 p.m., documented Resident #2 complained of right side neck pain and scheduled pain medication administered, will continue to monitor. Review of the facility Neurological assessment dated [DATE] at 10:30 p.m., revealed Resident #2 complained of headache. The assessment dated [DATE] at 1:30 a.m., revealed Resident #2 complained of headache. The assessment dated [DATE], ,[DATE] shift indicated Resident #2 complained of headache and nausea. Resident #2's record lacked indication the physician was notified of the complaints or sent to the emergency room as ordered by the physician for complaints of headache. Review of Resident #2's Progress Notes dated [DATE] at 3:30 a.m., revealed post fall assessment done and PRN pain medication given for pain. Review of Resident #2's Progress Notes dated [DATE] at 2:56 p.m. revealed Resident #2 had emesis (vomiting) 3 times. The nursing note failed to document notification to Resident #2 ' s physician following the change of condition. Review of Resident #2's Progress Notes dated [DATE] at 7:00 p.m., revealed no emesis or loose stools, appetite poor and Resident #2 complains of right side neck pain. Call placed to the Resident #2's physician. At 7:30 p.m. staff documented an order received from the Resident #2's physician for an X-ray of the c-spine (cervical) and portable radiology called and X-ray will be done tonight. Staff documented X-ray results faxed (facsimile) to the physician at 11:12 p.m. The Notes/clinical record lacked indication that staff verbally or by fax informed Resident' #2 ' s physician of resident's current change of condition. Review of Resident #2's Progress Notes dated [DATE] at 12:30 p.m. revealed Resident #2 complained of neck pain of 7 out of 10, reassessed pain after a.m. pain medication administered and Resident #2 rated pain 2 out of 10. At 5:29 p.m. staff documented Resident #2 complained of general muscle pain mostly of neck and shoulder area, Resident #2 had two loose stools at this time. The Notes/clinical record lacked indication of Resident #2's physician notified of the severity of neck pain Resident #2 continued to complain of or to follow up with the faxed X-ray results from [DATE]. Review of the radiology report dated [DATE], reported Resident #2 ' s status [REDACTED]. Impressions 3 mm (millimeter) anterior subluxation of C4 (Cervical/Neck vertebra) with respect to C5. In comparison with prior exam, findings are stable. No compression deformities. Mild [MEDICAL CONDITION]. Mild spondylosis. Review of Resident #2's Progress Notes dated [DATE] at 9:57 p.m., revealed Resident #2 reported general body aches, mostly neck and shoulder area, rated pain a 7 out of 10. Pain medication administered, repositioned, and massage given. Will have the 3rd shift follow up. The Notes/clinical record lacked indication Resident #2's physician notified of the ongoing pain and/or Resident #2's change of condition. Review of Resident #2's Progress Notes dated [DATE] at 11:58 p.m., revealed Resident #2 continued to complain of neck pain and at this time rated the pain a 3 out 10. Resident #2 repositioned. The Notes/clinical record lacked indication Resident#2's physician notified of ongoing complaints of neck pain following fall of [DATE]. Review of Resident #2's Progress Notes dated [DATE] at 2:17 p.m., revealed Resident #2 was administrated PRN pain medication for complaints of neck pain. Resident #2 rated neck pain a 6 out of 10. Review of Resident #2's Progress Notes dated [DATE] at 5:19 p.m., revealed Resident #2 complained of neck and shoulder area pain, PRN pain medication given at shift change, and pain is less severe. Resident #2 stayed in room for dinner. Awaiting physician's reply to X-ray results previously faxed. The Notes/clinical record lacked indication resident's physician notified of resident's current condition or follow up on X-ray results. Review of Resident #2's Progress Notes dated [DATE] at 10:20 a.m. revealed no new orders received related to X-ray results from [DATE], family notified. Resident #2 continues to complain of neck pain and rates the pain a 6 out of 10. Resident #2 repositioned, drink offered and distraction attempted. PRN pain medication administered. Review of Resident #2's Progress Notes dated [DATE] at 5:44 p.m., revealed staff received a phone call from Resident #2 ' s physician with orders for a soft collar to be applied to Resident #2's neck, [MEDICATION NAME] 5 mg (milligrams) three times a day, a medication for neck spasms, and a CT scan to be scheduled. The Notes/clinical record lacked any indication of any information regarding Resident #2's condition provided to the physician. Review of Resident #2 ' s progress notes dated [DATE] at 4:20 a.m. revealed staff removed the soft collar per request from Resident #2. Pain medication administered for complaints of discomfort. Review of Resident #2's Progress Notes dated [DATE] at 2:12 p.m., indicated an order received by Resident #2s physician for a CT scan of spine to be done on [DATE] at 10:15 a.m. Transportation arranged. Review of Resident #2's Progress Notes dated [DATE] at 3:53 a.m., revealed Resident #2 remained on bed rest this shift. Review of Resident #2's Progress Notes dated [DATE] at 10:47 a.m., revealed the staff received a call, from the center performing the CT, regarding Resident #2's result of the CT scan that showed a [MEDICAL CONDITION]-spine and Resident #2 will be transferred by ambulance to hospital emergency room . Family contacted. At 12:13 p.m. Staff called the emergency room regarding Resident #2 ' s and informed Resident #2 might be transferred to another hospital for surgical treatment. Review of Resident #2's Progress Notes dated [DATE] at 7:50 a.m., revealed staff called the second hospital and informed Resident #2 was admitted with [DIAGNOSES REDACTED]. Resident #2 is not a surgical candidate and has a very bad urinary tract infection Review of Resident #2's Emergency Department Notes, from the initial hospital dated [DATE] at 11:33 a.m., revealed Resident #2 presents with 2 neck fractures. Resident #2 will require a halo for treatment of [REDACTED]. Resident #2's neck immobilized in a brace at this time. Resident #2's condition is guarded and transfer arrangements at 12:20 on [DATE] to another hospital for further treatment. Review of the Resident #2's Neurology Discharge Summary dated [DATE] admitted and a [DATE] discharge date , Resident #2 had an unwitnessed fall and has been complaining of neck pain. Resident #2 admitted and upright imaging revealed stable cervical fracture. Discussion with family resulted in decision for comfort cares only and Resident #2 discharged back to facility with comfort care measures. Review of Resident #2's Progress Notes dated [DATE] at 8:34 p.m., revealed nurse entered Resident #2's room, resident's eyes closed, no pulse, no respirations, or blood pressure noted. Nurse documented Resident #2 had expired at 8:15 p.m., Resident #2's family member at bed side. Interview on [DATE] at 5:14 p.m., Staff E, CNA (Certified Nurse Aide) indicated on [DATE] came into work at 1:54 p.m. and during rounds with the off going shift, Resident #2 noted in his/her room sitting in a recliner in a reclined position, call light in hand and remote to the recliner in hand and a blanket covered Resident #2. Staff E indicated Resident #2 was dressed and had regular socks on. Staff E stated she was on break when Resident #2 fell . Staff E stated after Resident #2's fall she notified the nurse Resident #2 was not wearing gripper socks nor did Resident #2 have any in the room. Staff E indicated after Resident #2 ' s fall noted slower movements, depressed, not happy as normal. Staff E identified Resident #2 not acting per normal routine. Staff E stated you could tell Resident #2 not feeling normal by just looking at the resident. Staff E stated Resident had increase stiffness of body, complained of neck pain, did not want to move, and did not want to come out of room per Resident #2's normal routine. Staff E stated reporting this to the nurse (Staff G). Interview on [DATE] at 5:39 p.m. with Staff D, CNA stated staff heard Resident #2 yell for help and responded to Resident #2 ' s room. Staff D indicated seeing other staff members already in Resident #2 ' s room. According to Staff D staff found Resident #2 lying on floor, face down with head under bed. Staff D stated Resident #2 identified his/her head and neck hurt. Staff D stated with direction from the nurse Staff D and other staff members assisted Resident #2 from the floor using a mechanical lift and transferred Resident #2 to the bed. Staff D indicated Resident #2's call light was not activated prior to the fall. Staff D stated after Resident #2's fall and before going to the hospital Resident #2 was not his/her normal self. Staff D indicated being instructed to keep Resident #2 in bed, which was unusual for Resident #2. Resident #2 mostly slept and sat in the recliner and Resident #2 was capable of using the recliner controls. Staff D stated after the fall Resident #2 complained of pain, more than normal. Resident #2 failed to come out of room for meals as usual, required assist with feeding not identified prior to the fall and hardly ate any food. Staff D stated reporting this all to the nurse. Staff D indicated after Resident #2's fall staff noticed Resident #2 talking differently, experienced increased pain, decreased mobility, and didn't want to eat or drink Interview on [DATE] at 10:24 a.m., Staff F, LPN (Licensed Practical Nurse) stated Resident #2 failed to have gripper socks on, as care planned, prior to fall. Staff F indicated Resident #2 required gripper socks. Staff F reported staff educated on the use of gripper socks after Resident #2's fall. Interview on [DATE] at 11:56 a.m., Resident#2 ' s family member noted a change in Resident #2's condition after a fall. Family member stated the facility reported Resident #2's X-ray to be normal. The family member stated Resident #2's condition continued to decline, the resident refused to go out for meals, needed assist to eat, complained of increased neck pain, and wanted to sleep all the time. Family member stated this was not Resident #2's normal behavior. The family member stated calling Resident #2's physician, believes on a Monday, [DATE], and asked something to be done as the family believed Resident #2 was hurt. Interview on [DATE] at 12:17 p.m., Staff C, RN (Registered Nurse), unit manager, stated she had been off work when Resident #2 fell , returning to work on [DATE]. Staff C stated she was very surprised to see Resident #2 ' s change of condition, the resident experienced neck pain, decreased mobility, and loss of appetite. Staff C stated after the fall and prior to having the CT scan done Resident #2 was slurring words. Staff C stated would expect staff to call X-ray report to the physician and not just fax it and report to the physician Resident #2's change of condition. Staff C stated after the fall Resident #2 required assist with feeding and was moved to the assist feeding table in the dining room. Staff C indicated Resident #2 did not have gripper socks on at time of fall but had on regular socks. Staff C stated Resident #2 had no problems prior with operating the recliner/lift chair remote prior to fall. Staff C stated she expected staff to notify Resident #2's physician via phone of the condition change. Staff C indicated if Resident #2 had been sent out earlier to the hospital would have received further evaluation and treatment sooner Interview on [DATE] at 1:20 p.m., with Resident #2's physician indicated the facility did notify him of Resident #2's fall on [DATE] and gave orders for an X-ray. The physician stated the facility never notified him of Resident #2 ' s change of condition. The facility just faxed the X-ray results. The physician stated was not aware of Resident #2's condition change until a family member called and questioned the physician related to Resident #2 ' s status. The physician stated notified the facility and gave new orders that included soft collar to Resident #2's neck, CT scan, and medications for neck pain. The physician stated if he had been aware of Resident's condition he would have ordered further evaluation to be done. Interview on [DATE] at 3:04 p.m., Staff G, LPN stated working on [DATE], when Resident #2 fell and assigned to care for the resident at that time. Staff G indicated other staff responded to Resident #2 yelling out help and found the resident on the floor with head under foot of bed and Resident #2 ' s recliner noted to be in a full upright position. Staff G reported hematoma noted to Resident #2's forehead and resident complained of right hip pain. Staff G indicated Resident #2's physician notified along with family member. Staff G stated the physician ordered to monitor Resident #2 and if resident complains of bad headache send to the emergency room . Staff G stated on [DATE] he/she notified Resident #2's physician of neck pain, and X-ray order received. Staff G stated the X-ray was completed that night and faxed to the physician due to it not showing anything, however Staff G stated no documentation of Resident #2's status of condition given to the physician. Staff G stated she was off the next couple days and upon her return to work was surprised to see the change in condition of Resident #2. Staff G stated she received a phone call Resident #2's physician ordered a CT scan done and for Resident #2 to wear a soft collar to neck and medication for neck pain. Staff G stated she never questioned the call from the physician but believes Resident #2 ' s family member may have called the physician regarding Resident #2's increased pain and decreased mobility. Staff G stated staff are directed to notify a resident's physician of any condition change, including ongoing or worsening of pain, emesis, etc. and document it in the resident's clinical record. Staff G stated she did not contact Resident #2 ' s physician regarding the CT scan order and administration of pain medication for Resident #2. Interview on ,[DATE] at 11:36 a.m., Staff B, RN, stated she took care of Resident #2 after the fall. Staff B indicated Resident #2 had ongoing neck pain, a 6 out 10. Staff B not aware if Resident #2 ' s status was passed on to the oncoming shift regarding pain. Staff B indicated he/she did not contact Resident #2's physician and provided no reason this failed to occur regarding the condition change. Interview on [DATE] at 3:46 p.m., Staff A, LPN, stated taking care of Resident #2 after fall and did not receive any report from the prior nurse at shift change regarding Resident #2's condition. Staff A believed Resident #2 ' s physician was already notified regarding Resident #2's condition and staff was waiting for a call back from the resident's physician. Interview on [DATE] at 1:04 p.m. with Resident #2 ' s physician revealed a statement if the facility contacted the physician regarding the condition of Resident #2 after the fall an earlier evaluation would have occurred. Review of the facility Change in a Resident's Condition or Status Policy Statement dated [DATE], instructed staff to notify the resident's physician of a condition change including radiology reports. If no response from the physician within 48 hours the facility is directed to call the physician.

Based on observation, record review, employee written statement, facility policy review and physician and staff interviews, the facility failed to administer medication as ordered by the physician for one (1) of six (6) residents reviewed (Resident#1). On [DATE], a staff administered an inaccurate amount of [MEDICATION NAME] medication to a hospice resident. The facility reported a census of one hundred thirty one (131) residents. Findings include: The Minimum Data Set (MDS) Assessment Tool dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident had been under the care of hospice services. The MDS documented the resident had moderately impaired cognitive skills for daily decision-making. A Physician ' s Discharge Medication Reconciliation order dated [DATE] directed the nursing home staff to administer [MEDICATION NAME] ([MEDICATION NAME]) 10 milligrams (0.5 milliliters) every four hours as needed (PRN) for severe pain, from a [MEDICATION NAME] concentrated bottle of 20 milligrams per one milliliter. The Medication Record dated [DATE] indicated the resident received [MEDICATION NAME] Solution ([MEDICATION NAME]) on [DATE] at 8:00 p.m. The Controlled Substance Shift Count and Usage Records identified the as needed medication ([MEDICATION NAME]) had been available since [DATE], but the amount remained at 30mL until [DATE] at 8:00 p.m. The resident did not receive the PRN (as needed) [MEDICATION NAME] medication at the facility until [DATE]. The PRN Controlled Substance Shift Count and Usage Record documented the [MEDICATION NAME] concentration as 20 milligrams (mgs) per one milliliter, with directions to administer 0.5 milliliters (10 milligrams) by mouth every four hours. The documented date of [DATE] with the time of 8:00 p.m. revealed the amount on hand as 30 milliliters (mLs), the given amount as 0.5 milliliters (by Staff A), and the remaining amount as 25.5 milliliters. The documentation noted by Staff A at 10 p.m., the amount on hand as 25.5 mL with zero (0) given. The documented date of [DATE] with the time of 11:00 p.m. revealed the amount on hand as 21.25 milliliters as confirmed by two staff nurse signatures. (The form had a line drawn through the amount given at 11:00 p.m., indicating no amount had been administered since 8 p.m., when Staff A administered the medication.) The facility investigation form dated [DATE] at 11:10 p.m., identified a possible medication error for Resident #1 who received [MEDICATION NAME]. The form revealed it was unclear if the medication error hastened the resident's death. The facility educated the nurse and then suspended her indefinitely. The form had been signed by the DON. The Hospice Care Interdisciplinary Group Notes dated [DATE] at 6:45 p.m. documented the resident had been resting quietly in bed with family in the room, plan of care and medications reviewed. Documentation included the family had been aware that the resident was approaching death. The Hospice Care Interdisciplinary Group Notes dated [DATE] at 10:25 p.m. documented the visit was made for a decline in condition. Documentation revealed the residents blood pressure at ,[DATE], pulse 120, and breathing at 12 times per minutes with 15 to thirty second periods of no breathing. Documentation included Staff A informed the hospice nurse and the physician of a medications discrepancy, the family declined treatment. The Hospice Care Interdisciplinary Group Notes dated [DATE] at 11:10 the resident expired. Observation on [DATE] at 3:00 p.m. with Staff G, Registered Nurse (R.N.) and the Director of Nursing (DON) presented Resident #1 prescription box for [MEDICATION NAME] Oral Solution 100mg per 5(mLs) and (20mg per 1mL), with directions to give .25mL (5mg) by mouth or under the tongue every four hours as needed for pain, or difficulty breathing. The medication box indicated the bottle contained 30mLs. The prescription label indicated the prescription had been filled on [DATE]. Observation on [DATE] at 3:00 p.m. with Staff G, R.N. and DON present revealed a white bottle that contained a measured scale on the side of the bottle with a black mark above the 21mL line and below the 24mL line. Staff G reported that she had made this mark on the bottle on [DATE], and Staff K, R.N. had agreed also that the mark had been made where the medication volume was at. During an observation on [DATE] at 3:00 p.m. Staff G, R.N. poured the [MEDICATION NAME] into a clear plastic medication cup, and the medication cup indicated the volume of the [MEDICATION NAME] at 21.5mLs. According to the Kahl Home Employee Statement signed by Staff A, dated [DATE], the documentation indicated the following: Staff A administered Resident #1's his/her medications at 8 p.m., and Hospice/family requested she administer Resident #1's PRN (as needed) [MEDICATION NAME] sulfate. Staff A checked the MAR, opened the [MEDICATION NAME] (bottle), measured what she (thought) was the correct dose, .5mL. and then went to the resident's room. Staff A documented Staff H noticed the medication cup that Staff A had measured the dose into and suggested Staff A use the syringe that came with the medication. Staff A searched both medication carts and the medication room, but found no syringe. Staff A returned to Resident #1's room, (and) told Staff H she could not find a syringe. Staff A documented she used a straw to administer the dose to Resident #1, who sipped the medication through a straw. Resident #1 left a few mL's in the cup, so Staff A emptied what was left into a spoon and gave the medication to Resident #1. Half of the spoonful flowed out of the corner of Resident #1's mouth. The resident's family called Staff A to the resident's room at 9 p.m. concerned about Resident #1's breathing. Staff A assessed Resident #1 finding his/her Sp02 (oxygen saturation via pulse oximetry) at 94 %, 92 bmp (breaths per minute) with apneic respirations (slow or stop breathing) counting about 12 breaths/minute, uneven. Staff A determined Resident #1's hand grips were firm and his/her skin was warm. Staff A called Staff H to come look at Resident #1. Staff H assessed Resident #1 and suggested the change of status may be prompted by the [MEDICATION NAME]. The family asked Staff A to call the on call Hospice nurse to come and assess Resident #1. The hospice nurse arrived. Before the 3rd shift nurse Staff E arrived to count (medication), Staff H asked Staff A how much [MEDICATION NAME] Staff A had given Resident #1 after they discovered that the controlled substance sheet (of what was given) did not match the [MEDICATION NAME] order in the MAR. Staff A held up the empty plastic medication cup with the tip of Staff A's nail placed at the " 5" line. At 10 p.m., the (medication) count with the 3rd shift nurse, the medication discrepancy was discovered. Staff A notified the physician of the medication discrepancy. Staff A received orders to monitor Resident #1 and the physician would call back after he consultant with the pharmacist. Staff G (supervisor) notified the resident's POA (power of attorney) of the medication discrepancy and the resident's family member (at his/her bedside). The POA decided not to hospitalize the resident. The hospice nurse assed Resident #1 who expired at 11:10 p.m. During an interview on [DATE] at 9:08 a.m. the physician reported that Resident #1 had been admitted to the hospital due to not eating or drinking much at the nursing home, and had a [DIAGNOSES REDACTED]. The Resident had been under the care of hospice prior to the hospital admission on [DATE]. The family had wanted to admit the Resident to a Hospice House upon leaving the hospital, but no beds were available, so the resident returned to the nursing home with hospice services. the physician reported that Resident#1 had approximately a week to two weeks to live. The physician reported the Resident slept most of the time, and was not able to carry on a normal conversation during the Resident's stay in the hospital. The physician reported that when the nursing facility became aware of the Resident receiving too much of the [MEDICATION NAME] they called the on-call physician immediately. The physician reported that the nursing home did not have [MEDICATION NAME] (medication to reverse the effects of [MEDICATION NAME]) in the building. The physician reported the family had been educated on the options to treat the Resident's overdose, and had decided to no proceed with treatment to reverse the [MEDICATION NAME]. The physician reported the dose of [MEDICATION NAME] (100mgs) did cause the Resident to expire, and that it was very unfortunate that this happened to the Resident and if Resident #1 had went to the Hospice home, staff are much more familiar with the [MEDICATION NAME] dosage, this would most likely would not have happened. The physician agreed that the medication error was a simple math error and the nursing home staff responded immediately upon discovering the medication error. During an interview on [DATE] at 3:30 p.m. Staff H, (R.N.) Third Shift Supervisor reported she worked on [DATE] and came to work at 8:00 p.m. and paged the second shift supervisor. Staff H reported Staff K gave her a report that there were two readmissions and two new admissions. Staff H reported Staff K asked her to go check on a resident's skin with Staff L, LPN. Staff H reported she went to One North where Staff L usually worked, but Staff A had been on One North. Staff K reported Staff A had two readmissions. Staff H reported she went to do vitals on Resident #1, and offered the resident some fluids to drink, and asked the resident about pain. Staff K reported the resident did have pain, and the family member in the room told her that the resident last had pain medication at 4:00 p.m., and the resident hugged her. Staff H reported she went to the common area and Staff A had been setting up the residents medications at the medication cart. Staff H reported she then visited with the resident's family, Staff A then entered the room and stated she did not want to spill the resident's medication. Staff H reported she went to get a syringe for Staff A, and reported Staff A could use a straw or spoon. Staff H reported she looked for a syringe, but could not find one, and went back to the room and Staff A gave the resident the medication when she entered the room. Staff H reported she heard Staff A say oops I spilled a little, and Staff A got a washcloth for the resident, then both staff left the room. Staff H reported she went back to the common area and gave Staff A a report of the resident ' s vitals. Staff H reported she dealt with some staffing issues then headed over to Two North. Staff H reported that at about 9:25 p.m. Staff A asked what Kussmaul breathing was (describes as when a person pants and then pauses, and then takes a breath). Staff H reported she asked Staff A who was doing that breathing, and Staff A reported it was Resident#1. Staff H reported she went to One North and asked Staff A with visual aid of plastic medication cup how much [MEDICATION NAME] did Resident #1 receive. Staff H stated Staff A reported she did not give 10 mL after she had been showed the proper dose. Staff H reported she answered a page(call) in the One North area, then went to check on Resident #1. Staff H reported upon entering Resident #1's room Staff A kneeled at the resident ' s bedside, and the resident ' s respirations was even and unlabored. Staff H reported the family in the room reported the resident ' s breathing was different than before. Staff H reported the resident did not respond to verbal stimuli. Staff H directed Staff A to notify the Hospice Nurse. Staff H reported she went to check on staff and printed out a schedule for the next shift, then went to the first floor in-service room, and told Staff K about the [MEDICATION NAME] dose. Staff H reported at the end of the in-service the group walked over to One North, and Staff K went to do tub training. Staff H reported she heard Staff E say that she needs to write this different this is a documentation error. Staff H asked Staff E is she was counting, and Staff E replied Staff A needs to change her documentation when looking at the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff H reported she had been finishing up, Staff A and Staff E start counting narcotics. Staff H reported when she came back to One North she saw Staff A, Staff G, and Staff K were in the medication room. Staff H reported that Staff E told her that there was a medication discrepancy, then she went into the med room, and saw Staff A sitting on the floor, and Staff A reported she gave 5mLs of the [MEDICATION NAME]. Staff A and Staff K walked out of the med room. Staff H reported Staff G poured the [MEDICATION NAME] into a plastic med cup and the [MEDICATION NAME] measured at 21mL's. Staff H reported the physician was called to get [MEDICATION NAME]. Staff H reported Staff G and Staff K called the physician. Staff H reported the Hospice Nurse had been in the common area, and Staff A talked with the Hospice nurse. Staff H reported the Director of Nursing had been called, and the family had been notified of the medication error and educated on the treatment to reverse the [MEDICATION NAME]. Staff H reported the family decided not to send the resident to the hospital. Staff H reported that while she was on the phone with the Director of Nursing the resident passed away. Staff H reported that Staff A appeared very remorseful. Staff H reported that Staff A would have been the only one that would have had the narcotic keys. During an interview on [DATE] at 3:08 p.m. Staff G, R.N., Second Shift Supervisor reported she went to do a skin assessment on Resident #1 the evening the resident came back from the hospital. Staff G reported the resident had been sleeping and snoring upon entering the resident's room on [DATE] at about 9:15 p.m. Staff G reported the family had been at the resident's bedside. Staff G reported Staff H assisted in moving the resident so a skin assessment could be completed. Staff G reported when the skin assessment had been completed she left the room to work on paperwork in the One North charting room. Staff G reported she heard part of a conversation between Staff A and Staff H, which contained Staff H questioning Staff A as to how much medication had been given. Staff G reported that at about 10:00 p.m. she had been sitting at the One North common area table and saw Staff E at the medication cart and stated out loud, she does not know her math the 25.5ml should be 29.5mL. Staff G reported she asked Staff E where is the bottle, then Staff G went and got the keys or the medication cart from Staff A. Staff G reported she and Staff K looked at the bottle and measured out the contents of the [MEDICATION NAME] bottle for a volume of 21.25mL's with a syringe, and both her and Staff K signed the narcotic book. Staff G checked on the resident who presented as snoring with breaks in breathing about every fifth breath. Staff G reported staff then called the Director of Nursing, the physician, the power of attorney (POA) for the resident, and the Hospice Nurse had also been notified. Staff G reported the Hospice Nurse, and Staff A told the family about the medication error. Staff G reported Staff A was very upset. Staff G reported Staff A called the physician, and he stated he would call back after talking with the pharmacy. Staff G reported she called the power of attorney (POA) with details of the event, and gave the POA options for treatment, which the POA declined the treatment for [REDACTED]. Staff G reported that Staff A would have been the only staff member with the keys to access the [MEDICATION NAME] for Resident #1. During an interview on [DATE] at 4:00 p.m. Staff J, Registered Nurse (R.N.), Hospice Nurse reported that she saw the Resident at the nursing home on [DATE] at about 6:45 p.m.. Staff J reported the Resident had a poor verbal response, and appeared to be approaching death, but could not speculate as to how close to death. Staff J reported she had been the on-call hospice nurse at that time. Staff J reported she had a call from the answering service that the Resident had a significant decline on [DATE] at about 10:00 p.m. Staff J then reported she returned to the nursing home at 10:25 p.m. Staff J checked on the Resident, and the Resident had a very low blood pressure, and did not respond to verbal or tactile stimuli. Staff J reported she then left the Residents room. Staff J reported that she, Staff A, R.N. and another nurse closed the door to the charting room, and Staff A reported that she gave 5mLs of [MEDICATION NAME] instead of .5mLs of [MEDICATION NAME]. Staff J reported that the nursing home staff called the on-call physician right away, Staff A gave her the phone and the on-call physician reported that the nursing home facility did not have [MEDICATION NAME], and the on-call physician directed the nursing home staff to inform the resident's family of the [MEDICATION NAME] medication error. Staff J reported that she and Staff A informed the family that Staff A gave too much [MEDICATION NAME] to the Resident, and then explained the purpose of the [MEDICATION NAME] medication. Staff J reported the family at the bedside stated they would call the power of attorney for the Resident, and then the family decided not to send the Resident to the emergency room . Staff J reported she called the on-call physician back and told him of the family wishes not to transport the resident to the hospital, and the resident passed away at about 11:10 p.m. just after the phone call ended with the power of attorney. Staff J reported that Staff A reported she gave the [MEDICATION NAME] at 8:00 p.m. During an interview on [DATE] at 3:30 p.m. Staff E, R.N, Charge Nurse reported she usually worked first floor on the third shift. Staff E reported on [DATE] at 10:00 p.m. she went to report to work on the One North, and had a quick report from the shift supervisor Staff H that Resident #1 had a significant change. Staff E reported One North had two resident return from the hospital that night. Staff E reported Staff A forgotten to give an antibiotic to a resident, and Staff G told Staff A to go give the resident the antibiotic. Staff E reported she went to the medication cart to look at the medication records and looked at Resident #1's narcotic sheet and noticed that the [MEDICATION NAME] documentation revealed that .5mL's were given and noticed the amount left was 25.5mL's, with Staff A's signature. Staff E reported that on about [DATE] she had seen the [MEDICATION NAME] bottle for Resident #1 as sealed, and nobody had administered it to the resident. Staff E reported that she and Staff A reviewed the narcotic count records and observed the resident's [MEDICATION NAME] bottle with a small flashlight to contain about 21mL's. Staff E reported the [MEDICATION NAME] amount to the two shift supervisors Staff G and Staff K. Staff G and Staff K took the [MEDICATION NAME] bottle. Staff E asked Staff A how much [MEDICATION NAME] she gave, and Staff A confirmed that she 5mL's of [MEDICATION NAME] while pointing to the "5" on the clear plastic medication cup. Staff E reported the supervisors called the physician right away. Staff E reported she went to the One South floor gave two medications then returned to One North. Staff E reported the resident died at about 11:10 p.m. During an interview on [DATE] at 2:01 p.m. Staff K, (R.N.), second shift supervisor reported she assisted the ambulance staff transfer the Resident from the ambulance cot to the bed. Staff K reported the Resident appeared alert, tired, and weak. Staff K reported the Resident opened his/her eyes when called by name, and the family had been at the bed side. Staff K reported a Hospice staff member looked at the discharge medications and agreed with the orders for the resident. Staff K reported the family member reported the resident had been due for more [MEDICATION NAME]. Staff K reported she told Staff A, R.N. about the family request for the resident to receive [MEDICATION NAME]. Staff K reported she assisted with the paperwork and then left the floor at about 7:30 p.m. to work on other admission on another floor. Staff K reported the third shift supervisor, Staff H, R.N. came on at 8:00 p.m., and Staff K gave her report. Staff K reported that at 9:00 p.m. she went to conduct the Certified Nurses Aide (C.N.A.) meeting which lasted until about 10:10 p.m.. Staff K reported that Staff H went to the C.N.A meeting at 10:00 p.m. to check on the third shift staff attending the meeting. Staff K reported that Staff H got a page(call) at about 10:01 p.m. that Resident #1 had a change in condition, and that a nurse gave too much [MEDICATION NAME]. Staff K reported that she then did the C.N.A tub training, which lasted about ten minutes. Staff K reported she then walked over to the One North nurses station and saw Staff H, R.N., Staff G, R.N., Staff A, R.N., and Staff E, R.N. The Hospice nurse had been with the family. Staff A was very upset, and crying. Staff H called the DON, Staff G called the resident's power of attorney, and Staff A called the physician on call for the shift. Staff K reported the nursing home staff offered the family the choice to send the resident to the hospital to reverse the narcotic. Staff K reported the family declined to have the resident, and shortly after the power of attorney hung up with the facility the resident expired. Staff K took Staff A off the floor to get some fresh air outside. Staff K reported that Staff A and the Hospice nurse reported the medication error to the family. Staff K then had Staff A maker her statement in the nursing services office. Staff K reported she had no concerns about Staff A's nursing practice. Staff K reported that she had verified the amount of [MEDICATION NAME] left over with Staff G, and they placed a black mark on the side of the bottle where the [MEDICATION NAME] liquid measured up to, and also measured the medication out in a clear plastic medication cup as well, and the documentation is on the narcotic count sheet. During an interview on [DATE] at 3:30 p.m. , the Director of Nursing reported the facility staff attempted to call her right away at about 10:20 p.m. when they discovered the medication error. The DON called the facility at 10:47 p.m., and found out about the medication error, the resident's change in condition from Staff H. The DON directed Staff H to call the physician and ask about [MEDICATION NAME] medication. The DON reported that Staff H told her the physician had been made aware of the situation, as well as the family and the family did not want the resident sent to the hospital. The DON reported that during her conversation with Staff H the resident passed away. The DON reported that she directed Staff H to get statements from the staff, complete a medication count, inform all family members of the resident's passing, get a note from the Hospice nurse. The DON reported the facility did not have [MEDICATION NAME] in the emergency box (a box of medications that contain medication for emergency use), but now the facility does stock it in their emergency box. The Director of Nursing reported Staff A would have been the only person with the keys to access the resident ' s [MEDICATION NAME]. During an interview on [DATE] at 4:15 p.m. a pharmacist reported that [MEDICATION NAME] liquid bottles are sent with syringes to aid in proper measurement of the medication, and if the facility lost the syringe the pharmacy would send another one if needed. The Pharmacist reported that a facility could use a TB syringe, which all nursing homes commonly keep on hand. The Pharmacist reported that all [MEDICATION NAME] solutions are sent out sealed the exact same way they are delivered to the pharmacy. During an interview on [DATE] at 1:50 p.m. Staff B, Licensed Practical Nurse (L.P.N), reported she had uses a syringe to measure [MEDICATION NAME], (liquid [MEDICATION NAME]) (for other residents). During an interview on [DATE] at 2:15 p.m. Staff D, (R.N.) reported a syringe always comes with the [MEDICATION NAME] bottles, and staff should use a syringe to measure the [MEDICATION NAME] ([MEDICATION NAME]). During an interview on [DATE] at 2:35 p.m. Staff I, L.P.N, and Staff F, LPN reported that they use a syringe to administer the [MEDICATION NAME] (for other residents). The Policy titled Administering Medications dated [DATE] revealed documented that medications shall be administered in a safe and timely manner, and as prescribed. Some steps included in administering medication according to the facility policy include the following; Medications must be administered in accordance with the (physician) orders, including any required time frame. The individual administering the medication must check the label three times to verify the right medication, the right dose, the right time, and the right method of administration before giving the medication. The following information must be checked/verified for each resident prior to administering medications, allergies [REDACTED]. ..

Based on clinical record review and interviews with staff, physician, and whirlpool tub chair representative, the facility failed to plan for and direct nursing services to ensure one (1) of four (4) residents received adequate supervision from hazards. The facility census was 130 residents. Findings include: The admission face sheet printed 10/30/13, documented Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired decision making skills and [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) test revealed Resident #1 had moderate cognitive impairments (score of 9). The resident required two person physical assistance with activities of daily living (ADL) specifically bed mobility, transfers, and bathing. The test for balance identified the resident not steady and only able to stabilize with staff assistance when moving from seated to standing position, when moving on and off the toilet and during surface to surface transfers (transfer between bed and chair or wheelchair). The resident had impairments on one side of his/her upper and lower extremity. The Care Plan dated 4/5/13 directed staff to provide assistance of two staff with Sara lift (a sit to stand lift), assist with getting legs in and out of bed and positioning once in bed and encourage left hand splint as tolerated. The care plan directed staff to provide ADL standards of care. The care plan identified Resident #1 used a wheelchair of mobility, with staff to propel. The Fall Risk assessment dated [DATE], revealed the resident as at moderate risk for falls. A Fall Incident Report dated 10/16/13 at 7:30 p.m., revealed staff transferred the resident to the whirlpool chair with Sara lift. Before staff secured the arms of the whirlpool tub chair (ARJO) the resident leaned to the right and fell out of the whirlpool chair onto the floor. The resident sustained [REDACTED]. Staff applied a bandage to stop the bleeding. Progress Notes dated 10/16/13 at 11:23 p.m., for 7:55 p.m. revealed the medics transported the resident to the emergency room . At 11:34 p.m., the hospital called and reported the resident was admitted to the hospital for anemia, fall and possible gastrointestinal (GI) bleed. A Discharge Summary dated 10/20/13, revealed the resident had been brought to the emergency roiagnom on [DATE]. The hospital report dated 10/16/13 noted the resident struck his/her head and started to bleed profusely, which later stopped. The resident was brought to the emergency room and found to have a hemoglobin of 4.6 and was non-symptomatic. The head Computed Tomography (CT) scan showed no acute bleed. During the hospital course the resident received 5 units of blood which brought his/her hemoglobin up to 11.2 and at the time of discharge was 10.8. The report noted the resident had left hip & thigh pain ever since he/she came in, with the x-rays showing no fracture. The upper and lower scope for anemia GI did not find the source of the bleeding. The resident had a history of [REDACTED]. The hospital discharge [DIAGNOSES REDACTED]. The Major Injury Determination Form dated 10/17/13, revealed the resident's injuries were not considered major. During interview on 10/29/13 at 4:50 p.m. Staff F, certified nurse aide, CNA reported they and Staff G, CNA placed the resident front facing in the whirlpool tub chair (ARJO) with the sit to stand lift. Staff F stood in front of the resident. Staff F removed the sling from the resident and turned to place the sling on the lift and at the same time the resident fell off the chair. Staff F reported the safety belt and arms were not in place at the time of the fall. Staff F reported a sign hung in the spa room at the time of the incident that directed staff to position the resident side facing. Staff F asked the supervisor (Staff H) after the incident if they were supposed to position residents' side facing. Staff H directed Staff F to position residents front facing. Staff F reported he/she did not receive training on the whirlpool lift chair until after the incident. During interview on 10/30/13 at 3:05 p.m., Staff G reported they and Staff F placed the resident in the whirlpool tub chair (ARJO) front facing. Staff G was standing behind the resident. Staff G reported Staff F removed the sling and the resident fell off the chair. Staff G was looking at the floor when the resident fell . Staff G reported the safety strap and arms were not in place at the time of the fall. Staff G reported during orientation staff showed them to load the resident front and side facing in the whirlpool chair. It was not till just recently that Staff G was told to load the residents side facing. During interview on 10/30/13 at 2:24 p.m., Staff H, registered nurse supervisor investigated the resident's fall and interviewed Staff F and Staff G and determined staff placed the resident in the whirlpool chair front facing. Staff H had Staff I, CNA demonstrate how to place a resident in the whirlpool. Staff I demonstrated front facing. Staff H reported instructions in the spa room directed staff to place the resident side facing. Staff H reported it was a big debate amongst staff on how to position the resident in the whirlpool chair. The ARJO TUB CHAIR laminated posted instructions dated April 4, 2013, directed staff to position the resident in the whirlpool chair with the battery tower positioned on the side of the resident, place the seat belt securely around the resident, lower both arms to safely enclose the resident and never walk away from the resident until secured in the chair. A Floor Meeting sign in sheet dated 4/3/13 and 4/4/13 at 8:00 p.m. and 9:00 a.m., revealed 22 aides and two nurses attended the meeting on how to use the new whirlpool tubs. According to the Director of Nurses the facility had around 140 aides and 30 nurses employed at the facility. An email dated 10/7/13 at 9:07 a.m., documented the Director of Nursing informed Staff A, licensed practical nurse, LPN in-service director that he/she was informed by staff that Staff A taught staff to position the lift on the side of the tub. The Director of Nursing checked with maintenance staff and determined the proper way to load residents was front facing. On 10/7/13 at 10:56 a.m. the Director of Nursing directed Staff A to update the signs in the spa room. On 10/7/13 at 11:41 a.m., Staff A responded to the Director of Nursing. Staff A informed the Director of Nursing he/she always understood the chair went in from the side of the tub. Staff A informed the Director of Nursing that he/she looked it up online and the demonstration showed the chair being placed in the tub from the side. On 10/7/13 at 12:38 p.m., Staff A reported to the Director of Nursing that he/she called the representative from ARJO. The Representative reported he always teaches staff to position the chair from the side. The representative reported he never teaches from the front because of the danger. Staff A spoke to Staff C, CNA who echoed his/her beliefs and completes all the tub training. Staff B, LPN unit director interrupted Staff A and Staff C and was adamant that they were incorrect. On 10/7/13 at 1:41 p.m., the Director of Nursing informed Staff A that he/she planned to follow up with Staff C. The ARJO TUB CHAIR training dated 10/20/13, revealed the facility trained 84 staff on the use of the tub chair. The training directed staff to position the resident in the side facing position, place the arm rests down before doing anything else and not to move the sit to stand or total mechanical lift away from the chair without the safety strap secured and both arms in the down position. The training directed staff not to turn their back on the resident for any reason. The Nursing Orientation checklist sheet updated on 10/21/13, directed staff to complete the checklist within 7 days of employment. The instructions on the sheet directed staff to explain each area and perform a return demonstration. The sheet covered the spa shower chair and how to use the safety straps and arm bars once positioned in the chair. The sheet directed to never walk away from the resident until safely positioned in the spa chair with the safety strap and arm bar in place. During interview on 10/31/13 at 12:13 p.m., Staff D, CNA reported he/she attended the training in April by the ARJO representative. Staff D did not recall the instructions the representative provided. Staff D reported about a week ago he/she witnessed Staff B and Staff E, unit director use the whirlpool lift. Staff B and Staff E directed Staff D and Staff C to load the resident in the chair to the front or to the side. Staff D reported on 10/30/13, Staff B informed Staff D to only load from the side. During interview on 10/31/13 at 10:49 a.m., Staff C reported he/she trains new staff on how to use the whirlpool stand chair. Staff C did not attend the training in April on the new whirlpool tub. Staff C reported last week Staff B and Staff E showed Staff C and Staff D how to use the whirlpool lift chair. Staff B and Staff E told Staff C and Staff D to load front or side facing in the whirlpool chair. A couple of days later Staff E called Staff C and informed Staff C that they needed to retrain the staff to side load in the whirlpool chair. During interview on 10/30/13 at 10:01 a.m., the Director of Nursing reported the facility concluded that staff did not ensure the resident was secured in the chair. The facility started re-educating staff on 10/20/13, on the use of the whirlpool lift chair. The Director of Nursing updated the orientation checklist to never walk away from the resident until safely positioned in the chair with the safety strap and arm bars in place. During interview on 10/31/13 at 11:40 a.m., the ARJO representative reported he/she went over with staff in April how to operate the tub and load residents. The representative reported he/she directed staff to side load only. According to the representative the chair was not designed to front load and if staff side load the resident there was nothing for the resident to hold onto. During an interview with ARNP (Advance Registered Nurse Practitioner) on 10/30/13 at 9:08 a.m., revealed the resident had been admitted to the hospital after the fall. The resident was found very anemic (4.7)/ (4.6), and his/her hemoglobin was not redrawn to see if that was an error. The physician was not sure if the hemoglobin reading was accurate. The resident did not display any symptoms and had no history of anemia. During interview on 10/30/13 at 11:29 a.m., the resident's physician stated he did not feel the resident's low hemoglobin had anything to do with the fall. The physician reported there is an error rate of acute blood loss which takes time to show up on hemoglobin test. The physician reported usually hemoglobin of 7 is when symptoms would be noticed. The resident was on Coumadin so he/she could bleed a decent amount, and had the INR (International Normalized Ratio) of 2.0 (normal range) in the emergency room . The physician reported the fall was due to the mechanical (tub chair) and happened due to non-medical reasons.

Based on record review and staff interviews, the facility nursing staff failed to provide accurate assessment and timely interventions for Resident #1 following a change of condition. The facility identified a census of one hundred twenty four (124) residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 8/7/13, documented Resident #1 had the following Diagnoses: [REDACTED]. The MDS revealed the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision making. The assessment revealed Resident #1 required extensive assistance of two staff for bed mobility, transfer, dressing, toilet use, and with personal hygiene. The resident required limited assistance of one staff member for eating. The assessment revealed the resident had no history of falls in the past 6 months. A prior MDS dated [DATE] identified Resident #1 required extensive assistance of two staff for bed mobility, transfer, dressing, toilet use, and with personal hygiene. The resident required limited assistance of one staff member for eating. The resident's plan of care with an onset date of 11/15/12, documented the resident required assistance with all activities of daily living (ADL's). The care plan instructed staff to transfer the resident with the assistance of two staff and a gait belt. The care plan directed staff to propel the resident's wheelchair to destinations as the resident was non-ambulatory. Review of the C.N.A. (Certified Nurse Aide) concern sheet dated 8/5/13 at 3:40 p.m. filled out by Staff A, C.N.A., revealed Resident #1's left leg was swollen, and noted" left and right bruising". Staff A reported the concern to an agency nurse (Staff B). Staff A documented "(Staff B) said it's swollen cause of the rain." Review of the Incident Report dated 8/5/13 at 3:00 p.m. revealed the resident had a skin tear to the top of his/her left hand with bruising around it. The report revealed the staff had applied dressing to the area and the physician and family had been notified of the left hand skin tear. Review of the Nurse's Notes dated 8/5/13 at 8:00 p.m. lacked any indication of an assessment for Resident #1's left leg. The note revealed an entry by Staff B regarding a skin tear with bruising, first aid and the resident's family and physician were notified. The note lacked the location of the skin tear. Review of the 24 Hour Nursing Unit report dated 8/5/13 revealed the resident had a skin tear and bruise on his/her left hand. The report lacked any documentation of the concern to the resident's left leg or the resident's left great toe. Review of the C.N.A. (Certified Nurse Aide) concern sheet written by Staff C dated 8/6/13, with the time crossed out identified the resident's left leg was swollen and maybe broken. Review of the Nurse's Notes dated 8/6/13 at 6:30 p.m., revealed Staff D, Licensed Practical Nurse (LPN), documented a C.N.A. noticed resident's right knee swollen when assisting resident to bed. The knee measured 17.5 inches. The physician notified and ordered x-ray of knee. At 9:30 p.m. x-ray done. At 10:00 a.m. pain medication administered to resident for signs and symptoms of pain. Review of the Nurse's notes dated 8/7/13 at 4:00 a.m. the x-ray results were sent to the resident's physician. The resident's right knee remained [MEDICAL CONDITION] and tender to touch and staff gave the resident pain medication. Review of Nurse's Notes dated 8/7/13 at 6:30 a.m. revealed staff contacted radiology and told them they took and x-ray of right ankle and the order stated right knee. The note documented will x-ray right knee as soon as possible. At 9:40 a.m. radiology here and x-ray obtained of right knee. At 10:11 a.m. x-ray results received. At 11:30 a.m. new order received by resident's physician for left great toe that was bleeding, to cleanse the area with wound, dry and apply gauze every day until resolved. Review of the resident's clinical record lacked indication of assessment of right knee pain and swelling and of the left great toe incident. The record lacked indication that the physician had been notified of knee or great toe, or any physician's orders [REDACTED]. Review of the resident's clinical record indicated the resident's left great toe injury that occurred on 8/5/13 had not been documented on, physician notified or an order for [REDACTED]. Review of Nurse's Notes dated 8/7/13 at 2:00 p.m. reviewed the resident's physician here to see resident. A new physician's order [REDACTED]. The X-ray showed an acute mildly displaced supracondylar [MEDICAL CONDITION] shaft of the femur. Review of the Consultation Note dated 8/9/13, revealed the resident x-ray showed a right distal femur fracture. The resident was not likely a surgical candidate because of his/her ambulation status and severe medical problems. The resident was best treated with non-operative measures. The note revealed a hinge knee immobilize should be used and the resident remained strictly non-weight bearing. Review of the hospital Transfer Form dated 8/14/13 indicated the resident transferred back to the facility with orders that included Hospice care if family or resident approves. Review of Nurse's Notes dated 8/15/13 at 2:11 p.m., revealed Hospice here to evaluate resident. Review of Progress Note dated 8/19/13, the resident's physician signed a note indicating the resident had severe [MEDICAL CONDITION] and [MEDICAL CONDITION] and the femur fracture most likely caused by severe [MEDICAL CONDITION]. The note indicated there was a high probability that the injury could have occurred during a pivot transfer. Review of Nurse's Notes dated 8/11/13 by Staff B, LPN, revealed the documentation was charted as a late entry for 8/5/13. The note indicated Staff A, C.N.A., reported the resident's knees were hurting. Staff B documented she assessed the resident and the resident complained of pain under both knees. Staff B reported she did not note/(identify) anything unusual and rubbed lotion on both knees. Staff B reported that the C.N.A.'s asked if they should get the resident up out of bed for supper. Staff B instructed the C.N.A.'s to get the resident up so Staff B could give the resident something for pain and the resident could eat supper. Staff B documented the staff got the resident up and brought the resident to Staff B to show Staff B the resident's knee. Staff B documented the resident's right knee did look more swollen than before. Staff B documented routine pain medication had been administrated to the resident. Staff B documented nothing further of resident's right knee, however the C.N.A. reported she stepped on the resident's toe while transferring the resident to bed. The resident's toe had been bleeding and that Staff B and Staff D ( Registered Nurse (RN) Supervisor), cleansed the toe and applied dressing to it. Staff B documented she asked Staff D if an incident report needed to be completed regarding the resident's toe and Staff D stated no because of condition of toe nail. Review of the facility's investigation report dated 8/7/13 and signed by the DON (Director of Nursing) identified the resident had no recent falls. On 8/5/13, Staff A, C.N.A., and Staff G, C.N.A. reported to nurse Staff B around 4-4:30 p.m. that the resident had been in bed and complained of pain and his/her leg was swollen. Staff B instructed the C.N.A.s' to get the resident up. The C.N.A.s' reported that it took 3 staff to transfer the resident from the bed to the wheelchair and during the transfer the resident yelled out in pain. After the staff transferred the resident to the wheelchair they brought the resident to the nurse Staff B who was at the medication cart. Staff B felt the resident's knees and told the C.N.A.s ' that it was probably due to the rain. After supper the nurse (Staff B) had been told by the C.N.A.s' of the resident's left big (great) toe had been accidentally stepped on, by Staff G, during the transfer to bed and tearing the resident's left toe nail. C.N.As ' reported the nurse (Staff B) came into the resident's room and treated the toe nail. Staff B failed to document any assessment of the resident's right leg and also failed to document anything regarding the left toe nail. The next day on 8/6/13, the staff reported no problems with resident transferring on the day shift or complained of any pain. Later on 8/6/13 around 4-4:30 p.m. Staff C, C.N.A., reported to the nurse, Staff D, that resident came back from activities and was complaining of his/her leg hurting so Staff C looked at the resident ' s leg and reported it to the nurse (Staff D). Staff D stated that Staff C (C.N.A), reported the resident's leg was swollen and Staff D stated she would look at and assess the resident's leg after supper when they assisted the resident to bed. Staff D assessed the resident's leg after the resident had been assisted to bed and contacted the resident's physician and received orders for x-ray. The facility reported the resident had not had any recent falls and the last fall had been on 3/11/13. Interviews: Interview on 9/6/13 at 2:42 p.m., Staff A, C.N.A., reported on 8/5/13 around 3:00 p.m. she checked on Resident #1 at bed time noted a skin tear on the resident's left hand and reported it to Nurse(Staff B). Staff A indicated during report before the beginning of the shift from the prior day shift revealed no problems with the resident. Staff A stated she went to assist the resident with a transfer from bed to wheelchair around 4 p.m. and noted the resident's left knee was swollen. Staff A reported the resident voiced that his/her left knee hurts. Staff A reported that she and along with Staff G, attempted to transfer the resident from the bed to the wheelchair and the resident screamed out in pain. Staff A reported they sat the resident back down in bed and went to inform the nurse (Staff B). Staff A stated Staff B never came and checked on the resident at that time but instructed the staff to go ahead and get the resident up for supper. Staff A indicated it took 3 staff members (Staff A, Staff G, and Staff H) to transfer the resident from bed to the wheelchair, which was unusual for the resident to require that much assistance. Staff A indicated that after the transfer they took the resident to Staff B for her to look at the resident's knee. Staff A stated the resident had pants on and you could see that the resident left knee was more swollen than the right knee. Staff A reported Staff B, looked at the resident's knee, felt it, and told Staff A that the resident knee was swollen from (because of) the rain and to take the resident into the dining room for supper. Staff A stated the resident remained in the wheelchair until transfer to bed that night. Staff A stated again, it took the assistance of 3 staff members to transfer the resident to bed due to the resident's pain. Staff A reported the resident yelled out in pain during the transfer. State A stated during the transfer, Staff G, accidentally stepped on the resident's left great toe causing it to bleed. Staff A, Staff G, and Staff H, reported this to Nurse, Staff B, who came into the room along with nurse supervisor (Staff F). Staff A stated he/she told Staff B that the resident again screamed out in pain during transfer and that the resident's left toe had been accidentally stepped on during the transfer. Staff A stated after the nurse's attended the resident's toe, Staff A and Staff G assisted the resident in positioning lying in bed. Staff A indicated the resident complained of pain with repositioning. Staff A reported no known recent falls to the resident. Interview on 9/6/13 at 1:43 p.m., Staff H, C.N.A., stated while she assisted with a transfer for Resident #1, on 8/5/13 on 2nd shift, the transfer took 3 staff members (Staff H, Staff A, and Staff G). Staff H indicated the resident's right knee was really swollen and the resident complained of knee pain. Staff H indicated a transfer with the assistance of 3 staff was unusual for the resident; as well as the swelling and pain of right knee. Staff H stated they reported these concerns to Staff B. Staff H further stated nothing had been reported from the day shift of any injury or fall to the resident. Staff H stated she cared the resident when they first attempted to transfer the resident on second shift. Staff H stated this was a big change in the resident's condition from before and the resident now had swelling and pain to his/her right leg. Interview on 9/24/13 at 11:28 a.m., Staff G reported she assisted with transfers of Resident #1. Staff G stated before they got the resident up out of bed, they had reported to Staff B (nurse) the resident had swelling and pain to his/her leg. Staff B asked them to get the resident up. Staff G stated Staff B instructed the staff to go ahead and get the resident up. Staff G stated they (Staff A, Staff H and herself) returned to the resident's room and transferred the resident from the bed to the wheelchair. Staff G stated the resident had swelling to his/her right knee and yelled out in pain during the transfer, which was unusual for the resident. Staff G stated Staff B never came into the resident's room after they reported the knee swelling and pain. Staff G reported they then took the resident to the Staff B, who was at the medication cart and asked her to look at the resident's knee. Staff G reported Staff B looked and felt the resident's knees and stated it was caused by the rain. Staff G reported that after supper they were transferring the resident from the wheelchair to the bed when Staff G accidentally bumped the resident left great toe causing it to bleed. Staff G stated they assisted the resident to sit back into the wheelchair and then informed Staff B of what happened to the resident's toe during the transfer and that the resident had a lot of pain and swelling to the right knee. Staff G stated she did not receive report from the day shift on 8/5/13 that an incident or fall occurred. Interview on 9/6/13 at 3:19 a.m., Staff C, C.N.A., reported she took care of Resident #1 on 8/3/13 and 8/4/13 on second shift. Staff C stated she did not work on 8/5/13, but did work second shift on 8/6/13 and was assigned to the resident. Staff C reported after the resident attended an activity Staff C adjusted the resident's feet on the wheelchair pedals when the resident yelled out in pain, which was unusual for the resident. Staff C stated she reported it to the nurse (Staff D) who stated she would look at the resident after supper when the resident was assisted to bed. Staff C stated she took the resident to supper and then around 6:45 p.m. assisted the resident to bed (with the assistance of another staff member). During the transfer the resident yelled out in pain. Staff C reported she went to get the nurse (Staff D), who came into the resident's room and assessed the resident. Staff D stated no one from the prior shift that day had reported anything unusual for the resident. Staff C stated for Resident #1 to yell out in pain was a big change. Interview on 9/6/13 at 2:14 p.m., Staff F, Registered Nurse/Supervisor, stated on 8/5/13 she had been called to the floor due to Resident #1's skin tear to left hand and started to investigate the incident. Staff F indicated she had not been aware of the resident's right knee pain or swelling. Staff F stated when she went into the resident's room with the nurses (Staff B), she noted the resident's right great toe was bleeding and Staff F and Staff B addressed the issues. Staff F stated that no staff member mentioned to her about the resident's knee swelling or pain or how the skin tear to hand or toe injury occurred. Staff F indicated the next night she had been called to resident's room by Staff D (nurse), due to the resident's right knee swelling and complaints of pain. Staff F indicated they assessed the resident and called the resident's physician to obtain an order for [REDACTED]. Interview on 9/24/13 at 9:17 a.m., Staff B stated on 8/5/13 she came into work on second shift at 2:00 p.m. Staff B stated around 3:00 p.m. Staff A notified her of Resident #1's skin tear on the left hand. Staff B stated the day shift had not reported any incident that occurred to Resident #1. Staff B indicated she completed a full body assessment for Resident #1 after giving first aid for the skin tear, and noted no other injuries to the resident at that time. Staff B stated Staff A reported to her around 4:00 p.m. that the resident's knee hurt and there was swelling. Staff B stated she went to the resident's room and assessed the resident's knees. Staff B noted nothing unusual to the resident knee and the resident voiced no complaints of pain. Staff B stated she rubbed muscle cream to the back of the resident's knees. Staff B stated Staff A asked her whether they should get the resident up for supper because of the resident's knees hurting. Staff B stated she instructed the staff to go ahead and get the resident up. Staff B stated she did not think anything was wrong with the resident ' s knees and really thought the staff was concerned about getting the resident up due to the left hand skin tear. Staff B stated the staff brought the resident to her at the medication cart after they assisted the resident up out of bed and asked Staff B to look at the resident's knee. Staff B stated it looked like the resident had some swelling to the right knee, nothing out of the ordinary, and the resident had some pain. Staff B administered a scheduled pain medication at that time and told staff that it may be caused by the rain. Staff B reported the resident had supper and later when Staff A (and other Staff) transferred the resident to bed, one staff member accidentally bumped the resident's left great toe causing it to bleed. Staff B and Staff F went into the resident's room and the resident had been sitting in the wheelchair. Staff B and Staff F applied dressing to the resident's left toe. Staff B stated she asked the resident he/she still had knee pain and the resident replied no. Staff B reported she asked the Nurse Supervisor (Staff F) if an incident report needed to be filled out regarding the toe; and according to Staff B, Staff F stated no. Staff B stated she did not document any assessment regarding the resident's knee swelling or pain and did not document anything regarding the right knee of the resident's left great toe incident. Staff B stated she made a late entry on 8/11/13 regarding 8/5/13 as instructed to do so by her supervisor. Interview on 9/13/13 at 8:00 a.m., Staff E, Assistant Director of Nursing, stated that he/she expects staff to immediately assess any resident's complaints of pain, swelling, increase assistance for transfers, and any change of condition.

Based on observation, clinical record review and staff interviews, the facility failed to plan for and direct nursing care and services to ensure two (2) of six (6) residents received adequate supervision from hazards. Resident #3 sustained a head contusion after a fall from his/her wheelchair to the floor. Interviews and record review revealed the facility failed to update the resident's care plan to include a directive to not leave the resident unattended in his/her wheelchair in his/her room. In addition, the facility failed to plan for and direct services for Resident #1 who sustained a fall without injury during a transfer with staff. The facility identified a census of 109 residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 8/11/11 assessed Resident #3 with [DIAGNOSES REDACTED]. The cognitive assessment, Brief Interview of Mental Status (BIMS) determined moderate impairments with recall ability, repetition, orientation and the resident scored 9 out of 15 on the BIMS test.The assessment showed the resident had signs and symptoms of delirium (inattention, disorganized thinking, altered level of consciousness and decreased level of in activity) that fluctuated. The MDS documented that the resident required extensive two staff assistances with bed mobility, transfers, toileting and personal hygiene. A "balance during transitions and walking" test documented the resident as not steady and only able to stabilize with human assistance with moving from seated to standing position, moving on and off toilet and surface to surface transfers. Resident #3 used a wheelchair for locomotion and had no other falls. The Fall Risk assessment dated [DATE] revealed Resident #3 scored 14 points indicated the resident had a high risk for falls. The Care Plan dated 08/18/11 and updated revealed the resident had problems including extensive assistance required with activities of daily living due to Parkinson's and natural aging process and history of falls, needs mechanical lift with transfers and mobility, no longer ambulatory due to natural progression of Parkinson's. The Care Plan directed staff to transfer with the assistance of two and Sara or Hoyer (mechanical) lifts, provide a reclining wheel chair with staff propelling to all locations, encourage resident to use a call light to summon help when feeling weak or fatigued and encourage to lay down or sit in recliner while in room. The care plan documented on 09/26/11 staff received discipline, floor mats placed in room and staff checks as needed. The Nurse's Notes dated 09/25/11 at 4:20 p.m. documented staff found the resident on the floor. The resident indicated he/she attempted to go to the recliner and thought he/she could do it. The resident had a hematoma to the left forehead and transferred to the emergency room at 5:05 p.m. When the resident returned to the facility at 9:30 and complained of head pain the physician ordered neurological examinations and ice to the affected area. On 09/26/11 at 10:40 a.m. the resident had increased confusion and slurred, nonsensical speech and transferred to the emergency room per physician orders. At 2:10 p.m. the resident returned and complained of head pain. At 7:40 p.m. the resident attempted to exit the recliner. Staff unplugged the recliner. On 09/27/2011 staff noted increased confusion and the physician ordered a urinalysis. On 09/29/11 the physician ordered an antibiotic to treat a urinary tract infection (UTI). On 10/01/11 and 10/02/11 staff documented the resident had confusion. The Radiology Report dated 09/26/11 documented the resident had a CT Head without contrast due to a closed head injury. Findings included no prior exams for comparison, diffuse atrophy with no evidence of intracranial hemorrhage, large scalp hematoma over the left frontal region, no discrete skull fracture however is evident. Summary: Large scalp hematoma over the left forehead region. No intracranial acute process or hemorrhage. Diffuse atrophy and age related white matter disease. The resident also had negative left ankle, chest and left knee x-rays. The Emergency Department final report documented Resident #3 fell and suffered a head contusion. The Fall Incident Report dated 09/25/11 at 4:20 p.m. Resident #3 fell trying to self transfer to the recliner. The resident stated "I thought I could do it". Staff found the resident on the floor with a pillow under the head when the nurse entered the room. The resident had a head hematoma and staff notified the physician and sent the resident to the emergency room . Staff placed a sign in the resident's room "Please use call light for your safety". Staff received discipline. The Major Injury Determination Form signed by the physician on 10/11/2011 stated "Unable to determine". The facility Termination Form dated 09/26/11 documented the facility terminated Staff O, CNA for leaving Resident #3 in the wheelchair in his/her room. After the fall on 9/25/11, the Care Plan Summary (Care Card) dated October 2, 2011 directed staff to transfer the resident with two staff assistance and a Sara Lift, put in the recliner or bed when in room, and do not leave in wheelchair in room unattended. Observation on 10/17/11 at 4:46 p.m. revealed Resident #3 seated in the wheelchair near the nurse ' s station/fish tank area. The surveyor observed a large purple hematoma on the left side of the resident ' s forehead. Staff D reported they changed the Care Card because the resident liked to wheel his/her self back to his/her room, and now sits near the fish tank for closer staff observation. Observation on 10/18/11 at 7:30 a.m. revealed the resident in bed. The resident had no knowledge of the fall or how the injury occurred. Two staff transferred the resident from the bed to the toilet using a Sara mechanical lift. During an interview on 10/18/11 at 11:00 a.m., Staff O, CNA reported he/she didn't know Resident #3 could not be in the room alone. Staff O heard a crash and observed the resident on the floor and the wheelchair tipped over on the side. Ten minutes prior Staff O observed the resident seated in the wheelchair in the room looking at cards on the table with a call light nearby. Staff O indicated the resident's Care Card changed in August. Staff O had jury duty during the time staff updated the Care Card. Staff O knew the resident and never checked to see if the Care Card had updates. During an interview on 10/18/2011 at 12:00 noon, Staff D, CNA stated staff put Resident #3 in the doorway so staff can keep an eye on the resident. Sometimes the resident propelled the wheelchair in the room. Staff D stated after this last fall (9/25/11), they were told not to allow the resident alone in his/her room. Staff D stated usually Resident #3 watched television and was content. Evidently the resident's care plan changed the end of August, but Staff D stated we did not know it. Staff D reported usually will report changes at the beginning of the shift. Staff D reported prior to the fall, the resident was 1:1 assist with a gait belt and the resident had the ability to put the call light on. During an interview on 10/17/11 at 3:05 p.m., Staff L, CNA, CMA (Medication Aide) reported working as a med aide on 09/25/2011. At approximately 3:30 p.m., Staff L went to give Resident #3 medications and found the resident alone in his/her room seated in a wheel chair. Staff L moved the resident to the hallway and locked the breaks. Resident #3 could self propel the wheelchair. When the resident fell , Staff L stated Staff O entered the room and found the resident on the floor with his/her head on a pillow. Staff L stated Staff O summoned the nurse and the resident transferred to the emergency room . Staff L stated Staff O reported not knowing how the resident returned to the room. Each resident has a Care Card on their door for staff to observe. During an interview on 10/17/11 at 3:20 p.m., Staff M, RN reported observing Resident #3's on the floor after the fall and could see the hematoma developing on resident ' s head. The resident reported thinking he/she was strong enough. Approximately 20-40 minutes prior Staff M observed the resident outside of his/her room, where the resident generally sits. Staff M had observed the resident undo the wheelchair brakes, and use the call light. Staff M stated Staff L indicated she wheeled the resident out of the room. Staff M reported she asked Staff O when she had assisted the resident to the toilet. Staff M stated no staff knew how the resident got back into his/her room. During an interview on 10/17/2011 at 3:45 p.m., Staff N, CNA reported learning during orientation on second shift to check the resident Care Cards. Staff check the cards and go by memory. Resident #3 could hold onto the hand rail and propel the wheelchair into the room. Around 2:30 p.m. Staff N observed the resident before the activity from 2:30 - 3:30 or 4:00 p.m. Activity aides transport the residents back and forth from the activity. Staff N observed the resident seated in the doorway at 4:15 when Staff N went to break. When Staff N returned from break, he/she learned the resident fell . Typically the resident sits outside the room door, staff need to make sure the wheel chair brakes are locked. During an interview on 10/17/2011 at 5:20 p.m., Staff K, CNA reported working on 09/25/2011. Approximately 5-10 minutes before the resident fell , Staff K observed the resident seated in the doorway getting medications. Staff K and Staff O heard the resident scream and responded to the fall. Before the fall, the resident returned from activities and received medications in the hallway and then placed in the doorway of his/her room. Staff K reported the Care Cards are placed on the resident's door. Now the resident sits near the fish tank for closer observation. The resident can hold propel the wheelchair by holding onto the hand rail in the hall. Staff K assisted Staff O get the resident up out of bed. Staff K thought Staff O had been on break and just returned when the resident fell . Staff K reported Staff O commented the resident had the call light on. Staff K stated other people stated they saw the resident in the hallway. During an interview on 10/17/2011 at 4:15 p.m. Staff J, CNA reported working 09/25/2011 on second shift. Staff J observed the resident sitting in the doorway when going to break around 4:00 or 4:30 p.m.. Staff J reported Staff O told her the resident fell while self transferring from the wheelchair to the recliner. The Care Card on the resident's door has all the information needed on how to care for the resident. Staff J never worked with Resident #3. During an interview on 10/19/2011 at 9:30 a.m. the third floor Unit Manager said Resident #3's fall occurred on second floor, and had been in the room alone. The resident had capability to self propel the wheel chair. That day at approximately 2 o'clock p.m. the resident sat in the recliner and put the call light on. Now staff try to have the resident attend more activities and position for closer observation, farther from the room. The second shift supervisor has increased the time spent on third floor, and the falling leaf program should help as well. Staff O worked on third floor and should have known the process of Care Cards. During an interview on 10/18/2011 at 2:00 p.m., the DON reported Resident #3 had no falls for over a year. Staff updated the Care Card on October 3, 2011 to reflect the fall on 09/25/2011. Staff know to read the cards for updated information, they are told that in orientation. The DON stated beginning November 1st, the managers have to date Care Plans and Care Cards additions so staff are aware it ' s a new intervention. On June 10, 2011 the facility had a staff in-service and educated staff when they change a care card or care plan, both must be updated. The newly revised CNA Nursing Orientation checklist received from the DON included Charting - resident care cards, and ADL activities - Copy of gait belt policy provided and reviewed with CNA. 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had no cognitive impairments in daily decision making skills. The assessment identified the resident required extensive assistance from two staff to walk (ambulate) and assistance with transfers between surfaces. The assessment revealed Resident #1 had a prior stroke ([DIAGNOSES REDACTED]. The resident used a walker and wheel chair for mobility. The Care Plan dated 11/17/10 documented Resident #1 required assistance for upper and lower body cares due to prior pelvic fracture and history of CVA with left sided weakness. The care plan revealed the resident had been at risk for falls due to the use of history of CVA with left sided weakness, blind in left eye and recent fall with pelvic fracture. The Care Plan directed staff to transfer with two people with gait belt and extensive assistance or SARA (mechanical) lift as needed. The Care Plan indicated the resident wore gripper sox while in bed. The Quarterly Progress Notes documented Resident #1 had no falls the previous two quarters. The Nurse's Notes documented on 09/25/11 at 2:30 a.m., the CNA (Certified Nurse's Aide) transferred the resident from the shower chair to bed, had the resident hold onto the side rail of bed, had a gait belt around the resident's waist and the resident became weak at the knees, went down and hit his/her head on the night stand. No injuries observed. 09/25/11 at 12:00 noon, the resident complained of back pain and staff administered pain medication (Vicodin). At 2:00 p.m. the resident complained of pain and staff notified the physician. The physician ordered staff to apply a heating pad as needed. At 6:00 p.m. the resident complained of back pain and rated the pain at 8 on a scale of 0-10. At 9:20 the family asked staff to notify the physician in the morning and request an order for [REDACTED]. The Fall Incident Report dated 09/25/11 documented the resident fell at 2:30 a.m. during a transfer to bed. The resident slipped and fell and hit the left side of head. The immediate intervention included updating the Care Card directing staff to transfer with the assistance of two and a gait belt, and check slippers for proper grip. A Facility Discussion Form indicated Staff #B, CNA received a written discipline for failure to transfer Resident #1 on 09/25/11 without the use of a gait belt and not following Care Card interventions. The Care Card (Care Plan Summary) indicated Staff should transfer the resident with two staff and a transfer belt (gait belt). The Fall Risk assessment dated [DATE] revealed the resident scored 14 points indicating a high risk for falls. Observation on 10/17/2011 at 4:50 p.m. showed two staff transferred Resident #1 from the bed to the shower chair, toilet, shower chair and to the wheelchair with a gait belt. The resident smiled and communicated with staff. On 10/18/2011 at 9:05 a.m. the resident reported not really falling, but slipping because one caretaker failed to hang on, and failed to recall if staff used a gait belt. Afterwards the resident's back started hurting intensely. Most of the time they transfer the resident with two staff, and they prefer to have two. During an interview on 10/18/2011 at 2:00 p.m. the DON (Director of Nursing) reported the facility had a gait belt policy directing staff to use a gait belt anytime they assist a resident to transfer or ambulate. Staff receive the gait belt policy when hired at the same time they receive their gait belt. On 10/19/2011 at 8:00 a.m. the DON reported changing the CNA Orientation Checklist to include: Copy of gait belt policy provided and reviewed. The facility also began initiating a Falling Leaf Program that identified at risk residents. Resident #1 had four falls in the last year. The Care Card and Care Plan directs staff to transfer the resident with the assistance of two staff. The DON had no knowledge of where the thought to transfer the resident with assistance of one came from. The facility had a mandatory in-service where they discussed care plans and care card responsibilities. Staff #B failed to attend the meeting. During an interview on 10/18/2011 at 9:30 a.m. Staff B reported working the weekend of 09/25/2011. During the night Staff #2 transferred the resident to the shower chair and assisted the resident to the toilet. When Staff B transferred the resident from the shower chair to the bed, the resident's knees became weak and fell bumping his/her head. Staff B reported he/she had no gait belt on the resident during the transfers. At the time of the fall the resident required assistance of one staff to transfer according to the Care Card. The facility Gait Belt policy directs staff to follow the directions of the Care Card and Care Plan, and use your own judgment. That is what Staff B learned during orientation. During an interview on 10/19/2011 at 9:50 a.m. the Unit Manager reported Staff B should have transferred the resident with a gait belt and the assistance of two staff. The resident initially had no pain, then developed back pain, but had negative X-rays. Staff B received a discipline for not following the resident's Care Card. During an interview on 10/18/2011 at 11:50 a.m. Staff H, RN (Registered Nurse) and night shift supervisor reported Staff B revealed Resident #1 slid to the floor. Staff should use a gait belt for all resident's needing assistance to transfer. Newly hired staff receives 1 and 1/2 days orientation and reviews the policy book. During an interview on 10/18/2011 at 12:00 noon, Staff D, CNA reported they should use a gait belt with all residents who require assistance to transfer. Prior to this fall Resident #1 transferred with one assist and a gait belt. During an interview on 10/18/2011 at 12:35 p.m., Staff E, CNA reported Resident #1 transferred with two assist, then changed to one assist. Some staff used a gait belt; some did not, depending on what they were comfortable with. Staff should follow the Care Card. The Gait Belt Policy directs staff to follow the Care Card. If it states to use the gait belt, then staff use it. During an interview on 10/18/2011 at 10:30 a.m. Staff F, CNA reported staff receive a gait belt during orientation and to use it during transfers, ambulating residents and all residents requiring assistance. During an interview on 10/18/2011 at 9:40 a.m., Staff G, CNA indicated the Gait Belt Policy directs staff to use it all the time whit any resident requiring assistance greater than contact guard. Staff G learned of the policy during orientation. Staff review the Care Card for transfer instructions. During an interview on 10/18/2011 at 11:30 a.m., Staff I, CNA transferred with the assistance of one or two staff. Staff play it by ear. Care Cards direct staff when to use a gait belt. Staff I had no knowledge of a facility policy, staff follow the Care Plan. During an interview on 10/18/2011 at 2:45 p.m. Staff C, CNA reported training new CNA's on the day shift. Other staff provided training on second and third shift, however those staff no longer worked at the facility. Staff C revealed informing new hires to use a gait belt with all transfers and the CNA's should review Care Cards daily for new information. The Gait Belt Use policy dated 03/01/2006 included: Procedure- employees will use a gait belt when the resident requires "hands-on" assistance to transfer or ambulate.

Based on observation, clinical record review and staff interview, the facility failed to plan nursing services with wound care provisions for one of four residents. The facility failed to ensure that Resident #6 received the necessary interventions to promote healing and prevent deterioration of pressure sores. The facility identified a census of 114 residents. Findings include: 1. The May 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident required the assistance of two or more staff for moving in and out of bed, walking, dressing, toileting and bathing and identified the resident at risk for developing pressure ulcers. The resident care plan dated 3/9/11, identified the resident had a potential for impaired skin integrity related to pressure or trauma. The resident had a history of [REDACTED]. a. Assess skin status daily with cares and bathing. b. Assist as necessary for application of skin barrier. c. Encourage adequate intake of fluids. d. Pressure reducing mattress to bed. e. Gel cushion in wheelchair. f. Pericare daily and after incontinent episode. g. Waffle boots bilateral lower extremity (added 4/19/11). h. Wound nurse to follow and make recommendations (added 4/19/11). i. Float heels- waffle boots while in bed, encourage to leave shoes off (added 4/19/11). j. Staff to float heels when in bed, and waffle boots to both feet while in bed. Nurse notes dated 4/18/11 at 1:00 p.m., documented staff reported the resident complained of heel discomfort. Upon assessment bilateral heels were boggy. The left heel measured 6.0 by 3.0. The area was dark purple/red [DIAGNOSES REDACTED]. The right heel was boggy with open area in center of heel measuring 0.6 centimeters (cm) in diameter, the wound bed was pale pink, skin color peri wound non-blanchable. The physician was contacted for treatment. Review of the dietitian progress notes revealed no documentation of the wounds until 4/21/11 and weekly assessments after the wound was identified. The bath skin checks completed by certified nursing aides (CNA) dated 3/3/11, 3/7/11, 3/29/11, 4/7/11, and 4/11/11 did not show any problem areas identified to the resident's heels. Wound Care Progress Notes dated 4/18/11, documented the resident as sitting in a chair with feet elevated on a foot stool, heels floated. Assessment of the right heel revealed a dark purple non-blanchable and boggy area. Distal to achilles a 0.6 cm in diameter open area noted. Wound bed pale pink. Left heel also dark purple and non-blanchable no open area, heel was boggy. Treatment recommendation sent to physician. A physician facsimile dated 4/18/11, documented the residents bilateral heels boggy, dark blue/purple in color, non-blanchable. Left heel measured 6.0 by 3.0 and depth undetermined. Right heel had non-blanchable dark blue/purple area with 0.6 cm diameter open area right heel. Recommend treatment to the areas. The physician sent a facsimile back 4/18/11 approving of the treatment. Wound Care Progress Notes dated 4/20/11, documented the residents heels as dark purple, however blanchable at the time suggesting color of heels related to circulatory system and not pressure related. No changes recommended in treatment of [REDACTED]. Plan to continue to off load heels. Since open area on right heel measured 0.6 cm the consultant felt the resident must have laid on something to cause such a round wound. Encourage resident to leave off shoes. Wound Care Progress Notes dated 4/25/11, documented no change in open area to right heel. Wound bed remains pale pink, no [DIAGNOSES REDACTED] noted to either foot. Bilateral heels continue to be dark purple/red blanchable. Unable to palpate any pedal pulses, feet cool and dry. Plan to continue to off load heels at all times, encourage resident to leave shoes off. Wound Care Progress Notes dated 5/3/11, documented bilateral heels dark pink and boggy, no open area on left foot. Bilateral lower extremities were observed with resident seated in chair with heels floated off of foot stool. Right heel wound currently 100 percent covered with yellow slough, wound bed appears moist. Recommend treatment change to physician. A physician facsimile dated 5/3/11, documented the resident had a Stage III pressure area on the right heel. Wound measured 0.7 by 0.7 by 0.2. Wound bed moist and 100 percent covered with firmly adherent yellow slough. Recommend discontinuing current treatment and starting a new treatment to the right heel. The physician sent a facsimile back 5/3/11, approving of the new treatment. Wound Care Progress Notes dated 5/11/11, documented the right heel wound bed 100 percent covered with firmly adherent yellow slough, 0.6 cm diameter wound with depth of 0.2 cm, 0.1 cm undermining noted at 5:00 to 7:00. Periwound tissue dark purple and boggy. Heels were floated at all times, resident not wearing shoes. Left heel slightly boggy, no open area noted. Skin protectant applied to bilateral heels. Recommend treatment change to physician. A physician facsimile dated 5/11/11, documented the wound on the right heel measured 0.6 cm with a 0.1 cm undermining at 5:00 to 7:00. Wound bed 100 percent covered with firmly adherent yellow slough. Periwound tissue purple blanchable and boggy. Recommend changing treatment to right heel. The physician sent a facsimile back 5/11/11, approving of the new orders. Wound Care Progress Notes dated 5/18/11, documented the right heel open area measured 1.0 cm with 0.2 cm depth. The wound appeared macerated, white wound bed and periwound tissue. Left heel remained boggy, no open areas noted. Plan to continue with application of skin protectant and float heels while in bed, resident to leave shoes off while up during the day. A wound assessment progress report dated 4/18/11 documented the right heel as pressure or [MEDICAL CONDITION]. The area was purple and measured 6.0 by 3.0 and unable to determine depth. On 4/19, 4/20, 4/21, 4/25, 5/1, 5/8 and 5/15/11, the right heel remained purple/red and measured 6.0 by 3.0 and depth undetermined. A wound assessment progress report dated 4/18/11 documented the right heel open area as a Stage II and measured 0.6 cm by 0.6 cm with a depth of 0.1 cm. The area was pale pink with no drainage. On 4/19, 4/20, 4/21, 4/24, 5/1, 5/8 & 5/15/11, the right heel open area remained pink and measured 0.6 cm by 0.6 cm and 0.1 cm in depth. A wound assessment progress report dated 4/18/11 documented the left heel as unstageable, wound type pressure or circulatory. The area as red/purple and measured 6.0 by 3.0 and depth unable to be determined. On 4/19, 420, 4/21, 4/25, 4/30, 5/8 & 5/15/11, the left heel remained red/purple and measured 6.0 cm by 3.0 cm and depth undetermined. Interviews: During interview on 5/18/11 at 10:08 a.m., Staff H, wound nurse reported he/she was notified of the wounds on 4/17/11 and found both heels were purple but blanchable with areas and both measured 6.0 cm by 3.0 cm and no depth. The right heel also had a 0.6 cm long, 0.6 cm wide and 0.1 cm deep Stage 2 pressure ulcer. Interventions in place before they developed was to float the resident's heels. Interventions placed after the heels were identified were no shoes for the resident, waffle boots to both feet when in bed and float heels when in bed or in the chair. During interview on 5/20/11 at 1:05 p.m., Staff U, (certified nurse aide, CNA), reported they were supposed to keep only stockings on the residents feet and an air boot to the left foot. During interview on 5/20/11 at 1:11 p.m., Staff V, (licensed practical nurse, LPN), reported the resident developed the wounds a month ago and they were supposed to float the heels, put a moon boot to the right foot and a foam boot to the left foot. The resident was compliant most of the time with leaving the boots on. During interview on 5/20/11 at 1:26 P.M., Staff W, LPN reported there were no laboratory reports after the resident's wounds developed and the wounds first developed in the middle of April. The resident did have issues with the heels a year ago and we were supposed to put waffle boots on both feet whenever the resident was in bed and float the heels. Observation on 5/18/11 at 6:25 a.m., revealed the resident slept in bed without any waffle boots on his/her feet. The resident's bare heels were resting directly on the mattress. One waffle boot was found on the seat of the chair at the foot of the bed. At 7:10 a.m., the resident remained in bed without the waffle boots in place as planned. One waffle boot was found on the seat of the chair at the foot of the bed. On 5/18/11 at 7:32 the surveyor reviewed the care plan summary located on the back of the resident's door. The skin prevention section did not direct staff to apply waffle boots while in bed yet listed the following interventions: apply skin repair lotion, geri sleeves/sweaters/long sleeves, and report skin concerns immediately to nurse. The surveyor also noted the care plan summary in the notebook at the nurse's station did not address the need to place waffle boots on the resident's feet when in bed. Observation on 5/19/11 at 5:28 a.m., revealed the resident sleeping in bed without waffle boots on and both feet (bare) laid directly on the mattress. At 5:52 a.m., the resident remained in bed with a waffle boot lying on top of the right foot. The resident's right heel laid directly on the mattress. No boot was noted to the left foot and a dressing was lying on the bed beside the resident's left heel. At 6:07 a.m., the resident remained in bed with a waffle boot strapped to the right foot, however, the resident's bare heel was not in the boot and rested directly on the mattress. There was no waffle boot noted to the left heel. At 6:48 a.m., the resident remained in bed during a dressing change to the right heel with the air mattress machine unplugged. When asked what the tubes to the machine were for, Staff H, wound nurse, stated they were for the air mattress and did not check on the air mattress after the dressing change. Observation on 5/20/11 at 5:40 a.m., revealed the resident slept in bed with their feet directly on the mattress, with one foam boot that laid beside the resident's left foot and one waffle boot on the seat of the chair at the foot of the bed.