Every finding on record at Martin Health Center, INC

Based on observation, clinical record review, facility policy and staff interviews, the facility staff failed to implement Enhanced Barrier Precautions when administering intravenous medication for 1 of 2 residents (Resident # 45) review for infection control. The facility reported a census of 45 residents.Findings include:Resident #45's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS listed diagnoses of cancer, heart failure, and toxic encephalopathy (brain dysfunction from toxins). Resident #45's Care Plan revealed the following Focus Areas:Enhanced Barrier (EBP - infection control to stop germ spread), initiated on 4/23/26, related to a Peripherally Inserted Central Catheter (PICC) line, a Continuous Ambulatory Delivery Device (CADD) pump, and an antibiotic for bacteremia (bacteria in blood). Interventions included:Direct care staff and visitors to follow EBPDirect care staff to utilize gowns and gloves for all personal care.7/6/26: Staff to change PICC line dressing every 7 days and as needed if soiled. On 7/6/26 at 9:06 AM, Resident #45 had EBP signage posted outside the door. The signage directed everyone to clean their hands, including before entering and when leaving the room. It instructed providers and staff to wear gloves and a gown, and to refer to the Kardex for details. On 7/8/26 at 6:46 AM, watched Staff A, Registered Nurse (RN), put on gloves, flushed the PICC line and give an antibiotic. Staff A didn't wear a gown during the procedure. Staff A acknowledged Resident #45 required EBP and verbalized she should've put on a gown. On 7/8/26 at 10:44 AM, the Director of Nursing (DON) verbalized Resident #45 required EBP due to an intravenous (IV) line. The DON acknowledged staff must wear a gown and gloves with care, including when dealing with the IV. Staff A's Personnel File listed a hire date of 10/16/23. The File included the following:The RN Job Description listed a professional responsibility to utilize proper infection control practices to inhibit the spread of infection.The Checkpoint 2 Facility RN Orientation signed by Staff A on 10/31/26 identified Staff A received training in medication pass times and procedures, dressing changes including PICC line dressings, and IV start, site care, and removal. The form lacked training in applying and removing EBP. The Transmission Based Precautions/Isolation & PPE (Personal Protective Equipment) facility policy revised on 4/2/24 instructed the practice of infection control guidelines as recommended by the CDC (Centers of Disease Control) to reduce and prevent the spread of disease-causing agents among residents, employees, visitors, and other stakeholders. The policy section titled Enhanced Barrier Precautions Implementation directed to use EBP for Indwelling Medical Devices. EBP applies to residents with devices providing a direct pathway for pathogens, including central lines, indwelling urinary catheters, feeding tubes, and tracheostomy or endotracheal tubes.

Based on record review, staff interviews and Resident Assessment Instrument (RAI) manual review, the facility failed to transmit 5 Minimum Data Set (MDS) assessments for 1 of 12 residents viewed (Resident #50). The facility reported a census of 45 residents. Findings include:Resident #50's Minimum Data Set (MDS) Clinical report printed 7/6/26 reflected the following completed assessments:Quarterly MDS dated [DATE]Discharge Return Anticipated MDS dated [DATE]Entry MDS dated [DATE]Annual MDS dated [DATE]Quarterly MDS dated [DATE]The form lacked the accepted status to show the facility transmitted (sent electronically) the MDS assessments. Resident #50's Assessment History dated 11/19/25 listed a completed status. The form identified staff never added the assessment to a batch (file group). Resident #50's Assessment History dated 1/21/26 listed a completed status. The form identified staff never added the assessment to a batch. Resident #50's Assessment History dated 1/23/26 listed a completed status. The form identified staff never added the assessment to a batch. Resident #50's Assessment History dated 2/18/26 listed a completed status. The form identified staff never added the assessment to a batch. Resident #50's Assessment History dated 5/20/26 listed a completed status. The form identified staff never added the assessment to a batch. On 7/7/26 at 12:30 PM the Administrator reported the bed failed to appear in the Electronic Health Record (EHR) (digital medical record system), so the assessments didn't get transmitted. The Resident Assessment Instrument (RAI) Manual dated October 2025 instructed when staff must transmit an MDS. The policy required transmission within 14 days of completion.

Based on observation, clinical record review, policy review and staff interview the facility failed to properly store food according to manufacturer's directions, ensure staff contain hair in hairnets when in the kitchen, and failed to ensure hot food is held at 135 degrees Fahrenheit (F) for safety. The facility reported a census of 48 residents. Findings include: The initial kitchen observation completed on 5/12/25 at 9:48 AM on the second floor kitchen revealed the following: a. One 3/4 full carton of Ready Care thickened orange juice dated 4/18/25. The Manufacturer Directions on the side of the carton directed to discard 7 days after opening. b. One 1/4 full bottle of Thick It Clear Advantage Thickened Water, level 2, mildly thick, dated 4/15/25. The Manufacturer Label on the bottle directed to use within 14 days after opening. During a follow up inspection of the second floor kitchen on 5/13/25 at 10:54 AM the following observations were made: a. One 3/4 full carton of Ready Care thickened orange juice dated 4/18/25. The Manufacturer Directions on the side of the carton directed to discard 7 days after opening. b. One 1/4 full bottle of Thick It Clear Advantage Thickened Water, level 2, mildly thick, dated 4/15/25. The Manufacturer Label on the bottle directed to use within 14 days after opening. Interview on 5/13/25 at 11:00 AM Staff A, Dining Hospitality Coordinator, reported she was trained juices could only be used for three days, then they were to dispose of them. During an interview on 5/13/25 at 11:01 AM the Dietitian reported they follow the label directions from the manufacturer for discarding fluids. She couldn't answer if the date on the bottle was the delivery stock date or the open date as they date all food items when they come in for delivery. She expected the staff to date food and fluid items when opening and follow the label instructions. On 5/13/25 at 11:35 AM witnessed Staff D and Staff E, Certified Nursing Assistants (CNAs), prepare drinks in the kitchen with approximately 4-5 inches of side tendrils of hair hanging out of the sides of their hairnets. On 5/13/25 at 12:13 PM saw Staff D come out of the back kitchen with 4-5 inches of side hair hanging out of the sides of the hairnet, they opened a bag of Doritos and put it on the counter top for the cook to serve out to a resident. On 5/13/25 at 12:18 PM saw Staff D entered the kitchen with approximately 4-5 inches of side hair hanging out of her hairnet to get a resident pop from the pop machine. On 5/13/25 at 12:32 PM witnessed Staff D in the kitchen with 4-5 inches of hair hanging out the sides of her hair net as she obtained butter from the kitchen for a resident's sweet potato. The post meal temperatures completed on 5/13/25 at 12:37 PM revealed the temperature of the green beans at 123.1 degrees Fahrenheit. The green beans sat in a steam pan throughout the entire meals service from 12:04 PM to 12:37 PM with the stove burner in the off position. Staff C turned the oven down to 300 degrees Fahrenheit at 11:59 AM, then down to 250 degrees at 12:02 PM and finally turned the oven to the warm position at 12:04 PM. Interview on 5/13/25 at 12:41 Staff C verbalized hot food should be held at 135 degrees or higher. During an interview 5/14/25 at 1:00 PM the Certified Dietary Manager voiced staff are to have all hair contained in a hairnet when in the kitchens. The staff are trained to keep hot food temperatures above 140 degrees, but the staff know the actual requirement is to keep at a minimum of 135 degrees. If there is a lull in the meal service, the steam pans of food should be put back in the over to keep the food hot. During an interview on 5/14/25 at 1:37 PM the Dietitian reported she expected the hot food to be held at 135 degrees Fahrenheit or higher. In addition, she expected the staff to ensure all hair is covered with a hairnet before entering the kitchens. The Food Storage Policy, reviewed December 2023, under Procedure directed foods held in the refrigerator shall be appropriately covered, labeled and dated. The Food Temperature/Food Safety Policy, reviewed December 2023, directed to maintain all foods served at proper temperatures including during food preparation and service. The Policy directed food temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit during the holding and plating process. The Infection Control Staff Related Preventive Measures Policy, revised October 2024, directed dietary staff will wear hair restraints while in the kitchen areas to prevent hair from contacting exposed food.

Based on observation, clinical record review, policy review and staff interview, the facility failed to check gastronomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach and is sometimes referred to as a feeding-tube) placement prior to flushing water and administering medications down the g-tube for 1 of 1 resident observed (Resident #21). The facility identified a census of 48 residents. Findings include: Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified he rarely/never understood, he had no memory recall of current season, location of room, staff names and/or faces, or that he lived in a nursing home. The MDS reflected he had severely impaired daily decision making skills. Resident #21 had upper and lower extremity impairments on both sides of the body. The MDS listed him as dependent for care (oral care, toileting, dressing, bathing, turning in bed). The MDS included diagnoses of Parkinson's, unspecified, end stage renal disease, non Alzheimer's Dementia, and dysphagia (difficulty swallowing). The MDS documented Resident #21 received 51% or more of nutrition and 501 cubic centimeters (CC's, unit of measure) per day or more through a feeding-tube. A Nursing Facility Physician Visit Note dated 4/15/25 documented Resident #21 had diagnoses of dementia, gastrointestinal hemorrhage (excessive bleeding in the stomach) associated with peptic ulcer (an injury inside the body usually caused by increased acid production), colon ulcer of the large intestine and utilizing a feeding-tube. An Order Review History Report electronically signed by the Provider on 5/14/25 documented the following orders: a. Jevity 1.2 Calorie Oral Liquid give 105 milliliters (ML) via g-tube two times a day for tube feeding. Run the feeding for 14 hours. b. Flush g-tube with 60 ML water before and after medication administration. c. Measure g-tube from insertion site to the end of g-tube daily to check the tube placement. Notify the primary care provider if the measurements are off. d. Flush the g-tube with 150 ML water before and after the feeding two times a day. e. Medications may be crushed and cocktailed per g-tube (administration) every shift. f. Change piston syringe, graduate, feeding bag, and tubing every 24 hours. Document date and resident initials one time a day. On 5/14/25 at approximately 8:10 AM Staff A, Licensed Practical Nurse (LPN), reported Resident #21 tube feeding as not done and she would check it again soon. Around 8:20 AM Staff A reported Resident #21 feeding as almost done and she would disconnect his feeding soon. On 5/14/25 at 9:02 AM observed Staff A donned (put on) gloves and an isolation gown, then entered Resident #21's room to administer his morning medications. Staff A obtained a syringe dated 5/14/25 with a graduate (container used to collect fluid usually with measurements) dated 5/12/25 and proceeded to fill the graduate with water to perform the post feeding and medication flush prior to medication administration. Staff A opened the g-tube, attached the syringe and poured water into the syringe without checking for g-tube placement by aspirating (using the syringe to suck out contents) gastric (stomach) contents or measuring from the insertion site to the end of the g-tube. In addition, witnessed Staff A couldn't get the water to flow in the syringe and pushed the water with resistance into the g-tube to complete the remaining water flush, administer Resident #21's medications, and complete the final water flush. During an interview on 5/14/25 at 9:14 AM Staff A explained they aspirate for gastric contents but she didn't do that prior to administering his medication; or she could have used a stethoscope and listened to the resident's abdomen. Interview on 5/14/25 at 3:34 PM Staff B, LPN, reported the nurses are required to check placement of a g-tube by auscultating (listen to) the abdomen with a stethoscope and measuring the length on the g-tube. Staff B explained the nurse should check g-tube placement before administering medications down the feeding-tube. Staff B stated Resident #21 couldn't communicate if he had any issues with his feeding-tube. During an interview on 5/15/25 at 8:05 AM the Director of Nursing (DON) reported she needed to check the facility policy. After reviewing the policy, the DON stated the nurses check the g-tube placement by measuring the insertion site to the end of the tube daily. After reviewing the medication policy with the DON, she verbalized she expected the nurses to measure the g-tube placement to ensure the placement of the tube prior to medication administration. The Medication Administration Policy, revised October 2024 directed the nurse to check for tube placement per policy before administering medications down the g-tube. The Feeding-tube Placement Check Policy, revised October 2024 under Procedure directed the following: a. Feeding-tubes will have placement checks at least daily. b. Measure from insertion site to end of tube and document on the Medication Administration Record.

Based on observation, clinical record review, policy review and staff interview the facility failed to serve the physician ordered diet for 1 of 3 residents on a carbohydrate-controlled diet (Resident #47). The facility identified a census of 48 residents. Findings include: Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified she had short/long term memory impairment with moderate impaired daily decision making. The MDS included a diagnosis of type two diabetes mellitus (DM) with diabetic polyneuropathy (a condition where multiple peripheral nerves in the body are damaged from high blood sugar levels). The MDS reflected Resident #47 received insulin injections seven days a week and hypoglycemic (blood sugar lowering) medications while a resident. An Order Review History Report electronically signed by the Provider on 4/29/25 documented the following physician orders: a. Toujeo Solostar (insulin) subcutaneous solution pen injector 300 Units (U)/Milliliter (ML) inject 16 units subcutaneously one time a day related to DM with diabetic neuropathy. b. Metformin hydrochloride oral tablet 500 MG give 2 tablets by mouth two times a day related to DM with diabetic neuropathy. c. Humalog KwikPen (insulin) Subcutaneous Solution Pen Injector 100 U/ML. Inject per sliding scale: i. if 150 - 200 = 1; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400 = 5, and above 400 call Provider. d. Free Style Libre 3 Reader Device (continuous glucose monitor) inject 1 applicator subcutaneously every day shift, every 15 days. e. Provide a consistent carbohydrate diet (CCHO, a diet that focuses on consuming the same amount of carbohydrate at each meal to enhance blood sugar control), 60 - 75 grams of carbohydrates per meal. Resident #47's May 2025 Electronic Medication Administration Record (EMAR) showed indicated her Toujeo Solostar insulin increased to 20 Units subcutaneously in the morning of 5/2/25. The Care Plan Focus dated 5/2/25 identified Resident #47 had a nutritional problem related to type two DM with diabetic chronic kidney disease. The Care Plan directed to provide the diet per physician orders. The Week 1 Tuesday Noon 2/11/25 Dietician approved menu directed the following CCHO diet: a. 3 ounces of boneless barbeque ribs b. A #16 scoop (2 ounces) mashed sweet potatoes c. 4 ounces green beans with bacon and red onions d. One flakey biscuit e. One teaspoon margarine f. 4 ounces vine ripened watermelon g. 6 fluid ounces of milk On 5/13/25 at 12:07 PM watched Staff C, Dining Hospitality Coordinator, review Resident #47's meal ticket which listed her diet as a CCHO diet. Staff C plated 3 ounces of ribs, 4 ounces of sauteed green beans with bacon and red onion, 4 ounces of sweet potato, one flakey biscuit with margarine and a 4 ounce bowl of watermelon. On 5/13/25 at 12:40 PM Staff C reviewed Resident #47's meal ticket with the Surveyor and verbalized she had served the 4 ounce serving of sweet potatoes to Resident #47 and it should have been the #16 (2 ounce) scoop of sweet potatoes as listed on the meal ticket. She voiced she checked the menu extensions prior to meal service and she served Resident #47 the regular diet, not the CCHO diet. During an interview 5/14/25 at 1:00 PM the Certified Dietary Manager explained staff are to follow the diet as posted on the approved Menus as the serving sizes are on the menus to eliminate serving mistakes. The extensions are printed onto the daily menu, so the actual serving sizes are posted on the meal ticket. She expected the staff to follow the menus. During an interview on 5/14/25 at 1:37 PM the Dietitian reported Staff C made an honest mistake and she expected staff to serve the approved dietary menu. The Food Production and Service Policy, revised December 2023, directed the Registered Dietitian Nutritionist Supervisor of Dining Services and/or the Lead Hospitality Coordinator are responsible for seeing the menu is followed.

Based on record review, resident and staff interviews the facility failed to provide a safe mechanical lift (Hoyer) transfer for 1 of 3 residents reviews (Resident #1). The Hoyer strap came unhooked on the right upper side of the sling and Resident #1 fell from the Hoyer. The fall resulted in a right femur fracture and left rib fractures of the 3rd, 4th and 5th ribs. The facility reported a census of 46 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 listed as dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for all transfers. The Care Plan Focus revised 3/27/24 indicated Resident #1 had an activities of daily living (ADL) self-care performance and transfer assistance deficit related to the need for a Hoyer transfer, gout, and wound to left plantar foot. The Interventions directed staff that Resident #1 required 2 staff and a Hoyer for transfers. An Incident Report dated 8/22/24 at 3:20 PM documented Resident #1 had a witnessed a fall from the Hoyer. Resident #1 had a laceration to the back of the head and skin tear to the elbow. He reported pain to the right side, left shoulder, and chest area. The nurse called 911 and at approximately 4:10 PM the facility transferred him to the hospital. A Progress Note dated 8/22/24 at 8:36 PM documented Resident #1's radiology report indicated he had a right periprosthetic femur (type of hip fracture) fracture and left rib fractures of 3rd, 4th, and 5th ribs. In an interview on 12/16/24 at 10:20 AM, Resident #1 reported it all happened so fast. He reported they were not in a rush and had hooked him up right as far as he could tell. He said they lifted him off the recliner and began to move him to the bed. He didn't make it to the bed and he just fell out of the sling all of a sudden. Resident #1 reported the staff didn't jerk or make any moves to make it happen that he could feel. He just felt the shoulder area giving out and down he went. It all happened so fast that no one could react to help. He reported he went to the hospital and had a broken leg and ribs. He reports he still has pain in the areas. He reported the facility ended up getting a totally different sling because they wanted to not use the same kind of sling on him. During an interview on 12/16/24 at 12:53 PM Staff A, Certified Nurse Aide (CNA), reported Resident #1 already had the sling under him in the recliner. Staff A got the Hoyer from by the bed, turned it on, opened the legs and pushed it up to the recliner. Staff A hooked it up the upper extremity straps and right leg strap of the sling to the Hoyer. Staff B, CNA hooked up the leg strap on the left side to the Hoyer. Staff A reported both Staff B, CNA, and himself triple checked to make sure it was strapped well and then they began lifting Resident #1. In the process of moving Resident #1 they got halfway to the bed and the sling came unhooked on the right upper side. Staff A reported he was guiding the legs and right upper side when it happened. Staff A reported it all happened so fast he could not catch Resident #1 and he fell to the floor. Staff A reported they didn't move Resident #1 and called for the nurse. The Hoyer was still up and the sling was still hooked to the Hoyer for the 3 straps that were still hooked when the nurse came in the room. It was the right shoulder part of the sling that came unhooked. During an interview on 12/16/24 at 1:06 PM, Staff B reported Resident #1 already had the sling under him in the recliner and Staff A put the Hoyer up to the chair. Staff B reported she went and put gloves on in the bathroom and came back and hooked Resident #1 left leg area strap of the sling to the machine. Staff B reported Staff A hooked up the rest. Staff B reported it all happened so fast. Staff B reported Resident #1 sat in the sling fine and everything went good, until all of a sudden, the right-side upper strap came off and he fell to the floor. Staff B reported it happened about half way from the recliner to the bed. Staff B reported they didn't move Resident #1 and called the nurse. Staff B reported they both triple checked the sling and Hoyer prior to moving Resident #1 all was correctly hooked. During an interview on 12/16/24 at 1:26 PM Staff C, Licensed Practical Nurse (LPN), reported Staff A came and reported Resident #1 fell from the sling. Staff C reported as she entered Resident #1's rooms, she found him lying on the floor with his head on the Hoyer frame. The Hoyer sling was still hooked to the machine at 3 of the points the right upper strap was not hooked. She reported Resident #1 bled from a head laceration and skin tear to his elbow. Resident #1 reported pain to his upper extremities, so she called 911. Resident #1 transferred to the hospital via ambulance. Review of the personal file for Staff A identified a hire date of 5/2/24. He completed orientation checklist training on 7/16/24. The orientation checklist had transfers with a mechanical lift. Directing staff must demonstrate how to use the Hoyer as operator and patient guide. Review of the personal file for Staff B identified a hire date of 2/5/24. She completed orientation checklist training on 2/25/24. The orientation checklist had transfers with a mechanical lift. Directing staff must demonstrate how to use the Hoyer as operator and patient guide. Review of the facility lift inspection reports the Hoyer machine indicated the last inspections happened on 2/4/24 and 9/3/24. On 9/3/24 the Hoyer company listed the machine as in good condition, with no concerns noted according to the documentation. In an interview on 12/16/24 at 3:15 PM the Administrator reported the staff hooked up the sling using the middle hooks when transferred. She reported sling size was what therapy recommended when they determined him to be a Hoyer. She reported the facility acted right away to ensure it would not happen again. The facility corrected the deficiency by implementing the following: a. 8/22/24 after the incident took the Hoyer out of commission until inspected by EZ-Way on 9/3/24 b. The facility completed staff education and testing on 8/23/24. C. Ongoing facility audits of staff with the Hoyer lifts. D. 9/10/24 the Hoyer company representative reviewed the proper procedures and demonstrated how to use the Hoyer lift.

Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual the facility failed to complete Significant Change Minimum Data Set (MDS) assessment for 4 of 4 residents (Residents #14, #32, #35, and #37) within 14 days of identifying a significant change occurred. The facility reported a census of 46 residents. Findings include: 1. Resident #14's MDS assessment dated [DATE] indicated he didn't receive hospice care while a resident. The Hospice Certification and Plan of Care dated 4/12/24 identified Resident #14 elected to receive Hospice services. The Hospice Medicare Benefit Revocation dated 4/16/24 indicated Resident #14 choose to revoke hospice services. Resident #14's Clinical - MDS record reviewed on 7/11/24 indicated the facility completed an entry MDS assessment on 4/11/24 and a quarterly MDS assessment on 5/22/24. The review lacked documentation of a significant change MDS assessment following Resident #14's election of Hospice benefits or when he revoked his Hospice benefits. Interview on 7/10/24 at 4:00 PM Staff A, Nurse Mentor, stated they didn't have to do a significant change due to Resident #14 went off of hospice within the 14 days and didn't trigger 2 of the significant changes. The RAI Manual dated October 2023 instructed if a nursing home resident elects to receive the hospice benefit, the Centers for Medicare and Medicaid Services (CMS) requires the nursing home complete an MDS Significant Change in Status Assessment (SCSA). In addition, CMS requires a nursing home complete an SCSA when the resident comes off the hospice benefit (revoke). It is a CMS requirement to have an SCSA completed every time someone elects to use their hospice benefit, even if the facility completed a recent MDS and the only change is the election of the hospice benefit. The Significant Change MDS date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). The assessment reference date (ARD) must be less than or equal to 14 days after the IDT's determined the resident met the criteria for an SCSA (determination date + 14 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination the resident met the criteria for a SCSA. This date may be earlier than or the same as the CAA(s) completion date, but not later than. 48003 2. The Hospice Admission Consent form dated 6/19/24 identified Resident #32 started receiving Hospice services on 6/19/24. The Progress Note dated 6/20/24 at 3:08 PM reflected Resident #32 admitted to hospice on 6/19/24. The Clinical Record Review included an incomplete SCSA dated 7/2/24, greater than 14 days after the determination Resident #32 met the criteria for a SCSA. 3. The Medicare Hospice Election Statement dated 5/18/23 listed Resident #35 started Hospice services on 5/18/23. Resident #35's SCSA dated 5/30/23 reflected a completion date of 6/12/23, 11 days past the 14 days after the determination date of 5/18/223. 4. The Medicare Hospice Election Statement dated 11/21/23 reflected Resident #37 started Hospice services on 11/21/23. The clinical record review reflected Resident #35's SCSA dated 12/4/23 reflected a late completion date of 12/18/23. During an interview on 7/10/24 at 10:45 AM, Staff B, Nurse Mentor, reported when doing the MDS she followed the ARD when Staff A, Nurse Mentor, set them up. She reported the facility followed the regulations directed in the RAI manual. During an interview on 7/10/24 at 11:30 AM, Staff A, Nurse Mentor, reported when someone went on hospice she set the ARD out a little way to catch everything they need. She reported she didn't know the Hospice MDS SCSA needed completed within 14 days of going on hospice. She reported the facility followed the RAI manual.

Based on clinical record review and staff interview the facility failed to notify the state ombudsman as required for emergency transfers for 2 of 3 residents reviewed (Residents #2 and #8). The facility reported a census of 46 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Progress Note written on 12/24/23 at 11:12 PM reflected Resident #2 transferred to the hospital. The Progress Note on 12/25/23 at 7:06 AM listed Resident #2 admitted to the hospital. Review of the December 2023 Ombudsman notification form lacked documentation of Resident #2's discharged to the hospital on 12/24/23. 2. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 10, indicating moderately impaired cognition. Resident #8's Census listed statuses of hospital leave on the following dates: 8/30/23, 9/15/23, 12/21/23, 4/12/24, and 7/4/24. The Progress Note on 8/29/23 at 9:05 PM indicated Resident #8 admitted to the hospital. The Progress Note on 9/15/23 at 2:16 PM reflected Resident #8 admitted to the hospital. The Progress Note on 12/21/23 at 2:12 PM identified Resident #8 admitted to the hospital. Review of the August, September and December 2023 Ombudsman notification form lacked documentation of Resident #8 discharged to the hospital on 8/29/23, 9/15/23, and 12/21/23. During an interview on 7/9/24 at 11:43 AM the Administrator reported the facility didn't complete the 2023 Ombudsman reports correctly. On 7/9/24 at 5:11 PM the Administrator reported the facility didn't have a policy related to Ombudsman notification.

Based on clinical record review and staff interview, the facility failed to complete a new level I Preadmission Screening and Resident Review (PASRR) for Level I on 12/30/22 for 1 of 1 resident reviewed (Resident #26). The facility reported a census of 46 residents. Findings include: Resident #26's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anxiety, bipolar disorder, psychotic disorder, and non-Alzheimer's disease. Review Resident #26's PASRR Level 1 Screening Outcome dated 11/30/20 reflected a PASRR Level I Determination, No Level II required. Review of the clinical chart revealed this PASRR came with Resident #26 from another facility, but the current facility failed to submit a new PASRR due to new diagnosis and medication. The Progress Notes dated 6/19/24, and 7/2/24 for Resident #26 revealed follow up psychiatric visits related to bipolar. The Pre Admission Screening and Resident Review (PASRR) policy dated November 2022 revealed: To ensure the identification of nursing facility applicants and residents with serious mental illness and/or intellectual and developmental disability (MI/MR) receive appropriate placement, admission, or the ability to remain in the facility, but only if the facility can appropriately serve and provide the services they need. 1. Prior to admission, the referring entity completes the Level I process. 2. The Admission Director or designee reviews the Level I evaluation. 3. If Level I evaluation indicated the need for a Level II, the facility will suspend the admission until the completion of the Level II evaluation or until such time the facility received an exemption. 4. If the resident received a negative Level I evaluation, the facility may admit the resident as long as they can meet the needs of the individual according to the Admission Policy. In an interview on 7/9/24 at 3:29 PM, the Administrator reported the facility missed it. They should have submitted a new PASRR, and they would submit a new one that day.

Based on observations, interview, policy review and record review, the facility failed to provide one resident (Resident (R) 4) of 15 sampled residents, out of total sample of 46 residents, respect and dignity. Specifically, R4 was allowed to sit in, urine-soaked garments for over 90 minutes, while sitting in the dining room, during an activity and in the TV room with other residents. Findings include: Review of the undated Patients' Rights Policy revealed The resident has a right to a dignified existence, . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The record review on 06/13/23 at 4:45 PM revealed the Care Plan dated for 05/24/23, and found under the Care Plans tab in the Electronic Medical Record (EMR), did not include concerns for ADLs (Activity of Daily Living) for frequent soaking of garments. Review of R4 quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/23, revealed R4 was admitted on [DATE] with diagnoses that included renal insufficiency and hyperlipidemia. The MDS revealed R4 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating R4 was severely cognitively impaired. The MDS recorded R4 required extensive assistance with all Activities of Daily Living (ADL) except eating where he required limited assistance. R4 was frequently incontinent of urine, indicating R4 had seven or more episodes of urinary incontinence. Observation on 06/12/23 at 3:49 PM R4 was observed being in his room sitting in front of the TV with soiled wet jeans that were soaked through with a strong urine odor. Observation on 06/12/23 at 5:00 PM, R4 was being pushed to the dining room for dinner by Certified Nurse Aide (CNA)2. He had on jeans that were visibly soaked in urine and had a strong odor of urine. Observation on 06/13/23 at 8:25 AM, R4 was observed in his wheelchair eating, there was a strong odor of urine. Observation on 06/13/23 at 9:47 AM revealed, R4 in his room in front of the TV dressed in lighter blue jeans and noted to have a wet area to groin area soaked through his jeans with a strong urine odor. Observation on 06/13/23 at 1:05 PM, revealed R4 in his room sleeping. He has jeans on with wetness to his groin area. Urine odor persists in the room. Observation on 06/13/23 at 3:29 PM, revealed R4 in the dining room at a table with other residents playing bingo. He appeared to have the same jeans on as earlier that had wet area to groin area. Spouse was here visiting with R4 at the table. Interview on 06/13/23 at 3:51 PM, Certified Nurse Aide (CNA) 3 stated R4's cognition varies and some days better than others. CNA3 stated R4 received two showers weekly and required one to two-person to assist. She stated R4 was frequently incontinent. Interview on 06/13/23 at 4:00 PM with R4's Family Member (FM1), she stated she was aware that R4 was incontinent. R4 returned to his room, during the interview, from the dining area, jeans were again visibly soaked with urine. Interview on 06/13/23 at 4:21 PM with CNA3 and CNA4 in the room with R4. Both CNAs stated R4 required his briefs to be changed every one to two hours. They stated his brief remained an issue. They stated they were not sure what else could be done to prevent R4 from soaking through his jeans. They said R4 was soaked every time they changed him. Interview on 06/15/23 at 12:35 PM, with the Director of Nursing (DON). She stated she was aware of R4's incontinence. She stated he was on a diuretic called Bumex which caused him to urinate frequently. She says they are going to research further products that can be used for R4.

Based on record review, interview, and policy review, the facility failed to ensure two residents (Resident (R) 35 and 10) of 15 sample residents, out of a total of 46 sample residents, was afforded the opportunity to be included in all aspects of person-centered care planning. Findings include: Review of the facility policy titled, Care Plan Interdisciplinary Team, revised on 03/2023, read in pertinent part, Each resident's care plan shall be reviewed every 3 months or PRN (as needed) with changes in health/condition. Interdisciplinary team will meet to review with resident, resident's family/representative, and others who may be involved in the resident' care. 1. Review of R35's Face Sheet, located in Electronic Medical Record (EMR) under the Profile tab, revealed an admitted [DATE] with diagnoses which included pulmonary embolism without acute coronary pulmonale, cardiovascular and coagulations. Review of R35's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 04/14/23 revealed R35's was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of R35's Care Plan, original date of 11/05/19 and updated on 04/21/23, revealed a focus of [R35] remains Immediate Care Facility Level of Care (ICF/LOC). R35 is independent in decision making and makes her wants and needs known. Memory is intact. There was no documentation of R35's participation in the care planning meetings, nor being invited to the care planning meeting. During an interview on 06/12/23 at 12:52 PM, R35 revealed, I have not been invited or told about a care planning meeting. R35 revealed I am my own decision maker, I do not have a resident representative, although I do have family. 2. Review of R10's Face Sheet, in the EMR under the Profile tab, revealed an admitted [DATE] with diagnoses of major depressive disorder, recurrent, in partial remission and polyneuropathy, unspecified. Review of R10's quarterly MDS, located in the EMR under the MDS tab, with an ARD) of 05/19/23 revealed R10 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of R10's Care Plan, original date of 08/19/22 and updated on 05/26/23, revealed a focus of R10 will remain in ICF/LOC and would like her stay permanently. R10 does not want information on alternate placement and only wants to be asked on comprehensive assessments. R10, has adequate memory and can make their own decisions. During an interview on 06/12/23 at 12:46 PM with R10, the resident stated she was not invited or had discussed with staff care planning meetings. During an interview on 06/14/23 at 08:41 AM with the Household Coordinator (HHC), she stated she managed everything non-clinical in the unit. She stated it included activities and Social Service duties. The HHC stated this included scheduling care plan meetings, which were scheduled every quarter, and when there is a significant change. The process included reaching out to the resident representative and getting a date and time in place. The resident was involved in all the care conferences. During an interview on 06/14/23 at 12:57 PM with the HHC and Director of Nursing (DON), they stated they were not able to find any documentation of R35 or R10 attending a care planning conference. They stated they would be in the process of setting them up as soon as possible. During an interview on 06/14/20 at 2:37 PM with the Administrator, The Administrator stated they both have a BIMS of 15 and should be attending their care planning conference and involved in their care planning.

Based on observation, interview, and record review, the facility failed to assist residents with Activities of Daily Living (ADL) care for one of one resident (Resident (R) 3) of 15 sampled residents, out of a total sample of 46 residents reviewed for ADL's. Specifically the facility failed to ensure R3's chin hair was removed while receiving a shower. Findings include: 1. Review of R3's Face Sheet, located in the Electronic Medical Record (EMR) under the Admission record tab, revealed an admitted [DATE] with medical diagnoses that included Type 2 Diabetes, Acute Diastolic Heart Failure, Reduced mobility, and Muscle Weakness. Review of R3's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an assessment reference date (ARD) of 05/19/23, revealed a Brief Interview for Mental Status score (BIMS), of 15 out of 15, indicating R3 was cognitively intact. The MDS revealed R3 required extensive physical assistance of two persons for her personal hygiene needs. Review of R3's care plan, located in the EMR under the Care Plan tab last updated 05/29/23 read, .requires assistance with ADL care needs related to weakness and impaired mobility. The care plan goal read, will continue to assist w/her activities of daily living by requiring staff assistance through next review. One of the interventions included in the care plan was, Provide assistance with daily grooming, oral care, hair care. R3 care plan reviewed also did not indicate addressing resident's chin hair. Review of R3's Point of Care (POC) record, located in the EMR under the Tasks tab dated as recent as 06/07/23 indicated R3 required extensive assistance with her personal hygiene needs. During an initial observation on 06/12/23 at 10:20 AM, R3 was found in her room sitting up in her w/c (wheelchair). The surveyor noted while talking to her that she had a moderate amount of chin hair and dirty fingernails. During an observation on 06/13/23 at 08:50 AM, R3 was in her room, sitting up in w/c, had her oxygen in place per nasal canula. The surveyor asked R3 if she liked having chin hair, R3 animatedly responded no I do not. The surveyor asked R3 if she wishes for them to be removed, she responded yes. Record review on 06/13/23 at 4:55 PM, revealed resident shower schedule which confirmed Wednesday and Saturday. Interview on 06/13/23 at 4:50 PM, with Certified Nurse Aide (CNA)3 indicated that R3 has shower days on Wednesday and Saturday mornings or may get showers in between as needed, and that shaving needs are usually addressed with shampooing at that time. CNA3 did not seem aware that R3 has unwanted chin hair that was not addressed.

Based on observation, staff interview, and policy review, the facility failed to ensure one of one resident (Resident (R) 4) of 15 sampled residents, out of total sample of 46 residents, had a clean and homelike environment. Specifically, housekeeping staff failed to ensure R3's room did not have a strong scent of urine. Findings include: Observation on 06/13/23 at 8:45 AM, R4's room has an odor in the sitting area and bathroom, Observation on 06/13/23 at 1:05 PM, revealed R4 in his room, there was a strong odor of urine. Interview on 06/13/23 at 12:35 PM, with the Director of Nursing (DON) who stated she was aware of the strong urine odor in R4's room. She stated they have been trying different products and continue to investigate new products that can be used. Interview on 06/13/23 at 1:00 PM, with the Household Coordinator (HHC), stated she was aware of the strong urine odor in R4's room and had been trying different products. She stated she had steam cleaned the carpet at least once per month. She indicated it was difficult to remove the odor when R4 continued to urinate on the floor. She planned on looking for other solutions. Interview on 06/13/23 at 4:21 PM, with Certified Nursing Assistant (CNA) 3 and CNA 4, both stated R4's room had a strong urine odor unlike other resident's rooms on the 2nd floor that have incontinent issues. They also stated the carpet cleaning does not help. Policy review, revised 12/2022, 'General Guidelines and Cleaning Procedures revealed Resident's rooms will be thoroughly cleaned .to include a deep cleaning to resident's room on the first day of each month.

Based on observation, facility policy review and staff interview, the facility failed to label and date food items in order to reduce the risk of contamination and food-borne illness. The facility reported a census of 47 residents. Findings include: Observation on 1/3/22 at 9:38 AM during the initial tour of the 1st and 2nd floor kitchen freezers with Staff A, Hospitality Mentor, revealed the following: a. 5 frozen waffles not labeled or dated when opened. b. 18 mini pancakes not labeled or dated when opened. c. 1/2 of a 2 gallon bag of biscuits not labeled or dated when opened. d. Approximately 4 pounds of sausages not labeled or dated when opened. e. 2 1/2 pounds of chicken strips not labeled or dated when opened. f. 1 pound of broccoli not labeled or dated when opened. g. 6 hamburgers not labeled or dated when opened. h. 18 sausages not labeled or dated when opened. i. 20 ounces of mixed vegetables not labeled or dated when opened. j. 15 cheddar biscuits not labeled or dated when opened k. 5 garlic twists not dated labeled or dated when opened. l. 8 churros not labeled or dated when opened. m. 1 pound of french fries not labeled or dated when opened. n. 7 hot dogs not labeled or dated when opened. o. 38 mini pancakes not labeled or dated when opened. p. 8 waffles not labeled or dated when opened. q. 25 fish not labeled or dated when opened. Review of the facility's policy titled, Storage, with an effective date January 2021, revealed that foods held in the refrigerator or other storage areas shall be appropriately covered, labeled and dated. During an interview 1/06/22 at 11:01 AM, Staff A, Hospitality Mentor, revealed it is an expectation that staff label and date items after opening.

Based on observation, clinical record review, resident and staff interviews, the facility failed to ensure staff knocked and announced self before entering for one of one residents. (Resident #24) Findings include: 1. The Minimum Data Set Assessment ((MDS) dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status Assessment (BIMS) score of 15, indicating intact cognition. During observation on 1/8/20 at 10:41 a.m., Staff B, Occupational Therapist (OT), opened the shower room door and looked into room, without knocking first. Resident #24 stated someone was opening the door and Staff B closed the door. Staff B knocked and announced themselves and told the resident they wanted to talk with them after the shower to discuss therapy goals. During interview on 1/8/20 on 1:53 at p.m., the Director of Nursing (DON) acknowledged all staff should knock and announce themselves before entering a room. During interview on 1/8/20 at 2:10 p.m., the resident stated she felt uncomfortable when Staff B entered the shower room, without knocking, when she was in the shower.

Based on clinical record review and staff interview, the facility failed to develop and implement a comprehensive Care Plan for one of 13 residents reviewed. (Resident #24) Findings include: 1. The Minimum Data Set Assessment ((MDS) dated [DATE], revealed Resident #24 had [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The Care Plan did not include information or interventions for the use of insulin, anticoagulants, antidepressants and diuretics. During interview on 1/8/20 at 1:53 p.m., the Director of Nursing (DON) acknowledged the Care Plan should include interventions for medications which included anticoagulants, insulin, anti-depressants and diuretics.

Based on clinical record review, resident and staff interview, the facility failed to ensure one resident of 12 residents reviewed received a bath as planned/desired. (Resident #17) The facility census was 45 residents. 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #17 required supervision for bathing and had [DIAGNOSES REDACTED]. The Care Plan focus area revised 5/22/17, directed staff to provide assistance with bathing/showering two times a week and as necessary. Check nail length and trim and clean on bath day and as necessary. During interview on 11/6/18 at 1:30 p.m., the resident stated staff failed to provide two baths a week on a consistent basis and revealed baths were provided sporadically. The resident stated weeks go by when she has not received a bath at all. The resident liked to feel clean and desired to get regular baths. The Bathing document revealed the resident failed to receive a bath on the following scheduled bath days in (MONTH) (YEAR): 10/1/18, 10/4/18, 10/22/18, and 10/25/18 An untitled document directed the resident was to receive a shower on Monday and Thursday on the 6 a.m., shift. During interview on 11/7/18 at 10:00 a.m., Staff B, Co-Director of Nursing stated staff was to complete showers on scheduled days and if unable to complete as scheduled was to document and report.

Based on observation, clinical record review and staff interview, the facility failed to ensure safety devices were in place as planned for one of 12 residents reviewed to prevent accidents. The facility census was 45 residents. Findings include: 1. The Medication Administration Record [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status with a score of 7, indicating impaired cognition. The MDS assessment revealed the resident required extensive assistance with all transfers and bed mobility and had a history of [REDACTED]. The resident's care plan dated 11/9/17, identified the resident as a fall risk and interventions included use of a mechanical lift for all transfers and skid strips placed alongside the resident's bed. During observation on 11/6/18 at 10:54 a.m., revealed no skid strips present on resident's floor as planned. During interview at the time, Staff A, Director of Nursing stated the resident had moved from the second floor to the first floor and the skid strips must not have been placed on the floor in the new room. Staff acknowledged the skid strips were on the plan of care as a fall prevention strategy. During interview on 11/6/18 at 1:30 p.m., the Administrator stated it would be her expectation for the care plan to be followed. I

Based on clinical record review, observation and staff interviews the facility failed to provide adequate supervision and assistance when staff transferred one of three residents without the use of two staff (Resident #1) which resulted in a laceration. The facility reported a census of 74 residents. Findings include: 1. Resident #1 most recently admitted to the facility on [DATE] with an original admission on 7/19/2012. The MDS (Minimum Data Set) dated 8/3/2018 revealed the resident had moderately impaired cognitive skills for daily decision making and long and short term memory impairment, required extensive assistance of two staff to transfer from one surface to another, dress and use the toilet. The MDS reported she had [DIAGNOSES REDACTED]. She had one fall since the prior assessment without injury, one deep tissue injury. The Care Plan identified the resident had a risk for alteration in skin integrity related to weakness and physical limitations. It directed staff to administer treatments as ordered and monitor for effectiveness, float heels as tolerated, monitor labs and nutritional status. The resident had a skin tear to the left lower extremity hitting on wheel chair during transfer and a skin tear to the right wrist on 3/282/108 during transfer. It directed staff to identify causative factors and eliminate when possible, if skin tear occurs, treat per facility protocol and notify family and physician, wheel chair requires padding to connecting areas for the leg rests to be kept in place, keep skin clean and dry. It instructed staff to apply tubi-grip to bilateral upper extremities as resident allows added on 3/29/2018. Use caution during transfers to prevent striking arms, legs and hands against any sharp or hard surface added on 7/29/2017. The Care Plan directed staff to transfer with the assistance of 2 staff, a gait belt and wheeled walker initiated on 5/17/2017 and revised on 8/15/2018. The Care Sheet dated 6/1/2018 directed staff to use 2 assist and a gait belt to transfer and ambulate the resident, tubi-grips to upper and lower extremities at all times as tolerated and reproach if combative. physician's orders [REDACTED]. Nurse's Notes dated 6/5/2018 revealed Staff B, LPN (Licensed Practical Nurse) documented she was called to the resident's room by Staff A CNA who stated the resident leg was cut. Staff B found the resident seated on the edge of the bed with soaked paper towels applied to the right calf and blood dripped down the leg and pooled on the floor. Staff called the physician and received an order to send the resident to the emergency room due to being unable to close the laceration at the facility due to the size and depth. The wound assessment dated [DATE] revealed the resident had a 10 cm (centimeter) by 5 cm by an undetermined depth laceration to the right lateral calf. Wound measurements estimated at time of injury due to needing to apply pressure to area to control bleeding. Area was red with noticeably ecchymosis. The Unity Point Health Emergency Department notes dated 6/5/2018 included: The patient presented to the ER with laceration to lateral aspect of right calf due to a fall at the nursing home. Staff reported they attempted to steri-strip and could not get bleeding under control. Per nurse, the patient is supposed to be assisted by two people when ambulating, but only one person ambulated her and that led to the patient falling. Physical Exam: 8 cm laceration to the lateral right lower leg that was arching, but slicing with straight wound edges, extending into the subcutaneous fat with no deeper structures visible. No deep sutures necessary. Observation on 8/31/2018 at 11:30 a.m. revealed the resident seated in the room in the recliner with feet up and a call light within reach. The wheeled walker sat near the resident. Two staff transferred the resident with a gait belt from the recliner to the wheel chair using extensive assistance. She wore Derma-Savers and blue boots on her lower extremities. On 9/4/2018 at 10:45 a.m. revealed a healed scar on her right lower, lateral calf and she wore Derma-Savers and blue boots on lower extremities. During an interview by phone on 9/4/2018 at 12:10 p.m. and in person on 9/6/2018 at 2:05 p.m. Staff A, CNA (Certified Nurse's Aide) revealed on 6/5/2018 at approximately 6:45 p.m. she prepared Resident #1 for bed. The resident suffered from skin tears so her arms and legs are to be protected. Staff A provided the resident with upper body care and pushed the wheel chair to the bed. Staff A put a gait belt on the resident and transferred the resident to the bed. The resident had no Derma-Savers on her legs. When Staff A transferred the resident to the bed, the resident gasped. Staff A lifted up the resident's pants and saw a laceration. Staff A called the nurse and two staff came. Staff A revealed she knew the resident required two staff to transfer but had seen other staff transfer the resident with one assist. Staff A indicated she had transferred the resident alone before even though the Care Sheet said two assist. When Staff A received training, she knew to go by the Care Plan. At the time the facility used resident Care Sheets and Resident #1 required assistance of two and a gait belt.

Based on clinical record review and staff interview, the facility failed to immediately separate one staff member from one resident after an alleged abuse allegation was made. (Resident #6). The facility census was 123 residents. Findings include: 1. The Minimum Data Set (MDS) completed on 5/26/17, identified Resident #6 with a Brief Interview of Mental Status (BIMS) score of 4 which indicated severe cognitive impairment and required extensive assistance for bed mobility, transfers, dressing and toileting. The care plan with a revision date of 5/17/17, indicated the resident will yell out at times during cares/rolling/wheeling in wheelchair. During interview on 8/1/17 at 1:20 p.m., Staff C, registered nurse, RN stated between 2:00 a.m. and 3:00 a.m. on 7/21/17, Staff A, certified nurse aide, CNA and Staff B, CNA came to her and reported they walked into Resident #6's room and saw Staff D, CNA with her hand over the resident's mouth. Staff C stated the resident did not like to be moved and cried out. Staff C stated she told both CNA's for just them to provide care for the resident for the remainder of the night. Staff C stated she did not feel the resident was in immediate danger so she waited until the Nurse Mentor, Staff E, came in at approximately 7:00 a.m. the morning of 7/21/17. Staff C acknowledged she should have texted the Nurse Mentor and asked Staff D to leave. Staff C acknowledged Staff D completed her shift that night.

Based on clinical record review and staff interviews, the facility failed to ensure resident's safety during transfers. Involved a resident that sustained a fall resulting in a fracture, intracranial hemorrhage and hospitalization for 1 of 4 residents sampled for review (Resident #2). The facility reported a census of 124 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 7 out of 15 on the BIMS (Brief Interview for Mental Status) test that identified severe cognitive impairment. The MDS indicated Resident #2 required the assistance of one staff member walking in his/her room and two staff members walking in the hallway. The MDS indicated Resident #2's balance was not steady and was only able to stabilize with staff assistance walking. The MDS indicated Resident #2's active medical [DIAGNOSES REDACTED]. The MDS indicated Resident #2 received antipsychotic and antidepressant medications daily. The MDS indicated no falls since admission to the facility. The Care Plan initiated [DATE] for Resident #2 identified risk for falls related to unaware of safety need, confusion, incontinence and a history of falls. The interventions encouraged the caregivers to push call light button to obtain assistance with transfers and walking on [DATE] and revised on [DATE]. The interventions also indicated Resident #2 transferred with the assistance on one person, a walker and a gait belt. An intervention dated [DATE] indicated when walking in room and hallway use the assistance of two persons, with second person to follow with wheelchair. An intervention dated [DATE] instructed the staff to use wheelchair for transfers to the toilet. According to the care plan a focus area for Resident #2 included Activities of Daily Living self-care performance deficit due to Dementia and cancer. The intervention initiated [DATE] and revised [DATE] directed the private duty caregivers to use the call light when Resident #2 needed to ambulate with a walker outside the room. Apply a gait belt and use assistance of staff to push a wheelchair behind. Toilet use required staff participation initiated on [DATE] and revised on [DATE]. Care Conference notes dated [DATE] at 2:30 p.m. noted comments included: discussed possibility of not using gait belt in room, therapy will assess and discussed scheduling walks to limit wait time. The facility's investigation noted Resident #2's medical [DIAGNOSES REDACTED]. Resident #2 was admitted on [DATE] to the CCDI (Chronic Confusion or Dementing Illness) cottage. Resident #2 previously lived at home with private duty caregivers. The family chose to continue with private duty caregivers on admission to the facility. On [DATE] Resident #2 fell in his/her bathroom. Resident #2 hit the back of his/her head and sustained a laceration to the back of the head. The facility sent Resident #2 to the emergency room per the family's request. Resident #2 was admitted to the hospital for the treatment of [REDACTED]. A Hospice Transfer Record dated [DATE] indicated the resident admitted to the facility with Senile Dementia used a walker and required stand-by-assistance. A History and Physical dated [DATE] noted Resident #2's medical [DIAGNOSES REDACTED]. The [AGE] year-old presented to the office for a follow up visit. The resident was hospitalized [DATE] with dysphasia and had a PEG (percutaneous endoscopic gastrostomy) tube placed. A cystoscopy completed on [DATE] revealed a cauliflower shaped bladder tumor. An MRI conducted on [DATE] revealed multi-level bulging disk and also some enhancement of the bone marrow in the lumbar spine with a question of spinal metastases. He/she was hospitalized on [DATE] with balance problems. He/she had [DIAGNOSES REDACTED] diagnosis, received a second opinion and the decision was made not to pursue aggressive surgery unless symptomatic or active bleeding. A physician placed him/her on Seroquel because of increased problems with agitation and hallucinations. A Progress Note dated [DATE] at 5:00 p.m. indicated Resident #2 was lowered to the floor in his/her bathroom by a private duty caregiver. Resident #2 reported his/her knee went out. The intervention instructed the private duty staff to call for assistance with toileting for the 72 hour post fall observation period. A Progress Note dated [DATE] at 6:45 p.m. indicated a private duty caregiver reported while transferring Resident #2, he/she became weak and was lowered to the floor. The resident reported his/her knee gave out. Skin assessment revealed a fading bruise to the mid-back from the previous fall. Intervention indicated the private duty care givers are directed to call for assistance during transfers for 72 hours. A Progress Note dated [DATE] at 3:23 p.m. indicated a private duty caregiver reported when walking back from the bathroom, Resident #2's right knee got weak and the caregiver lowered Resident #2 to the floor. Intervention indicated the facility requested a Physical Therapy screen for safe transfers. A Progress Note dated [DATE] at 2:40 p.m. revealed Resident #2 on the floor, caregiver reported Resident #2 was combing his/her hair when his/her right knee got weak and the caregiver lowered Resident #2 to the floor. Intervention instructed the staff to use a wheelchair for all transfers until therapy made recommendations. A communication request sent to Resident #2's physician by hospice services noted Resident #2 sustained three falls in the last two weeks due to his/her knees gave out. Staff and family request Resident #2 have physical therapy evaluation for safety and safe transfers. A physician's orders [REDACTED]. A Physical Therapy (PT) report dated [DATE] indicated Resident #2 experienced recent falls due to buckling of the right knee. PT staff demonstrated to hospice care aides how to transfer with wheeled walker, instructed to use gait belt. Staff to use one assist with wheeled walker and gait belt, and Resident #2 may walk with the assistance of two persons due to a history of the buckling of right knee. Recommendation by PT, instructed the staff to transfer Resident #2 with assistance of one with gait belt and wheeled walker and to walk Resident #2 in the room and in hallway with wheeled walker, gait belt and the assistance of two persons. Review of the private duty assessment care plan, Resident #2 ' s care needs included: DO NOT LEAVE (HIM/HER) ALONE AT ANY TIME! (HE/SHE IS A FALL RISK DUE TO POOR BALANCE! If need assistance, push the call button and staff from the facility will come and assist. [DATE]: Use gait belt for transfers. The resident is stronger in the morning and gets weaker as the day does on. When up walking, you don't need to hold on to him/her but stay close in case he/she loses his/her balance. Ambulation: [DATE]: the resident is an assist of one with walking in his/her room and 2 in the hallway. Transfers: transfer to wheel chair when taking to the bathroom. A Progress Note dated [DATE] at 11:14 a.m. noted the staff received a call from Resident #2's family/Power of Attorney, informed of change to two assist, GB (gait belt), walker with ambulation, OK to use W/C (wheelchair) for ambulation if Resident #2 requests. Family voiced concern the private duty staff was not knowledgeable regarding use of gait belts for safety purposes. Offered to provide some instruction to private duty staff by our staff to show how to use gait belt but cannot guarantee they will use it. Family voiced understanding of this. Homemaker service will make up a sign up sheet for private duty staff to ask for gait belt training. Sign up will be located in Resident #2 ' s room next to journal on desk. Care plan updated to include private duty staff to press call light button when Resident #2 is requested to ambulate with walker instead of wheelchair. When interviewed on [DATE] at 3:19 p.m. Resident #2's Power of Attorney stated he/she called the facility and requested the facility provide education to the private duty staff due to not all private duty staff are trained nursing assistants. A Hospice Care Plan dated [DATE] indicated Resident had difficulty finding words during conversation, was forgetful and had frequent episodes of confusion had an increase in weakness and had falls in the past month. A Hospice progress note dated [DATE] noted the resident was very forgetful. Resident #2 reported he/she often felt fatigued. Resident #2 ambulated short distances with assistance of one, walker and gait belt. A Progress Note dated [DATE] at 10:14 a.m. staff observed Resident #2 lying on the bathroom floor, walker near him/her and blood from a laceration on the back of the head and a small bump on the right frontal side of the head. According to the progress note staff observed the private duty caregiver with Resident #2 and he/she complained of pain to the right hip and shoulder area. Staff called the Primary Care Provider and received orders to transfer Resident #2 to the hospital for evaluation and treatment. The Transfer Form dated [DATE] indicated the resident sustained [REDACTED]. The emergency room (ER) Radiology report dated [DATE] at 1:03 p.m. for Resident #2 ' s right hip radiograph revealed a [DIAGNOSES REDACTED]. The fracture fragments are separated by several millimeters. A Hospital CT Scan (Computed Tomography) report dated [DATE] at 1:33 p.m. indicated Resident #2 sustained head injuries. These injuries included a subarachnoid hemorrhage in the right parietal region, a subarachnoid hemorrhage and apparent superficial hemorrhagic contusion in the region of the right sylvian fissure and hemorrhage and edema in the scalp at the injury site in the right posterior parietal region. A Hospital report dated [DATE] at 7:40 p.m. indicated the [AGE] year-old resident presented to the emergency room after a fall at the nursing home. Resident #2 was walking to the bathroom with the use of a walker and lost his/her balance. Resident #2 fell backwards, hit his/her head on a wall. According to the Hospital report Resident #2 complained of pain to the right hip. Tests revealed a small subarachnoid hemorrhage; however Resident #2's medications included Plavix (blood thinner) that placed Resident #2 at risk for increased bleed. Resident #2 was demented and oriented to person only. The examination revealed minimal swelling in the right thigh. Anticipated greater than two stay hospital stay with a palliative (comfort care) course of treatment to be discussed with family. The facilities Incident Report Log revealed Resident #2 fell on [DATE] and the facilities intervention instructed the private duty caregiver to push call button for staff assistance with toileting for 72 hours. Resident #2 fell again on [DATE] and the facilities interventions instructed the private duty caregiver to push call button for staff assistance with transfers for 72 hours. Resident #2 fell again on [DATE] and the facilities intervention was for physical therapy to evaluate. Resident #2 fell again on [DATE] and the facilities intervention was for the use of wheelchair for transfers until physical therapy made recommendations. Resident #2 fell again on [DATE] resulting in a fractured hip and subarachnoid bleed and the facilities intervention was to transfer Resident #2 to a hospital for evaluation and treatment and nursing staff to assist with mobility. When interviewed on [DATE] at 10:05 a.m. the Administrator stated Resident #2 admitted to the facility from home after he/she sustained a decline in his/her condition. Resident #2 received care from a private duty care service. The Administrator stated the private duty service had a separate care plan for Resident #2 ' s care. The facility did not provide orientation and/or training to or for the private duty caregivers. On [DATE] the private duty service sent a new caregiver to care for Resident #2. The caregiver believed when she assisted him/her to the bathroom, she needed to place the commode over the toilet. She had one hand on Resident #2's walker and used the other hand to move the commode when Resident #2 fell . According to the Administrator Staff D reported right away she made a mistake. When interviewed on [DATE] at 4:29 p.m. Staff D a private duty caregiver stated, on [DATE] she arrived at the facility to care for Resident #2. She received a one-hour orientation by another private duty caregiver. Staff D observed Resident #2 walk in the hall with the assistance of two people. Later Resident #2 requested to go to the bathroom. Staff D put on the call light, waited a couple of minutes. Resident #2 did not want to wait for help. Staff D applied a gait belt to Resident #2 and walked him/her to the bathroom with the use of a walker. Staff D held onto the front of the walker when she turned away from Resident #2 and attempted to position the commode over/on top of the toilet. Resident #2 fell backwards and struck his/her head. Staff D left the room to obtain assistance from the facility staff. When interviewed on [DATE] at 9:40 a.m. Staff A, Nurse Mentor stated as the nurse mentor, she was not informed and was not aware of the need to educate the private duty caregivers on the training and use of the gait belt. It was her understanding that private duty caregivers who are certified nursing assistants (CNA ' s) could provide cares, however if not certified, the facility staff provide care for resident ' s. Staff A denied knowledge of which caregivers are CNA ' s. Staff A stated, she believed Resident #2 fell and sustained injury due to the private duty caregiver was not appropriately trained to work with Resident #2 and was not informed of Resident #2's history of his/her knee buckling. Staff A stated the facility failed to provide the private duty caregivers any care plans or instructions on how to care for Resident #2. Staff A stated, there was a communication barrier between the facility and the private duty caregivers. On [DATE] the caregiver informed her she assisted Resident #2 to the bathroom. The caregiver had her hand on Resident #2's walker and tried to put the commode with the bucket over the toilet. Staff A commented as a result Resident #2 fell backwards. When interviewed on [DATE] at 10:20 a.m. Staff B Licensed Practical Nurse (LPN) stated, Resident #2 had about 10 to 15 different private duty caregivers. Staff B stated most of the private duty caregivers did not assist Resident #2 with toileting needs. Staff B stated all new private duty caregivers called facility staff for assistance when Resident #2 needed assistance with cares. Staff B stated, sometimes there was a gap in communication between the facility and the private duty caregivers. Staff B received a phone call from Resident #2's family that voiced concern regarding the wisdom of the private duty caregivers in the use of a gait belt. Staff B stated, she was unsure who was responsible to provide training to the private duty staff. Staff B stated the facility staff utilized care instruction sheets for resident ' s however the private duty staff never requested these instructions on how to care for Resident #2. When interviewed on [DATE] at 9:15 a.m. Staff C a private duty caregiver stated, she cared for Resident #2 in his/her home prior to admission to the facility and at the facility. Staff C stated Resident #2 had a history of [REDACTED]. Staff C stated Resident #2's ability to stand declined so caregivers had Resident #2 sit in the wheelchair while at the bathroom sink. Staff C stated, about a month prior to Resident #2's fall with fracture the facility informed her to begin using a gait belt. Staff C reported she felt it was much safer with the gait belt. Staff C stated when she used a gait belt, she always held onto the gait belt. Staff C stated, caregivers used two assistance with walking in the hallway due to the Resident #2 became weak and/or his/her knee buckled and he/she sat down quickly. Staff C stated, when Resident #2's knee buckled in the bedroom, Staff C steadied him/her and assisted Resident #2 to sit. According to Staff C Resident #2 utilized the toilet during the daytime and the commode at nighttime.