Every finding on record at MercyOne Centerville Medical Center

Based on observation, clinical record review and staff interviews, the facility failed to verify the dosage on a bottle of Morphine was correct when received from the pharmacy and failed to administer the correct dose of Morphine as ordered for one of four residents reviewed (Resident #1). The facility reported a census of 18 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 12 and had the following diagnoses: Diabetes Mellitus, Anxiety Disorder and COPD (Chronic Obstructive Pulmonary Disease). The MDS also identified Resident #1 to be totally dependent on staff for assistance with showers/baths, lower body dressing, putting on and removing footwear and required substantial/maximal assist with toileting, upper body dressing and personal hygiene. On [DATE] the Care Plan identified Resident #1 with the problem of risk of discomfort related to end of life process and directed the staff to administer pain medications as ordered if non-medication interventions were ineffective. Evaluate effectiveness of pain relieving medications.A review of the Physician Orders revealed an order dated [DATE] for Morphine Sulfate Oral Solution 10 mg/5ml (milligrams per milliliter). Give 1 ml by mouth every 4 hours as needed for air hunger.A review of the copy of the label on the plastic bag which contained the bottle of Morphine dispensed [DATE] had documentation of the following instructions: 100 ml bottle of Morphine Sulfate give 1 ml (2mg) every 4 hours as needed for severe pain or air hunger. Maximum dose 12 mg per day.A review of the copy of the label on the box which contained the Morphine revealed it was dispensed [DATE] with directions: 30 ml Morphine Sulfate solution 100 mg per 5 ml (20 mg/ml). Take 1 ml (20 mg total) every 4 hours as needed for severe pain or air hunger.A review of the Controlled Medication Utilization Record revealed the following:Medication Label - Morphine 20 mg/ml. Take 1 ml (20 mg) q 4 hours prn severe pain or air hungerDate received [DATE]Quantity received: 30 mls.A review of the Progress Notes dated [DATE] at 12:24 PM documented the resident complaining of not being able to breathe. Head of bed elevated with oxygen in place at 2 liters per nasal cannula. Oxygen saturation level 94%. The [DATE] Medication Administration Records revealed an order for Morphine Sulfate 10 mg/5ml give 1 ml q 4 hours as needed for pain or air hunger. Doses signed out as given on [DATE] at 12:24 PM, and [DATE] at 00:50 AM and 4:50 AM.A review of the Progress Notes revealed the following:On [DATE] at 00:50 AM Resident having labored breathing respirations 40 per minute. MS (Morphine Sulfate) given to assist with breathing.On [DATE] at 4:50 AM Resident sitting up in recliner. CNA reported that resident was complaining of back pain when in bed and was transferred from bed to recliner with Hoyer. This nurse informed resident regarding medication to assist with her breathing per communication board. Resident took MS (Morphine Sulfate) orally and sips of water following. Note resident had audible crackles in upper airway, continues to have labored breathing, oxygen on at 2 liters per nasal cannula. Oxygen saturation was 92%On [DATE] at 12:50 PM Morphine discontinued awaiting new order and lasix discontinued due to resident not having any output in her catheter bag. Vital signs 97.5-96-24-100/42. She has been lethargic, not having any output and not able to take anything in except a sip of water with morning dose of lasix.On [DATE] at 1:51 PM New order received and noted from the ARNP for Morphine 10mg/5ml to give 1ml 2mg oral solution every 4 hours PRN.On [DATE] at 1:44 PM This order is outside of the recommended dose or frequency. Morphine Sulfate Oral Solution 10 Give 1 ml by mouth every 4 hours as needed for air hunger This dose fails a general dose range check based on drug inputs and/or the patient information provided. This drug's dose should be adjusted based on renal function. Manual screening is required.On [DATE] at 1:55 PM Family here with resident called LPN to room as resident was not breathing, no pulse no respirations at 1:50 PM.A review of the Facility Incident Report dated [DATE] had the following documentation:Two nurses asked this nurse to look at Morphine orders for Resident #1 and directions on the bottle.Morphine ordered was 10 mg/5 mls concentration with directions to give 1 ml(2mg) very 4 hours as needed for air hunger or pain.Bottle dispensed from pharmacy was 20 mg/ml with directions to give 1 ml Q 4 hours PRN.The nurses reported the resident received 3 doses of the 20 mg/ml.ARNP who wrote the original order and the primary care physician were notified.A review of the Facility Process Change Alert Form dated [DATE] documented a process change for Morphine administration due to a medication error. The process change documented when accepting Morphine from the pharmacy to check it against the order. Prior to dispensing medication/order and container, two nurses will ensure accuracy, two nurses will verify amount of morphine in syringe is correct prior to administration and documented.In an interview on [DATE] at 2:16 PM, Staff A, LPN reported when a nurse receives a narcotic from the pharmacy, the following process should be followed: a nurse will accept all medications from the pharmacy. The nurse should compare what was being sent and what was actually sent, look at the dosage and quantity, look at the paper sent with drugs and make sure they are the same. When administering a narcotic, the nurse should check the resident, look at the order, dosage, proper drug, sign it out on the narcotic sheet and on the EMAR. When she administered Resident #1's Morphine on [DATE] at 12:24 PM, she admitted she looked at the EMAR, did not look at the dosage on the EMAR, did not check the concentration. The EMAR said to give 1ml it did not say how many milligrams. Resident #1 had labored breathing and complained of back hurting. Staff A looked at the bottle, the directions on the bottle and the directions on the narc sheet. They were both the same. They both said to give 1 ml which was 20 mg (this was printed on the label on the bottle 20 mg per ml). She checked the printed discharge paperwork from acute care and found the order for Morphine. She could not remember the exact order, or if it said give 1 ml or not. According to what she was reading, she thought she had a med error. She assessed Resident #1 and her vital signs were normal, she was comfortable, easy to awaken. Her breathing wasn't as labored, she said she was comfortable. After that she talked to the nurses in the hospital to show them the bottle and the discharge paperwork, they had assured her that she had given the correct dose and it was not unusual to give that dosage and they give that dosage. The next day on [DATE], the nurses talked to ARNP and she told us that the nurses gave the incorrect doses. She had received the 20 mg for a total of 3 doses. The ARNP confirmed the order was supposed to be 2 mg per dose. On [DATE] at 1:50 PM she was laying in bed, no heart, no respirations. She was [AGE] years old and admitted to hospice for end stage COPD. When asked how the error could have been prevented, she reported the pharmacy sent the wrong concentration with the wrong directions. She admitted she should have double checked the dose. The EMAR only showed to give 1 ml, but did not designate what the concentration was. Changes to the process in accepting Morphine from the pharmacy included: when Morphine is received, the nurses compare what was received against the actual order in the EMAR against the bottle. There has to be 2 nurses to double check the dosage. The nurses are to make a progress note when this is completed until they are able to adjust this in the EMAR.In an interview on [DATE] at 6:18 AM, Staff B, RN reported the process when a nurse receives Morphine from the pharmacy is as follows: when the pharmacy delivers it, only a nurse can accept the Morphine. She would view to make it is for the right resident and make sure it's the right medication. She would check it in the computer to make sure it's the correct medication. If there is a discrepancy, she would send it back with that pharmacy person and get clarification. When asked what the process is when giving a narcotic she stated when administering Morphine, she should make sure she has the right resident, right dosage, the correct time. With Morphine there have been different dosages, concentrations. She would check it against the order in the computer. When she administered the doses on [DATE] at 00:50 AM and 5:50 AM, she reported she went in and checked on her after rounds and her respirations were pretty rapid, O2 saturation (oxygen level) was 92% on 2 liters of O2. She was a little restless, her breathing was really labored at 40 per minute. She went to the med cart, pulled up the narcotic book and pulled up PCC. On the narcotic sheet, the dose was 20 mg/ml. She stated the house supervisor came over to assess her and determined that she could use the Morphine for the air hunger. Before she gave her the morphine at 00:50 AM and before the 2nd dose at 0450, she listened to her lungs and she was alert and talking. Her breathing was labored. Staff B stated she could not recall the actual the dose of Morphine that was ordered. The MAR had documentation to give Morphine 20 mg per ml and to give 1 ml every 4 hours as needed for air hunger and pain. She administered 20 mg. Staff B stated on [DATE], she was informed that Resident #1 expired early afternoon and that the wrong concentration of Morphine had been sent for her. The error could have been prevented by verification of the medication. She should have reviewed the actual documentation of the original order. She admitted she should have questioned if the 20 mg being a big dose for her. She was not sure what the normal dose would be for a hospice resident, would depend on history of taking narcotics in the past. She did work a lot with hospice residents. When asked if any changes made to the system for receiving Morphine from the pharmacy after this incident, she reported she had recommended to have someone else double check the order before giving the med and when receiving the Morphine from pharmacy. If there is any question, the nurse should call the physician to make sure she had the correct order and correct medication. The nurses are to make an entry on the nurse's note attached to the MAR to show the double check was completed.During an interview on [DATE] at 6:56 AM, when asked of Staff C, RN Night Shift Supervisor if he recalled checking on Resident #1 on the night of [DATE] , he reported she was asleep in bed, respirations were 40 per minute. He informed Staff B, RN about it and let her know her respirations were labored and if she had orders for Morphine to give it to her to help relax her breathing. He was not aware that Resident #1 received the wrong doses of Morphine that night. He was informed about it on [DATE] the next morning that pharmacy had dispensed the wrong concentration. When a nurse is preparing to give Morphine, the nurse should make sure it's the right patient, right dose, right medication, right time. The error could have been prevented if the nurse double checked the order, called the physician or hospice and questioned the 20 mg order.In an interview on [DATE] at 8:44 AM, Staff D, RN reported the process when receiving Morphine from the pharmacy is as follows: when pharmacy delivers, she would open the bag, remove the medication from the bag, it comes with a paper with what is sent, she would compare the bottle with what it says on the paper. Then she would take it to the nurse who has the cart and we would both look at it and make sure it's the right dose and put it in the narc box. She verified this was not the process when Resident #1's Morphine was delivered [DATE]. She verified that she was the one that signed the utilization record, however, did not think she was the one that accepted it from pharmacy. She could not recall what the dosage was on the bottle at that time. She was informed of the error on [DATE] when Staff A informed her that she made a medication error and gave Resident #1, 20 mg of Morphine. Staff D stated she should have received according to what the order read on the MAR Morphine 10 mg per 5 ml, give 1 ml which would been 2 mg. The box said 20 mg per 1 ml and give 1 ml. She gave 1 ml, but the dosage was wrong. She stated the Pharmacy made an error with the label and sending the wrong concentration. She recalled seeing the original orders. She thought the order was entered correctly into PCC in EMAR, but underneath it also said that what was sent by pharmacy that the dose. She stated to prevent a similar error, the nurse should double check the order with what was dispensed, make sure you have the right dose, make sure you have someone else double check it with you if you have doubts. She should've checked it with the house supervisor to double check it. Staff D stated the changes that were made after this incident were when the Morphine comes in, the nurse needs to double check with a second nurse, double check the actual bottle against the order and the utilization record and make sure everything is correct. After double checking, we document that in the progress note. The nurses need to double check with another nurse before administeringIn an interview on [DATE] at 12:30 PM, the DON reported when administering medications, she would expect the nurses to follow the 5 rights, verify the dosage was correct with another nurse for Morphine. When accepting Morphine from the pharmacy, she would expect the nurses to follow these steps: 2 nurses double check from the order in PCC (Electronic Health Record) against the drug. Any discrepancy, any question, the process needs to be stopped, contact the physician and the pharmacy. Two nurses need to verify the dosage against the MAR, just like they do for insulin. They would double sign in the narcotic book. She verified the original order for Resident #1 for the Morphine was 10mg per 5 mls and give 1 ml. When asked what could have prevented the error, she reported when Staff A, LPN accepted the medication from the pharmacy, she should have had another nurse double check and verify the dose of what was delivered against the PCC orders. Before it was given, it should have been double checked again before the nurse gave it. After Staff A, took the bottle itself and the order that came from the hospital transfer sheet to the nurse's station on Med/Surg where Resident #1 lived before coming to LTC. They verified that the 20 mg dose was correct as that what they gave. Staff A gave the 20 mg dose thinking she gave the correct dosage. The DON felt Staff A did not check it against the original order. Staff B, RN took what Staff A told her was correct and gave Resident #1 another 2 doses at almost 1:00 AM and 4:50 AM. She gave the 2nd dose because Resident #1 was still complaining of air hunger and pain. She added that it looks like the nurses failed to double check the dose against the order. It was correctly transcribed on the MAR. When Staff E, LPN came to work on [DATE], she pulled the Morphine out and verified it against the MAR and knew it wasn't right and that's when she called the physician and pharmacy to let them know of the error. She took medication out of service, wasted it and received new orders. She ended up expiring before she would get new orders.In an interview on [DATE] at 10:56 AM, the Pharmacist, reported when the pharmacy receives the order from the facility fax or electronic order the following process is followed: An order entry technician enters the order into our system. That order goes to a pharmacist that does an initial verification of the order, validating the order elements as well as doing a drug utilization review - allergies, reactions, those types of things. This then goes to the judication team, they would work the claim with insurance. At that point, the system will generate a label which the back end technician would then place label for that technician to fill the order by pulling the actual product from the shelf. Once the prescription has been filled and labeled, it will go to a pharmacist who will then verify the product against the label, to make sure what the label states against what has been filled. After that, it will go to the staging technician who scans it for delivery. Then the drug gets delivered to the facility by our delivery driver, obtains proof of delivery. The nurse who receives will sign for proof of delivery. This will then close the chain. When asked to explain the error for Resident #1's order for Morphine that was dispensed, she reported on [DATE], the order the pharmacy received was written for Morphine 10 mg per 5 ml and dispensed as 100 mg per 5 ml. Give 1 ml (20 mg) a 4 hours PRN severe pain. When asked what she felt could have caused the error she reported the error occurred at the initial data entry, the incorrect drug was selected. This is entered by the entry order technician. When asked if she felt this error could have been prevented, she reported she could not speculate that.In an interview on [DATE] at 11:51 AM, the ARNP (Advanced Registered Nurse Practitioner) reported the original order she wrote for Resident #1 on [DATE] when she was discharged from the hospital and admitted to LTC (Long Term Care) was for Morphine 10 mg per 5 ml and give 1 ml every 4 hours, PRN (as needed) for air hunger or pain. The maximum total dose for 24 hours was 12 mg. On [DATE], Staff E, LPN brought the box of Morphine and reported she did not think they received what she the ARNP ordered. The ARNP looked at the box and saw Morphine 20 mg per 1 ml. She verified that Staff E was correct, the ARNP did not order that dose. The ARNP called the pharmacist, she could not recall his name and asked her to read the order she sent and what did they dispense. The pharmacist reported they dispensed the wrong medication and were not aware of the error until the ARNP phoned them. The orders that she had sent to them was clear and showed that the order was for Morphine 10 mg per 5 ml and give 1 ml (2 mg) q 4 hours PRN. When asked what she felt Resident #1's cause of death was attributed to, she reported Resident #1 was declining and placed on hospice. She was pretty much not responding when she was admitted her to LTC. She was not conversing with the family, not eating, not drinking much. She was definitely declining. The ARNP called Staff E and instructed her to remove that Morphine from the area immediately.In an interview on [DATE] at 1:47 PM, Resident #1's Primary Care Physician reported she did not believe the cause of death for Resident #1 was due to the Morphine. The hospice nurse was the one that notified the physician. It was unfortunate that pharmacy sent the wrong dose. The dose should have been 2 mg instead of 20 mg. Resident #1's urine output was decreased starting the day before, her kidneys were starting to shut down. She was in the process of dying. A review of the Facility Policy titled: Drug Dispensing and Distribution dated as last revised [DATE] had documentation of the following:The pharmacist will verify the order in the hospital computer system, including review of the order.The technician will prepare any doses not available in the Automated Medicated Dispensing System as necessary. Prior to being sent to the nursing unit, all doses are checked by a pharmacist.Upon receipt of the medication, the nurse will compare the medication with the order on the MAR (Medication Administration Record) Discrepancies are clarified prior to administering the medication. The nurse will record doses given on the MAR.A review of the Facility Policy titled: Medications, dated as last revised [DATE] had documentation of the following:When the pharmacy is closed, the house supervisor or licensed designee will obtain the medications. An after-hours pharmacist is available to verify new medication orders via the electronic health record. The 5 patient rights are reviewed during medication administration. All medication are labeled by pharmacy personnel.

Based on initial kitchen tour observation, facility policy review and staff interview, the facility failed to ensure the removal of out dated nutritional supplement drinks from a dry good storage area in the kitchen in order to prevent the service and resident consumption of an unsafe, expired food product. The facility reported a census of 19 residents. Findings include: On 8/25/25 at 10:51 AM, during an initial tour of the kitchen, observation revealed a total of 13 Glucerna, a type of nutritional shake supplement, creamy strawberry flavor in 8 ounce individual serve cartons an expiration date of July 2025. The expired Glucerna drink was located on a dry storage shelf in kitchen with other supplement drinks, including other non-expired Glucerna flavors. The Dietary Manager confirmed the Glucerna in the creamy strawberry flavor had expired the end of July 2025. ON 8/26/2025 at 9:22 AM, the Dietary Manager reported dietary staff had removed the out dated Glucerna. The Dietary Manager explained Staff C, Dietary Aide, went through the supplements and looked for out dated product daily, but had over looked the creamy strawberry flavored Glucerna due to none of the residents being on that particular flavored supplement. Review of the facility policy, titled Food Safety, Temperature and Labeling, dated April 2026, revealed kitchen staff discarded any food item in storage after it's expiration date.

Based on clinical record review, policy review, and staff interviews, the facility failed to inform residents/resident representatives in advance of the risks and benefits of psychotropic medications for 5 of 5 residents reviewed for medications (Residents #3, #4, #10, #14, #18). The facility reported a census of 19 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 7/11/25, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety disorder, and diabetes. The MDS stated the resident took antipsychotics and antidepressant medications and listed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. The facility policy Gradual Dose Reduction and Use of Antipsychotics/Psychoactive Drugs revised 4/2023, stated staff would notify the resident/responsible party of the initiation, increase, or decrease of any psychoactive medications. The Order Summary Report listed the following orders:a. 5/13/25 sertraline (an antidepressant) 100 milligrams(mg) 1 tablet by mouth one time a day for depressionb. 5/19/25 trazodone (an antidepressant) 50 mg 0.5 tablet by mouth one time a day for mood c. 8/12/25 olanzapine (an antipsychotic) 5 mg 1 tablet by mouth in the morning for episodic behaviorsd. 8/12/25 olanzapine 10 mg 1 tablet by mouth in the afternoon for episodic behaviors The facility lacked documentation they provided the resident/resident representative, in advance, information regarding the risks and benefits of the above psychotropic medications. 2. The MDS assessment tool dated 7/21/25, listed diagnoses for Resident #10 which included anxiety, osteoarthritis (inflammation of the bone and joints), asthma, chronic obstructive pulmonary disease, or chronic lung disease (diseases which can cause shortness of breath/difficulty breathing). The MDS stated the resident received anti-anxiety and antidepressant medications and listed her BIMS score as 14 out of 15, indicating intact cognition. The Order Summary Report listed the following orders: a. 1/18/24 alprazolam (an anti-anxiety medication) 0.5 mg by mouth two times a day for anxietyb. 9/24/24 duloxetine (an antidepressant) oral capsule delayed release sprinkle 20 mg by mouth one time a day for depression The facility lacked documentation they provided the resident/resident representative, in advance, information regarding the risks and benefits of the above psychotropic medications. 3. The MDS assessment tool, dated 6/16/25, listed diagnoses for Resident #14 which included anxiety, depression, and low back pain. The MDS stated the resident received an antidepressant medication and listed the resident's BIMS score as 14 out of 15, indicating intact cognition. The Order Summary Report listed the following orders: a. 2/28/25 duloxetine oral capsule delayed release sprinkle 60 mg capsule by mouth one time a day for depression The facility lacked documentation they provided the resident/resident representative, in advance, information regarding the risks and benefits of the above psychotropic medications. On 8/27/25 at 3:22 p.m., the Director of Nursing (DON) stated she could not locate any consents for psychotropic medications. She stated she spoke with the pharmacist and they would assist her with completing them. 4. The MDS assessment for Resident #3, dated 6/23/25, identified the resident had diagnoses of chronic obstructive pulmonary disease, anxiety, and depression. The BIMS revealed a score of 15 out of 15 (indicative no cognitive impairment). The Clinical Physician Orders listed the following psychotropic medications (medications that affect mental processes and behaviors): a. Duloxetine delayed release sprinkle 60 mg capsule, give one capsule one time per day for depression, effective 4/10/25. b. Alprazolam 0.5 mg, give one tablet by mouth three times per day for anxiety, effective 3/27/25. The facility lacked documentation they provided the resident/resident representative, in advance, information regarding the risks and benefits of the above psychotropic medications. 5. The MDS assessment for Resident #18, dated 7/15/25, identified the resident had diagnoses of Hemiplegia (paralysis or weakness on one side) following cerebral infarct (stroke), insomnia, depression and anxiety. The Clinical Physician Orders listed the following psychotropic medications: a. Buspirone 5 mg tablet, give 5 mg by mouth three times per day for anxiety, effective 11/12/24. b. Sertraline 100 mg, give one tablet by mouth one time per day for depression, effective 10/1/24. c. Tylenol PM 500 mg-25 mg (Diphenhydramine) tablet, give one tablet by mouth, effective 4/15/24. The facility lacked documentation they provided the resident/resident representative, in advance, information regarding the risks and benefits of the above psychotropic medications.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to wear appropriate personal protective equipment (PPE) during personal cares for 2 of 2 residents (Residents #1 and#13) reviewed on Enhanced Barrier Precautions (EPB) and failed to clearly identify/carry out the correct level of infection control precautions for 1 of 1 residents reviewed for Transmission Based Precautions (Resident #3). The facility reported a census of 19 residents. Findings include:1. The Minimum Data Set (MDS) assessment tool, dated 7/15/25, listed diagnoses for Resident #13 which included arthritis, heart failure, and hypertension. The MDS stated the resident had 1 unstageable pressure ulcer and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The undated facility policy Enhanced Barrier Precautions, directed staff to carry out enhanced barrier precautions during high contact resident care activities such as wound care and catheter care. The policy directed staff to wear a gown and gloves. An 8/19/25 Health Status Note stated the resident had a raised area on his calf with a scant amount of bloody drainage. On 8/27/25 at 9:33 a.m., Staff D Licensed Practical Nurse (LPN) measured an area on the back of the resident’s left calf as 1.0 centimeters (cm) x 0.8 cm (length x width). The area had a scant amount of yellowish drainage. Staff A then measured an open area with a red wound bed in the resident’s intragluteal cleft as 0.1 cm x 0.4 cm x less than 0.1 cm depth. Staff D wore gloves but did not wear a gown during the measurements. On 8/27/25 at 1:09 p.m., Staff B LPN stated staff should follow enhanced barrier precautions (EBP) any time they completed catheter care or wound care. She stated with Resident #13, she would follow EBP guidelines including a gown and gloves. On 8/27/25 at 1:22 p.m., Staff D Licensed Practical Nurse (LPN) stated she did not wear a gown during Resident #13’s wound cares because she did not expect the wound to be draining. On 8/28/25 at 10:54 a.m., the Director of Nursing (DON) stated staff should wear a gown when completing catheter cares and wound cares. She stated if staff were in doubt, they should wear a gown. 2. The MDS assessment for Resident #1, dated 6/20/25, listed diagnoses of chronic obstructive pulmonary disease and fibromyalgia, required substantial or maximum assistance for personal hygiene and transfers, and was dependent on staff for toileting hygiene, bathing and dressing. The MDS identified the resident had an indwelling urinary catheter. The MDS listed a BIMS score of 7 out of 15, indicative of a moderate cognitive impairment. A physician order, dated 7/8/25, included an order for an 18 French Foley catheter with a 10 cubic centimeter (cc) (balloon device filled with a liquid to hold the catheter in place in the bladder). On 8/26/2025 at 10:06 AM, Staff D, LPN, and Staff F, LPN, entered Resident #1's room. Staff F donned a gown and gloves. Staff D donned gloves, but not a gown. Resident #1 was laying in bed on her right side facing the window. Resident #1 was noted to have a catheter and wore an incontinent brief. Staff D positioned herself on the resident's right side and Staff F was on the resident's left side. Staff D assisted Staff F with repositioning the resident on her back and raised up the resident's shirt. Resident #1 had a visibly excoriated areas on her right and left lower abdominal area. Staff D identified the excoriated areas as a yeast infection. Staff D placed one hand on the resident's abdomen and the resident's hand with her other hand while Staff F applied Clotrimazole antifungal medicated cream to the excoriated areas. Staff D pulled the resident's incontinent brief down and pushed the top front of the brief through the resident's upper thighs. Staff D then held the resident's thighs open while Staff F cleansed the resident's perineal area with a wet disposable wipe. Staff D helped Staff F to roll the resident to her right side, and Staff D held the resident in place by putting one hand on the resident's upper hip and another on the resident's buttock area. Resident #1's leg was noted to be touching Staff D's scrubs while Staff F used wet wipes to clean the resident's buttock area. Staff F rolled the incontinent brief under the resident and started a new brief. Staff F assisted Staff D to roll the resident to her back and then to her left side while Staff D removed the old brief and positioned the new brief in place. Staff F and Staff D repositioned the resident on her back, and Staff D pulled the new brief up between the resident's legs. Staff D and Staff F started to apply the resident's pants over her feet and Staff F pulled the catheter bag through leg of pants. Both staff rolled the resident to the right and left to pull her pants up and place the Hoyer lift (type of mechanical lift) vest under resident. Both staff placed socks and shoes on the resident. Staff F positioned the lift by bed and Staff D connected the lift straps to machine. Staff F removed her gown and gloves, completed hand hygiene, left the room and returned with the resident's wheelchair. Staff F gloved and operated the lift to raise the resident from the bed while Staff D held the resident's catheter bag. Once the resident fully raised off the bed, Staff D took over running the lift. Staff D positioned the resident over the wheelchair and lowered her. Staff D then clipped the catheter bag to the wheelchair. On 8/27/25 at 1:25 PM, Staff D reported she did not wear a gown during the observation of Resident #1's personal cares and transfer because she was not doing catheter cares. 3. The MDS assessment for Resident #3, dated 6/23/25, identified the resident had diagnoses of chronic obstructive pulmonary disease and diabetes. The MDS identified the resident had an indwelling urinary catheter. On 8/25/2025 at 11:34 AM, during initial tour of the nursing home, observation of Resident #3's room door revealed an EBP sign and personal protective equipment (PPE) supplies hanging in a bag on the door. Observation of Resident #3 revealed the resident to have a urinary catheter. Review of the electronic Clinical Physician Orders revealed an order, dated 6/10/25, to change the Foley catheter using an 18 French every 2 weeks. Review of the form, titled Resident Matrix, dated 8/25/25, revealed no residents to be identified on transmission based precautions. On 8/28/25 at 8:54 AM, the Infection Preventionist (IP) reported Resident #3 was currently on transmission based precautions (TBP) for a Vancomycin Resistant Enterococci (VRE) infection of the urine. The IP reported Resident #3 had been on the TBP, specially contact precautions, since 8/12/25. The IP reported this meant staff needed to wear gown and gloves for any contact with the resident. The IP reported the resident and DON were aware. The IP explained staff implemented EBP for urinary catheters, tracheostomies, feeding tubes and open wounds or ulcers including diabetic foot wounds, venous stasis ulcers, any open wounds or pressure ulcers. The IP reported PPE, including gown and gloves, should be worn by staff for personal hands on care, wound care or touching the medical device system. On 8/28/2025 at 9:25 AM, the IP and surveyor observed the signage outside of Resident #3's room. The IP confirmed staff had placed the wrong sign outside of Resident #3's which only identified the resident was on EBP. The IP changed the sign to identify the resident was on contact precautions. On 8/28/2025 at 9:49 AM, Staff B, LPN, reported she did not know the difference between EBP and TBP. Staff B was not aware if any residents on contact precautions. On 8/28/2025 at 9:51 AM, the DON reported being aware Resident #3 was on contact precautions since 8/12/25. The DON reported she had a huddle with the nurses present on 8/12/25 and asked nursing staff to take the PPE and sign to place on the resident's door. The DON reported being unaware that Resident #3 was not identified on the matrix as being on TBP, and the DON had been unaware that Resident #3's room had not correctly identified the resident as being on contact precautions. On 8/28/25 at 9:55 AM, Staff D, LPN, reported that none of the residents were on TBP. Staff D, LPN, reported that Resident #3 was on EBP. Review of the facility policy, titled Infection Prevention and Healthcare Epidemiology Isolation Corporate Policy, dated 4/2025, revealed transmission based precautions included contact precautions. Staff used contact precautions for known or suspected infections with epidemiologically important microorganisms, including VRE, that could be transmitted by direct or indirect contact. Contact precautions included the use of gloves, gown, mask/eye protection/face shield if resident care activities were likely to generate contact with splashing, secretions, excretions.

Based on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility failed to offer the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations (Resident #2). The facility reported a census of 19 residents. Findings include:On 8/28/2025 at 8:52 AM, the Director of Nursing (DON) reported that it was the responsibility of the Infection Preventionist to ensure the residents got their immunizations.On 8/28/2025 at 8:54 AM, the Infection Preventionist (IP) reported she had worked in her role at the facility for 11 years. The IP reported the facility followed CDC guidelines when offering immunizations to residents. The IP reported the DON and nursing staff were responsible for ensuring residents were offered and received immunizations. Review of CDC guidelines, dated 10/2024, revealed the following recommendations:Administer Prevnar 20 (PVC20), Prevnar 21 (PVC21), or Vaxneuvance (PVC15) for all adults 50 years or older who have never received any pneumococcal conjugate vaccine, or whose previous vaccination history is unknown.If a person received just Prevnar (PVC13) at any age, administer PVC20 or PVC21 one year or greater after the administration of PVC13.If a person received PVC13 at any age and Pneumovax (PPSV23) vaccine at age [AGE] or older, administer PVC20 and PVC21 5 years or greater after the last dose of PPSV23. Review of the clinical record for Resident #2 revealed the following:a. The Minimum Data Set (MDS) assessment, dated 7/9/25, identified an admission date of 10/13/14, the resident was over age [AGE], and had diagnoses that included major depressive disorder and magnesium deficiency. The assessment identified a Brief Interview for Mental Status (BIMS) score of 8 out of 15 (indicated a moderate cognitive impairment).b. On 8/28/25, review of Resident #2's immunization status revealed the resident received a dose of Pneumovax (PPSV23), dated 9/14/2010. The resident was over age [AGE] at the time of the PPSV23 dose administration. The clinical record lacked documentation of whether facility staff offered or administered Resident #2 a pneumococcal conjugate vaccine, Prevnar 20 (PVC 20), Prevnar 21 (PVC21) or Vaxneuvance (PVC15), per CDC guidelines. On 08/28/2025 at 11:58 AM, the IP confirmed Resident #2 should have been offered a pneumococcal vaccine based on the resident's previous pneumovax immunization in September 2010.Review of the undated facility policy, titled Long Term Care Vaccination Program, revealed, in accordance with CDC guidelines for immunization, nursing staff were responsible for screening residents on admission for pneumonia vaccination status, providing education on the risks and benefits of receiving the pneumococcal vaccine, documenting education and obtaining a signed consent/declination form.

Based on clinical record review, policy review, and staff interviews, the facility failed to adequately assess areas of skin impairment for 1 of 3 residents reviewed for skin concerns (Resident #4) and failed to document care planning and collaboration and communication with Hospice services for 1 of 1 residents reviewed receiving end-of-life care (Resident #2). The facility reported a census of 19 residents.Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 7/1125, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety disorder, and diabetes. The MDS stated the resident was at risk for developing pressure ulcers and listed Brief Interview for Mental Status (BIMS) score 9 out of 15, indicating moderately impaired cognition. The untitled facility policy, dated 2025, stated residents were reassessed on a quarterly basis or sooner if their physical status changed. a. A 3/21/25 Health Status Note stated (staff) removed the resident’s sock and found a bandage over a 0.5 centimeter x 0.5 cm area with erythema(redness) which measured 10 cm x 9 cm. A 3/21/25 Non-Pressure Skin Condition Report stated the resident had an abrasion on her right third toe. The facility lacked documentation prior to 3/21/25 of an assessment of the skin area and the application of the bandages. b. A 6/23/25 Health Status Note stated the resident had a bandage on the right forearm on 6/22/25 and 6/23/25. The resident had a 0.5 cm skin tear to the area. The facility lacked documentation prior to 6/23/25 of an assessment of the skin area and the application of the bandage. On 8/27/25 at 12:52 p.m., Staff A Certified Nursing Assistant (CNA)/Activity Director stated she applied bandages before to Resident #4 but notified the nurse of this. On 8/27/25 at 1:22 p.m., Staff D Licensed Practical Nurse (LPN) stated Staff A applied bandages and the nurses then assessed the area. On 8/28/25 at 10:54 a.m., the Director of Nursing (DON) stated CNA's were not allowed to apply bandages. She stated she heard that Staff A applied one to Resident #4 and she asked her not to do that and notify the nurse. 2.The Minimum Data Set (MDS) significant change in condition assessment for Resident #2, dated 4/9/25, and the quarterly MDS assessment, dated 7/9/25, identified a facility admission date of 10/6/2014, indicated the resident received hospice services, and identified diagnoses of major depressive disorder, edema (fluid retention), unspecified joint pain, and hypertension (high blood pressure). The MDS assessment, dated 7/9/25, included documentation of an assessed Brief Interview for Mental Status (BIMS) score of 8 out of 15 (indicative of a moderate cognitive impairment). a. Review of the the current Care Plan for Resident #2 revealed a last goal update of 9/5/24, and anticipated target completion dates of all goals for 10/21/25. The Care Plan failed to identify the resident received hospice services or include any interventions in relation to hospice. Review of the clinical record for Resident #2 revealed a hospice document, titled Team Care Plan, dated 6/11/25, revealed a hospice admission date of 3/25/25, identified diagnoses of major depressive disorder, chronic obstructive pulmonary disease (COPD), pain in the thoracic spine, and heart failure. The hospice care plan included orders for hospice nursing, hospice aide, hospice social worker and spiritual counseling services. Review of the clinical record for Resident #2 revealed a lack of documentation to indicate whether or not facility staff had included hospice in care planning. On 8/27/25 at 1:44 PM, the MDS Coordinator reported being responsible for completing all of the MDS assessments and care plans on residents. The MDS Coordinator reported being the person responsible for inviting hospice staff to the care plan meetings and reported hospice should be included in the invite for resident care plan meetings. The MDS coordinator reported either she or the Director of Nursing (DON) maintained contact with hospice and documented all contact with hospice in the clinical record. The MDS Coordinator denied maintaining any type of documentation to show evidence that hospice had been invited to participate in the care planning meetings for Resident #2. On 8/27/25 at 2:47 PM, the Hospice Registered Nurse (RN) for Resident #2 reported she had not received an invite to the resident's care plan meeting. The Hospice RN reported that hospice maintained documentation of all contact with the facility and had no documentation to support the facility had invited hospice staff to participate in care plan meetings. b. Review of the clinical record for Resident #2 revealed the following discrepancy in oxygen orders: An electronic health record (EHR) physician order entry, dated 10/16/23, revealed an order for oxygen to keep stats (blood oxygen saturation level) above 90 percent. A hospice document located in the resident's hard chart, titled Team Care Plan, dated 6/11/25, revealed a physician order for oxygen 5 liters continuous per nasal cannula for COPD/dyspnea (difficulty breathing) and an effective start date of 3/25/25. A scanned hospice document, titled Recertification Statement for Second 90 Day Period, dated 6/23/25 to 9/20/25, revealed an ongoing order for oxygen 5 liters continuous per nasal cannula. The EHR lacked documentation of an updated oxygen order to reflect the order initiated by hospice on 3/25/25. c. Review of facility progress notes related to oxygen administration revealed the following: A note, titled Health Status, dated 3/28/25, included documentation of oxygen (O2) on per nasal cannula @ 2 liters, O2 sat (saturation) 95 percent. A note, titled Health Status, dated 4/1/25, included documentation of O2 sat of 97 percent on 2 liters per nasal cannula. A note, titled Orders-Administration Note, dated 4/6/25 included documentation that the resident had oxygen saturation level of 90 percent on room air (RA) when placed in bed for the night. Oxygen applied and saturation 98 percent on 2 liters per nasal cannula. A note, titled Orders-Administration Note, dated 4/10/25 included documentation that the resident had oxygen saturation level of 88 percent. Staff documented they applied oxygen at 2 liters per nasal cannula. O2 sat now 92 percent. A note, titled Health Status, dated 4/17/25, included documentation the resident oxygen saturation was 93 percent on room air. A note, titled Health Status, dated 4/18/25, included documentation the resident oxygen saturation was 92 percent on room air. A note, titled Health Status, dated 4/19/25, included documentation the resident oxygen saturation was 96 percent on 2 liters of oxygen. A note, titled Health Status, dated 4/21/25, included documentation the resident was on 2 liters of oxygen. A note, titled Orders-Administration Note, dated 5/30/25 included documentation that the staff placed oxygen on the resident at 2 liters. A note, titled Health Status, dated 6/2/25, included documentation the resident was on 2 liters of oxygen. A note, titled Orders-Administration Note, dated 6/20/25 included documentation that the staff placed oxygen on the resident at 2 liters. A note, titled Health Status, dated 6/24/25, included documentation the resident had taken her oxygen off when resting. Resident O2 sat was 82 percent on RA. Oxygen applied at 2 liters per nasal cannula. O2 SAT now at 98 percent with oxygen on. Encouraged resident to leave oxygen on while resting in bed. A note, titled Health Status, dated 7/7/25, included documentation the resident oxygen saturation was 93 percent on room air. A note, titled Orders-Administration Note, dated 7/22/25, included documentation the resident had removed the oxygen. Staff assessed the resident's oxygen saturation level was 75 percent on RA and came up to 91 percent on oxygen 2 liters. d. On 8/27/25 at 2:47 PM, the Hospice RN reported not being notified of the following changes in condition and medication changes: A note, titled Health Status, dated 5/13/25, included documentation the facility Advanced Registered Nurse Practitioner (ARNP) rounded today and gave orders for Prednisone 20 milligrams (mg) 1tablet by mouth daily for 5 days. The Hospice RN reported facility staff did not make her aware of this order change. The facility's clinical record for Resident #2 lacked documentation the facility notified hospice of the medication change. A note, titled Health Status, dated 7/7/25, included the following documentation: VS (vital signs)-98.1 (temperature), 67 (pulse), 18 (respirations), 132/66 (blood pressure), 93% (oxygen saturation level) RA (room air). Resident with c/o (complaint of) I feel sick, everywhere before supper meal this shift et. (and) refused to eat anything. Afebrile. PRN (as needed) Zofran given with effectiveness. Resident with c/o burning with urination as well. Fax sent to PCP (primary care physician) with update. Fluids encouraged et. taken poor. Urine with foul odor et. dark in color. Call light in reach. The facility's clinical record for Resident #2 lacked documentation the facility notified hospice of the resident's change in condition. A note, titled Health Status, dated 7/8/25, included documentation the facility ARNP was at the facility on rounds and received new orders to discontinue Colace (a medication used to treat constipation). The facility's clinical record for Resident #2 lacked documentation the facility notified hospice of the medication change. The Hospice RN reported the hospice continued to have a current order for the resident to receive Colace 100 mg, one capsule by mouth every day. A note, titled Orders-Administration Note, dated 8/12/25, included documentation the facility Medical Director rounded at the facility and ordered to hold Magnesium (400 mg by mouth every day) and monitor gastrointestinal habits. The facility's clinical record for Resident #2 lacked documentation the facility notified hospice of the medication change. The Hospice RN reported the facility staff did not notify her on the resident's Magnesium being held due to episodes of diarrhea until 8/25/25. On 8/28/25 at 12:00 PM, the DON reported she coordinated and communicated with hospice through emails and phone calls. The DON reported it was her responsibility to review hospice orders and care plans. The DON was unaware of the discrepancy between hospice and facility oxygen orders. Review of the contract, titled Hospice Service Contract, with Resident #2's hospice, dated 7/30/23, revealed the facility agreed to provide care and services per the Hospice Plan of Care. Services included medication administration. The facility agreed to contact the hospice immediately for any significant change in condition and any clinical complications that could result in alteration in the Hospice Plan of Care (medications, treatments, care or services). The hospice RN was responsible for overall coordination of the resident's care. The facility agreed to designate one person who was responsible for the implementation of the agreement.

Based on observation, clinical record review, policy review, and resident and staff interviews, the facility failed to provide sufficient activities for 3 of 3 residents reviewed for activities (Residents #5, #6, and#18). The facility reported a census of 19 residents. Findings include: 1. The annual Minimum Data Set (MDS) assessment tool, dated 5/13/25, listed diagnoses for Resident #5 which included heart failure, anxiety, and depression. The MDS stated the following activities were very important to the resident: books, newspapers, being around animals, news, group activities, favorite activities, going outside for fresh air, and religious practices. The MDS listed the resident’s Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Long Term Care (LTC) Resident Activities, effective 1/2025, stated the facility would provide an on-going person centered activity program. An 8/15/25 Care Plan entry stated the resident would continue to attend activities twice per day. On 8/25/25 at 11:40 a.m., Resident #5 stated the facility provided an activity calendar but 50-75% of the activities did not occur because staff had to work the floor. She also stated there were never activities on the weekends. The June 2025 Documentation Survey Report V2 report stated the resident participated in activities on 6/2/25, 6/3/25, 6/4/25, 6/9/25, 6/11/25, 6/13/25, 6/17/25, 6/18/25, 6/19/25, 6/23/25, and 6/26/25. The July 2025 Documentation Survey Report V2 stated the resident participated in activities on 7/1/25, 7/2/25, 7/16/25, 7/17/25, and 7/24/25. The August 2025 Documentation Survey Report V2 stated the resident participated in activities on 8/5/25, 8/6/25, 8/12/25 and 8/26/26. The facility lacked further documentation of activities offered during the period of 6/1/25 to 8/27/25. On 8/27/25 at 12:52 p.m., Staff A Certified Nursing Assistant (CNA)/Activity Director stated she was unable to complete activities at times due to working the floor (as a CNA). She estimated that she could not complete 40% of the activities due to this. She stated weekend staff were supposed to complete activities but she was told this was not done at times. On 8/28/25 at 10:54 a.m., the Director of Nursing (DON) stated she wanted to complete a couple activities per day but that had not happened because the AD worked as a CNA. She stated they worked on hiring. 2. The annual MDS assessment for Resident #6, dated 3/25/25, listed diagnoses of non-Hodgkin lymphoma, macular degeneration (degenerative eye disease) and edema (fluid retention). The MDS stated the following activities were very important to the resident: books, newspapers, magazines, news, going outside for fresh air, and religious practices, and it was somewhat important to the resident to do her favorite activities. The MDS listed the resident’s BIMS score as 15 out of 15, indicating intact cognition. The quarterly MDS assessment for Resident #6, dated 6/23/25, listed the resident's BIMS score as 15 out of 15. The electronic form, titled Activities Quarterly/Annual Participation Review, dated 6/26/25, documented Resident #6 attended most mid-morning activities and the resident's favorite activities included dice, exercise, church and going outside on good weather days. The resident visited with family most afternoons. On 8/25/25 at 12:24 PM, Resident #6 reported that she liked to participate in activities offered by facility staff. Resident #6 reported she participated every day unless the Activity Director got pulled to the floor to help with resident cares. On 8/25/25 at 3:05 PM, observation of the dining room/activity room revealed the room was empty of residents and staff. In an interview, at the same time of the observation, the MDS Coordinator confirmed a group activity had been scheduled at 3:00 PM and would have taken place in the dining room. The MDS Coordinator reported no activities had occurred today (8/25/25) due to the Activity Director, Staff A, CNA, being scheduled to provide resident cares for the day. The MDS Coordinator reported the Activity Director was pulled away from activities and scheduled to work the floor as a CNA and provide resident cares a couple times per week. On 8/28/25, review of document, titled Task, dated August 2025, revealed Resident #6 had participated in activities a total of 5 days in August (8/5, 8/6, 8/12, 8/26 and 8/27/25). 3. The quarterly MDS assessment for Resident #18, dated 7/15/25, identified the resident had diagnoses of Hemiplegia (paralysis or weakness on one side) following cerebral infarct (stroke), insomnia, depression and anxiety. The electronic form, titled Activities Quarterly/Annual Participation Review, dated 7/18/25, documented Resident #18 attended some activities and the resident's favorite activities included dice, bingo, church, parties, going outside and visiting with people. Staff described the resident as a social butterfly. On 8/25/25 at 12:05 PM, Resident #18 reported she participated in some of the activities offered at the facility. Resident #18 reported there were times the Activity Director cancelled scheduled activities due to having to work on the floor (provide resident cares). Resident #18 reported the Activity Director cancelled activities two times last week (the week of 8/18/25), and then cancelled activities today (8/25/25) due to having to work on the floor. On 8/28/25, review of document, titled Task, dated August 2025, revealed Resident #18 had participated in activities a total of 5 days in August (8/5, 8/6, 8/12, 8/26 and 8/27/25).

Based on clinical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure nursing staff provided personal hygiene assistance to a dependent resident in a timely manner after an episode of bowel and urine incontinence for 1 of 1 resident's sampled (Resident #15) with a reported concern of delayed assistance in care. The facility reported a census of 19 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #15, dated 8/16/25, identified diagnoses of hemiplegia (paralysis on one side of the body) following cerebral infarct (stroke), hypomagnesemia (low magnesium level) and obstructive sleep apnea (difficulty breathing or loss of breath when asleep). The MDS assessment included a Brief Interview Mental Status (BIMS) score of 14 out of 15 (indicative of a mild cognitive impairment) and assessed the resident was dependent on staff for toileting hygiene, dressing and transfers, and required maximum assistance for personal hygiene. The Care Plan for Resident #15, last revised 8/25/25, revealed the resident had increased confusion at times and required extensive to total care with all activities of daily living related to dementia and impaired mobility. The Care Plan identified the resident had total bowel and bladder incontinence, was at risk for skin breakdown and required perineal care after each incontinence episode and should be toileted every shift.On 8/25/25 at 1:48 PM, during an interview with Resident #15 and their family member, Resident #15 reported he needed assistance from staff to move in bed and staff helped to reposition him every couple of hours. Resident #15 reported that he was a Hoyer lift (type of mechanical lift) for transfers and required an assist of two staff. Resident #15 reported being incontinent of bowel and bladder and identified that he used an incontinent brief. The resident reported one night, about one week ago, on either a Wednesday (8/20/25), or Thursday (8/21/25), staff did not come in and check on him during the night. Resident #15 reported that he had a large bowel movement (BM) and urinated a lot and laid in the BM and urine for 4 hours. Resident #15 reported Staff B, Licensed Practical Nurse (LPN), came in on the morning shift, found him soiled and cleaned him up. Resident #15 reported Staff B, LPN, was upset, told him that it was not acceptable to be left in BM and urine, and told him that she was going to talk with the staff responsible. Resident #15 reported being on fire from the urine and BM being on his skin and being mad that no one came in to check on him. Resident #15 was unclear on whether or not he used his call light. Resident #15's family member reported not being present, but confirmed the resident told the family member about the concern after it happened. On 8/26/25 at 2:25 PM, Staff B, LPN, reported she recalled the incident last week when she walked into Resident #15's room and found the resident incontinent of BM and urine. Staff B, LPN, was not sure which morning it happened, but reported she had worked on Wednesday (8/20/25), Thursday (8/21/25) and Friday (8/22/25) and started all three days at 6:00 AM. Staff B, LPN, reported she could smell the BM and urine when she walked into Resident #15's room. Staff B, LPN, reported the resident's call light was not on. Resident #15 told Staff B, LPN, that he had been incontinent of bowel and urine for 4 hours, no staff came to check on him, and he did not see his call light. Staff B, LPN, reported the call light was within reach of Resident #15, but slightly under the resident. Staff B, LPN, reported staff should have checked on Resident #15, and explained staff were supposed to do rounds on the residents between 3:00 AM and 4:00 AM. Staff B, LPN, reported the Director of Nursing (DON) had worked the floor starting at 2:00 AM on the morning it happened, but left prior to Staff B, LPN, getting to the facility at 5:45 AM. Staff B, LPN, reported that Staff E, LPN, worked nights, and was still present when Staff B started working on the floor at 6:00 AM. Staff B, LPN, reported she talked with Staff E, LPN, about the resident not getting checked and not getting incontinence cares. Staff B, LPN, reported that Staff E, LPN, told Staff B that Staff E thought the DON had checked on and took care of Resident #15. Staff B, LPN, reported Resident #15 could be an assist of one staff for personal/toileting hygiene. Review of the nursing schedule for August 2025 revealed the following: a. Staff B, LPN, worked Wednesday (8/20/25), Thursday (8/21/25) and Friday (8/22/25) starting at 6:00 AM.b. Staff E, LPN, worked Wednesday (8/20/25), Thursday (8/21/25) from 6:00 PM to 6:00 AM.c. The DON worked Thursday (8/21/25) from 2:00 AM to 6:00 AM. On 8/26/25 at 3:30 PM, the DON reported being unaware of a complaint voiced by Resident #15 of not getting his incontinence care done timely. The DON confirmed she had worked during the night one night last week. The DON reported Resident #15 was usually up off an on throughout the night, and the resident would use his call light. The DON explained the resident would take his continuous positive airway pressure (CPAP- breathing device used to help treat sleep apnea) machine off and put it back on, and the staff would try to bundle the CPAP application with the resident's incontinence cares. The DON reported the expectation that staff go up and down the halls and look in rooms to check on residents every 2 hours. The DON explained that staff helped all residents and were not assigned specific residents. On 8/26/2025 at 3:49 PM, the DON reported she had come in at 2:00 AM on Thursday 8/21/25. The DON reported the MDS Coordinator had gotten off at 2:00 AM when DON came on. The DON confirmed she worked with Staff E, LPN. The DON thought she might have left early, as soon as Staff D, LPN, and Staff F, LPN, came in. The DON reported a system of staff talking back and forth to let know who they had taken care of when working together. On 8/27/2025 at 6:12 AM, Staff E, LPN, confirmed she worked night shift and had worked until 6:00 AM on Thursday 8/21/25. Staff E, LPN reported on night shift the staff completed rounds on the residents every 2 to 3 hours. If a resident was a check and change (totally incontinent), they would check the resident and change them if needed during those rounds. Staff E reported that the residents often started to wake up around 3:00 AM and needed to go to the bathroom or needed to have their incontinent brief changed. Some residents liked to get up early, so they would start getting those residents up. Staff E reported that they were extremely busy from 3:00 AM until the end of their shift at 6:00 AM. Staff E explained that Resident #15 usually turned his call light on when he needed changed, but sometimes they had to wake him up. Staff E reported Resident #15 had episodes of confusion, or would be more out of it at times. On 8/21/25, Staff E confirmed she worked with the DON. Staff E reported being unaware that Resident #15 had not been checked or changed until Staff B, LPN, came out of Resident #15's room with the soiled linens. Staff E, LPN, explained that Staff B, LPN, told her Resident #15 complained that he had not been checked or changed and laid in BM and urine for 4 hours. Staff E reported she thought that the DON had checked on Resident #15, as she had been helping another resident. Staff E reported the DON had left early and she was unaware that Resident #15 had not been checked. On 8/27/2025 at 10:39 AM, Staff B, LPN, reported the condition of resident and appearance of the dried feces matched the resident's complaint that he had been incontinent for 4 hours. Staff B reported some of the feces had dried to the resident's skin and stained the linens. Review of the facility's policy, titled Scope of Service-Long Term Care Department, dated 12/2024, identified staff would provide whatever care was needed for each resident based on their assessment and care plan.

Based on clinical record review, resident and family interview, staff interview, hospice staff interview, and review of facility policy, the facility failed to ensure staff revised a resident's care plan to include hospice services within 7 days after the completion of a significant change in condition comprehensive assessment and failed to include hospice professional staff in the care planning process for 1 of 1 sampled residents reviewed for hospice services (Resident #2). The facility staff failed to include resident/family in the participation and development of their care plan for 1 of 1 residents reviewed for care planning participation (Resident #15). The facility reported a census of 19 residents. Findings include:1.The Minimum Data Set (MDS) significant change in condition assessment for Resident #2, dated 4/8/25, and the quarterly MDS assessment, dated 7/9/25, identified a facility admission date of 10/6/2014, indicating the resident received hospice services, and identified diagnoses of major depressive disorder, edema (fluid retention), unspecified joint pain, and hypertension (high blood pressure). The MDS assessment, dated 7/9/25, included documentation of an assessed Brief Interview for Mental Status (BIMS) score of 8 out of 15 (indicative of a moderate cognitive impairment).Review of the the current care plan for Resident #2 revealed a last goal update of 9/5/24, and anticipated target completion dates of all goals for 10/21/25. The care plan failed to identify the resident received hospice services or include any interventions in relation to hospice. Review of the clinical record for Resident #2 revealed a hospice document, titled Team Care Plan, dated 6/11/25, revealed a hospice admission date of 3/25/25, identified diagnoses of major depressive disorder, chronic obstructive pulmonary disease, pain in the thoracic spine, and heart failure. The hospice care plan included orders for hospice nursing, hospice aide, hospice social worker and spiritual counseling services.Review of the clinical record for Resident #2 revealed a lack of documentation to indicate whether or not facility staff had included hospice in care planning.On 8/27/25 at 1:44 PM, the MDS Coordinator reported being responsible for completing all of the MDS assessments and care plans on residents. The MDS Coordinator reported being the person responsible for inviting hospice staff to the care plan meetings and reported hospice should be included in the invite for resident care plan meetings. The MDS coordinator reported either she or the Director of Nursing (DON) maintained contact with hospice and documented all contact with hospice in the clinical record. The MDS Coordinator denied maintaining any type of documentation to show evidence that hospice had been invited to participate in the care planning meetings for Resident #2.On 8/27/25 at 2:47 PM, the Hospice Registered Nurse (RN) for Resident #2 reported she had not received an invite to the resident's care plan meeting. The Hospice RN reported hospice maintained documentation of all contact with the facility and had no documentation to support the facility had invited hospice staff to participate in care plan meetings.On 8/28/25 at 12:00 PM, the DON reported that hospice staff should be invited to the resident's care plan meetings. 2. The MDS assessments for Resident #15, dated 2/18/25, 5/19/25 and 8/16/25, identified diagnoses of hemiplegia (paralysis on one side of the body) following cerebral infarct (stroke), hypomagnesemia (low magnesium level) and obstructive sleep apnea (difficulty breathing or loss of breath when asleep). The MDS assessment, dated 8/16/25, included a BIMS score of 14 out of 15 (indicative of a mild cognitive impairment). On 8/25/25 at 1:48 PM, during an interview with Resident #15 and their family member, Resident #15 and the family member reported not being invited to care plan meetings and not participating in the care planning process. Review of the Care Plan for Resident #15 revealed facility staff last updated the Care Plan on 8/25/25.Review of the form, titled Plan of Care Meeting Attendance, for Resident #15 revealed documentation of care plan meetings, dated 11/19/24, 5/20/25, and 8/19/25. The meetings included documentation of staff signatures who were present for each of the meetings, but did not include the name/signature of the resident or the resident's family member. The Plan of Care Attendance form lacked documentation of a care plan meeting for the MDS assessment, dated 2/18/25.Review of the clinical record for Resident #15 revealed a lack of documentation of resident and/or family participation or refusal to participate in the care planning process and meetings. On 8/26/25 at 2:47 PM, the MDS Coordinator reported she invited residents to the care plan meetings. The MDS Coordinator explained that care plan meetings for residents were held in the DON's office, or if a larger location was needed, the meetings were held in the sunroom. The MDS Coordinator reported the DON sent the invite letter for care plan meetings to the family members. The MDS Coordinator reported only a handful of residents participated in the care plan meetings. On 8/26/25 at 2:50 PM, the DON reported sending out invitation letters to residents' family members for the care plan meetings, but did not have any documented evidence to show that she had sent the letters.Review of the facility policy, titled Comprehensive Care Plans, dated 7/2025, revealed facility staff would invite residents every 3 months to the care conference meeting by mail with the date and time in the letter. Others invited to the meetings could include family members and consultants. The Plan of Care must be reviewed/revised within 14 days of any significant change in condition, and not less than quarterly. Review of the facility's policy, titled Scope of Service-Long Term Care Department, dated 12/2024, identified staff would notify families of care conferences by letter. Staff, family, members of the interdisciplinary team were consulted and involved in the care planning conference.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the care plan identified diuretic (a medication which reduced fluid in the body) and antidepressant medications and failed to address the risk of skin impairment for a resident with a history of skin breakdown for 2 of 16 residents reviewed for care plans (Residents #10 and #17). The facility reported a census of 19 residents.Findings include:1. The Minimum Data Set (MDS) assessment tool dated 7/21/25, listed diagnoses for Resident #10 which included anxiety, osteoarthritis (inflammation of the bone and joints), asthma, chronic obstructive pulmonary disease, or chronic lung disease (diseases which can cause shortness of breath/difficulty breathing). The MDS stated the resident received diuretic and antidepressant medications and listed her BIMS(Brief Interview for Mental Status) score as 14 out of 15, indicating intact cognition. The facility policy Comprehensive Care Plans, effective 7/2025, stated Care Plans would include skin conditions and medications. The August 2025 Medication Administration Record (MAR) documented the resident received duloxetine (an antidepressant) and furosemide (a diuretic). Resident #10's Care Plan did not address the resident's diuretic or antidepressant medications or provide staff with information related to possible side effects to monitor. 2. The MDS assessment tool, dated 7/23/25, listed diagnoses for Resident #17 which included hemiplegia (paralysis on one side of the body), Parkinson's disease (a disease which caused tremors and lack of mobility), and muscle wasting. The MDS stated the resident was at risk for developing pressure ulcers and listed his BIMS score as 13 out of 15, indicating intact cognition. A Care Plan Focus area, revised 5/14/25, stated the resident was at risk for impaired skin integrity related to his suprapubic catheter (a catheter surgically inserted through the abdomen into the bladder to drain urine). The Care Plan did not address the resident's risk of skin breakdown on his coccyx (tailbone).An 8/13/25 Health Status Note stated the resident had an open area to the coccyx which measured 0.3 centimeters (cm) x 0.3 cm x 0.1 cm (length x width x depth). On 8/28/25 at 10:54 a.m., the Director of Nursing (DON) stated the care plan should address high risk medications and the risk for skin impairment.

Based on clinical record review, policy review, and staff interview, the facility failed to complete required Minimum Data Set (MDS) assessments for 2 of 16 residents reviewed (Residents #3 and #7). The facility reported a census of 19 residents.Findings include:1. Resident #7's electronic health record (EHR) MDS list, reviewed on 8/28/25, documented her 7/24/25 quarterly MDS was in progress. The facility MDS Transmission Policy and Procedure, revised 3/2015, stated the facility would ensure accurate completion and submission of federally required assessments including quarterly, discharge, and reentry assessments. On 8/27/25 at 1:50 p.m., the MDS Coordinator stated she was aware she did not complete the MDS assessments very well lately and said she did not get enough time for this. She stated she found one that was due “last month” that was not completed. On 8/28/25 at 10:54 a.m., the Director of Nursing (DON) stated staff should complete MDS assessments in the appropriate time frames. 2.The MDS assessment for Resident #3, dated 6/23/25, identified the resident had diagnoses of chronic obstructive pulmonary disease and diabetes. The Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15 (indicative no cognitive impairment). On 8/25/25 at 1:19 PM, the resident reported a recent hospitalization in July 2025. Review of the clinical MDS list for Resident #3 revealed a lack of an MDS to indicate the resident discharged to the hospital with an anticipated return or reentry to the facility in the month of July 2025. On 8/28/25, review of Progress Notes for Resident #3 revealed the following: a. A progress note, titled Health Status Note, dated 7/15/25, included documentation the resident transferred to the hospital emergency room on 7/15/25. b. A progress note, titled Orders-Administration Note, dated 7/16/25, included documentation the resident was admitted to the hospital on [DATE]. c. A progress note, titled Health Status Note, dated 7/21/25, included documentation the resident discharged from the hospital and returned to the nursing home on 7/21/25. On 8/28/2025 at 12:07 PM, the DON confirmed staff should have completed MDS assessments related to Resident #3's hospitalization 7/15/25 to 7/21/25, including a MDS for discharge with anticipated return and a MDS re-entry to the facility.

Based on clinical record review, resident interview, and staff interview, the facility failed to notify the State Long-Term Care Ombudsman of the hospitalization and discharge of residents for 2 of 2 residents sampled (Resident #3 and #23) with a hospitalization or discharge. The facility reported a census of 19 residents. Findings include:1.The Minimum Data Set (MDS) assessment for Resident #3, dated 6/23/25, identified the resident had diagnoses of chronic obstructive pulmonary disease and diabetes. The Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15 (indicative no cognitive impairment).On 8/25/25 at 1:19 PM, the resident reported a recent hospitalization in July 2025.Review of the clinical MDS list for Resident #3 revealed a lack of an MDS to indicate the resident discharged to the hospital with an anticipated return or reentry to the facility in the month of July 2025.On 8/28/25, review of Progress Notes for Resident #3 revealed the following:a. A progress note, titled Health Status Note, dated 7/15/25, included documentation the resident transferred to the hospital emergency room on 7/15/25. b. A progress note, titled Orders-Administration Note, dated 7/16/25, included documentation the resident was admitted to the hospital on [DATE].c. A progress note, titled Health Status Note, dated 7/21/25, included documentation the resident discharged from the hospital and returned to the nursing home on 7/21/25.The clinical record lacked documentation of notification of the State Long-Term Care Ombudsman.On 8/28/25 at 1:31 PM, the Administrator confirmed facility staff failed to notify the State Long-Term Care Ombudsman of Resident #3's hospitalization. The Administrator reported the facility did not have a policy to address notification of the State Long-Term Care Ombudsman.2. The MDS assessment for Resident #23, dated 7/27/25, indicated the resident was admitted to the facility on [DATE] and discharged on 6/27/25.A Progress Note, titled Health Status Note, dated 6/27/25, included documentation the resident discharged with hospice services to home with a plan to die at home. The clinical record lacked documentation of notification of the State Long-Term Care Ombudsman of the discharge for Resident #23.On 8/28/25 at 1:28 PM, the Administrator reported she and the Director of Nursing (DON) were unaware of the need to notify the State Long-Term Care Ombudsman of resident discharges and hospitalizations.

Based on clinical record review, policy review, and staff interviews, the facility failed to ensure staff dressed a resident in a dignified manner and utilized incontinent products appropriately for 1 of 2 residents reviewed for dignity (Resident #4). The facility reported a census of 19 residents.Findings include:The Minimum Data Set (MDS) assessment tool, dated 7/11/25, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety disorder, and diabetes. The MDS stated the resident was dependent on staff for lower body dressing and toileting hygiene and listed her Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating moderately impaired cognition. The facility policy Scope of Service-Long Term Care Department, revised 5/2019, stated the facility would maintain respect for residents. A Care Plan entry, revised 8/1/23, stated the resident required extensive assistance with all activities of daily living (ADLs). A Care Plan entry, revised 4/14/24, stated the resident required extensive assistance with dressing. On 8/27/25 at 12:52 p.m., Staff A Certified Nursing Assistant (CNA)/Activity Director stated she observed staff bring Resident #4 to the dining room after a shower in a nightgown with a lap blanket covering her legs. She stated she thought this was a dignity issue. On 8/27/25 at 1:09 p.m., Staff B Licensed Practical Nurse (LPN) stated she heard of a resident in the dining room with only a lap blanket covering the legs. She stated she educated the CNA regarding this. She stated she was aware that staff applied more than one incontinent product to Resident #4 such as a pull-up with a pad in it. Staff B stated she informed staff this was not appropriate and they did this because she soaked through. Staff B stated staff needed to change the resident more often (rather than placing double products on her). She stated she last saw this happen a couple of weeks ago. On 8/27/25 at 1:50 p.m., the MDS Coordinator stated she observed Resident #4 in the dining room with a shirt and a brief on and a blanket covering her. She stated she did not know why staff did this. She stated the resident threw the blanket off and she thought she should have pants on. She stated she also observed residents with double incontinent products on and stated she thought staff did this because they were heavy wetters. She stated she thought staff did this for convenience. On 8/28/25 at 10:54 a.m., the Director of Nursing (DON) stated staff should not bring residents to the dining room without pants and she was not aware that happened.

Based on observation, policy review, and staff interview the facility failed to follow infection control measures to prevent cross contamination during food service for 1 of 2 meals observed. The facility reported a census of 18 residents. Finding include: Observation of the noon meal service on 5/13/2024 at 11:50 AM revealed the following concerns: A. Staff D (Cook), did not wear gloves and handled buns with bare hands which she then served to residents. B. Staff D sneezed on her right arm while she held a plate of food in her left hand. She did not wash her hands then served the plate to a resident. A review of the facility provided policy titled Hand Hygiene revised on January, 2017 documented the following procedure: hands shall be washed before handling food, after sneezing, coughing, or blowing the nose. On 5/16/2024 at 10:27 AM, the Director of Food and Nutritional Services stated in the above situation staff should discard the food, wash their hands, and prepare a new plate of food for the resident.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to utilize a gait belt in order to ensure a safe transfer for 1 of 6 transfers observed (Resident #1). The facility reported a census of 18 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 3/16/24, listed diagnoses for Resident #1 which included a history of falling, anxiety disorder, and diabetes. The MDS stated the resident required substantial/maximal assistance for toilet transfers and listed the Brief Interview for Mental Status (BIMS) score as 3 out of 15, indicating severely impaired cognition. An 8/4/23 Post Fall Huddle Form/Variance stated staff heard the resident yell and found her sitting the floor next to her bed. 12/6/23 Health Status Notes stated staff heard the resident yelling and found her prone (on her stomach) on the floor near the bed. The resident bled from a laceration (cut) on the left forehead, transferred to the ER, and received 4 stitches. A 12/6/23 Post Fall Huddle Form/Variance stated staff heard the resident yelling and found her lying face down on the floor near the bed. The facility added a monitor to the room while in isolation. A 5/5/24 Post Fall Huddle Form/Variance stated staff heard the resident yelling and her alarm went off. The resident developed a goose egg and transferred to the ER. A 5/5/24 Health Status Note stated the resident admitted to acute care for a urinary tract infection (UTI) and acute kidney damage. On 5/14/24 at 12:54 p.m. Staff B Certified Nursing Aide (CNA) and Staff C CNA assisted the resident to stand up from the wheelchair and sit on the commode. The staff members did not utilize a gait belt. After the resident was finished, Staff B and Staff C each stood on one side of the resident and held her under her arms as she stood up. Staff B provided perineal cares (cleansing of private areas) and they pulled up her pants. The resident then took a few steps and sat down in her wheelchair. The staff members did not use a gait belt but there was one hanging on the wall by the bathroom door. Review of the Care Plan revealed the following: A 7/27/20 entry stated the resident was at risk for falls related to impaired mobility, a fluctuation in her ability to transfer, poor weight bearing at times, and an inability to follow directions related to lethargy (a lack of energy). An 11/20/21 entry stated the resident walked with staff assistance and a walker. The facility policy Falls Prevention, revised 4/2024, stated staff should use gait belts with any patient transfers based on risk factor category assessments. On 5/15/24 at 2:16 p.m., the Director of Nursing (DON) stated staff should utilize a gait belt with Resident #1.

Based on clinical record review and staff interview the facility failed to maintain accurate advance directive records for 2 of 16 residents reviewed (Residents #8 and #9). The facility reported census of 18. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had diagnoses of Coronary Artery Disease, Hemiplegia, and Cerebrovascular Accident (CVA). The MDS documented the resident scored 13 on a Brief Interview for Mental Status (BIMS) exam, which is indicated cognitively intact. Record review, on [DATE] at 02:15 PM, revealed the resident's chart did not contain the Iowa Physician's Orders for Scope of Treatment (IPOST). During an interview on [DATE] at 12:32 PM The DON looked in the chart unable to find the IPOST. The DON stated they would try to locate it. During an interview on [DATE] at 12:20 PM The DON stated she obtained a new IPOST. 47582 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 entered the facility on [DATE] and was admitted to Hospice Care on [DATE]. The MDS also documented a Brief Interview for Mental Status (BIMS) of 10 indicating moderate cognitive impairment. On [DATE] at 11:15 AM, during a record review of Resident #9's physical chart, it was noted the Iowa Physician Orders for Scope of Treatment (IPOST), documented a Do Not Attempt Resuscitation (DNR) choice for the Cardiopulmonary Resuscitation (CPR) category. The IPOST was signed and dated on [DATE] by Resident #9 and did not include the physician signature. The electronic health record (EHR) review revealed an active order for DNR code status dated [DATE]. On [DATE] at 12:40 PM, the Director of Nursing (DON) confirmed the IPOST for Resident #9 did not include a physician's signature. The DON further stated Resident #9 had a DNR code status and the IPOST had to be signed by the physician. The DON stated she was going to obtain the signature from the physician shortly. On [DATE] at 1:00 PM, the DON reported that she notified the physician and obtained a signature on IPOST for Resident #9. Review of the facility provided policy Advanced Directives revised on ,d+[DATE] documented IPOST is an official order from the physician and signed by the physician, resident and witness.

Based on observations, record review, and interviews the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of COVID-19 in accordance with the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommendations. The facility reported a census of 18. Findings included: 1. The CMS QSO-20-38-NH guidance dated 8/25/20 included guidance to ensure residents are maintaining social distancing during group activities and communal dining. The guidance directed when residents are outside of their rooms (who are not on Transmission Based Precautions) need to utilize a cloth face covering or facemask as part of source control. If a cloth facemask in not tolerated the resident may cover his/her mouth and nose with tissues. The residents must maintain 6 feet between each other, perform hand hygiene, and wear cloth face coverings. The Iowa Guidance on Phased Easing of Restrictions for Long-Term Care Facilities updated August 10, 2020 guided the facility to limit group activities, but some activities may be conducted in facilities not currently experiencing an outbreak with social distancing, hand hygiene, and use cloth face covering or facemask. Activities that require or encourage residents to handle the same object are prohibited. Residents may eat in the same room with social distancing (limited number of people at tables to ensure space of at least 6 feet). During an observation in the dining room on 9/8/20 at 12:09 p.m., revealed 13 Residents had lunch trays. The 3 tables near the window and into the dining room had a resident at each end of the table. The tables were spaced 3 feet between each table (2 floor tiles at 18 inches each). Although the tables only had 2 Residents at each table they were not spaced at least 6 feet from each other or from the other tables during the meal. 2. During an observation on 9/8/20 at 3:38 p.m., revealed 8 Residents in the Dining Room with the Activity Director. Each resident had their own ball. The Activity Director used a grabber to pick up the balls and returned them to each resident after each resident tossed them on to a board on the floor. The Residents were spaced in close proximity to each other. The group of 8 Residents and the Activity Director were spaced in a circle 12 feet in diameter. Although they all were wearing face masks they did not maintain social distance from each other. 3. During an observation on 9/9/20 from 3:26 p.m. to 3:59 p.m., revealed 5 Residents and the Activity Director sitting around two tables all wearing facemasks, but not 6 foot away from each other. They played a card game. They passed cards around to each other and when they had 4 of a kind they picked up the spoon in front of them. If they observed another Resident pick up a spoon then they picked up a spoon. All of the Residents touched the cards, as they passed them around the table. When they finished playing spoons, the Activity Director passed a bag of candy around. Each Resident reached into the bag and dug around to find a piece of candy and then passed the bag to the next person. The last Resident passed the bag to the Activity Director. The Residents exited the room without any hand hygiene. During an interview on 9/10/20 at 2:49 p.m., the Vice President of Patient Services acknowledged the Residents should maintain social distancing during meals and activities. During an interview on 9/10/20 at 2:49 p.m., with The Director of Nurses acknowledged she knew about the card game but did not know about the bag of candy being passed around with each resident getting their own candy out of the bag. 4. During observations on 9/8/20 at 12:00 p.m., revealed 13 Residents in the Dining Room. Two residents sat at each table, except one resident who sat at a table by herself. The tables were arranged in a row with one longer table by the back wall. The Residents seated at the smaller tables had only 36 inches between them. The two residents seated at the back table had at least 6 foot between them but those residents sat only within a couple of feet of the resident at an adjacent table. Three staff also sat next to residents who required feeding assistance, in addition to the thirteen residents in the dining room. 5. During observation on 9/8/20 at 3:35 p.m., revealed 8 Residents seated in chairs/wheelchairs in a circle in the Dining Room with the Activity Director. The Residents had less than a foot between each other, as they took turns throwing a ball at a board on the floor. 6. Observations on 9/9/20 at 7:20 a.m., revealed 9 Residents seated at tables in the Dining Room. The tables had 2 Residents seated at each table with 3 feet between Residents. 7. During observation 9/9/20 at 10:55 a.m., revealed 4 Residents seated at the Dining Room tables as the Activity Director read to the residents. The residents had less than 3 feet between each other. 8. During observation on 9/10/20 at 2:15 p.m., revealed the Long-Term Care Unit medication refrigerator had a large amount of ice buildup along the back wall of the refrigerator. Staff A (Licensed Practical Nurse) reported the nightshift staff cleaned and defrosted the medication refrigerator. During an interview on 9/10/20 at 2:25 p.m., the Director of Nursing (DON) reported she expected staff cleaned and defrost the medication refrigerator as needed. The DON confirmed the medication refrigerator had a lot of ice buildup and needed defrosted, and stated the night shift staff had the responsibility for cleaning and defrosting the refrigerator. A facility policy for Storage of Drugs dated 12/1/07, revealed facility personnel shall inspect nursing storage area for proper storage compliance on a regularly scheduled basis.

Based on record review, and interview, the facility failed to attempt non-pharmacological interventions prior to administrering anxiety medications for 1 of 1 sampled (Resident #12). The facility reported a census of 19. Findings include: 1. The Minimum Data Set assessment dated [DATE] documented Resident #12 had [DIAGNOSES REDACTED].#12 had moderate cognitive impairments. The MDS dated [DATE] documented Resident #12 required extensive assistance with bed mobility, transfers, and personal hygiene. The Care Plan dated 10/30/18 revealed Resident #12 had [DIAGNOSES REDACTED]. The care plan included the following non-pharmacological interventions: a. Attempt to redirect conversation. b. Resolve basic needs such as hunger, cold, pain, and bathroom. c. Offer television or music. d. Offer reassurance. e. Offer a fan, wet washcloth, or the removal of a blanket to help cool. Review of the (MONTH) 2019 and (MONTH) 2019 Medication Administration Records revealed Resident #12 had an order for [REDACTED].#12 received the [MEDICATION NAME] on 5/6/19, 5/24/19, 5/28/19, and 6/21/19. The Behavior Monitoring Sheet dated 2/25/19 listed interventions to attempt prior to the administration of an anxiety medication but stated this was not required for residents receiving Hospice services. During an interview on 6/25/19 at 1:43 p.m., the Director of Nursing stated it was her understanding it was not a requirement to document non-pharmacological interventions attempted prior to the administration of prn anti-anxiety medications for residents receiving Hospice services. Review of the clinincal record revealed the facility failed to attempt non-pharmacological interventions prior to administering the Lorazeapam.

Based on record review and interview, the facility failed to submit a Preadmission Screening and Resident Review (PASARR) to Ascend Management when 1 of 1 sampled (Resident #12) had a change in mental condition. The facility reported a census of 19. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #12 had [DIAGNOSES REDACTED]. The Notice of Negative Level 1 Screen Outcome dated 6/23/15 revealed Resident #12 had no mental disorders. The Medication Management without Psychotherapy note dated 3/20/18 revealed Resident #12 had a [DIAGNOSES REDACTED]. The Advanced Registered Nurse Practitioner visit notes dated 7/10/18 revealed Resident #12 had a [DIAGNOSES REDACTED]. The Care Plan dated 10/30/18 documented Resident #12 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented Resident #12 had [DIAGNOSES REDACTED]. The undated progress note revealed Resident #12 had increased anger and behaviors in (YEAR). The facility arranged psychiatric services for Resident #12. Resident #12 continued to see psychiatric services until 8/7/18. The Practitioner determined Resident #12 no longer needed follow-up visits. Review of the clinical record revealed the facility failed to submit a PASARR when Resident #12 had a change in condition. The PASSAR policy dated 5/2019 directed the staff to complete a new PASARR if a change of condition occurred. During an interview on 6/25/19 at 1:43 p.m., the Director of Nursing (DON) stated she was not aware she needed to resubmit a PASARR related to new [DIAGNOSES REDACTED].#12 had psychiatric services and was stable so she did not think this was required. During an interview on 6/27/19 at 9:40 a.m., the DON stated the facility submitted a status change report to Ascend Management.

Based on record review, observation, and interview, the facility failed to report an injury of unknown origin to the Department for 1 of 1 sampled (Resident #14). The facility reported a census of 19. Findings: 1. The Minimum Data Set (MDS) assessment dated [DATE] listed Resident #14 had [DIAGNOSES REDACTED]. Resident #14 had moderate cognitive impairments. The MDS dated [DATE] documented Resident #14 totally dependent on staff for bed mobility, dressing, toilet use, personal hygiene and bathing. The Care Plan dated 12/4/18 revealed Resident #14 required extensive assistance with activities of daily living. During an observation on 6/24/19 at 11:12 a.m., revealed Resident #14 had a 1-inch (length) by 2-inch (width) dark bruise below his right eye. Review of the Nurse's Notes dated 6/23/19 at 6:55 a.m., revealed Staff A (Nurse Aide) assisted Resident #14 out of bed at 6:55 a.m. and noticed Resident #14's right eye had swelling and a bruise. Staff A reported this to the charge nurse. The undated facility investigation revealed on 6/23/19 at 6:55 a.m. Staff A noticed Resident #14's right eye had swelling and a bruise. Staff B (Nurse Aide) reported she did not see the bruise at 5:30 a.m. when she assited Resident #14 with his shirt. During an interview on 6/26/19 at 8:08 a.m., the Director of Nurses (DON) reported the facility completed an investigation and did not determine the source of the injury. The DON suspected Resident #14 rubbed his eye, which resulted in the injury. The DON reported the facility did not reported the injury as they only report major injuries. The Patient/Resident Abuse-Investigation of Allegations policy revised on 10/2018 directed the facility to investigate unusual bruises and notify the State Agency of suspected abuse immediately. During an interview on 6/26/19 at 9:21 a.m., Staff A (Nurse Aide) reported she noticed the bruise on Resident #14's face and notified the nurse immediately. During an interview on 6/26/19 at 9:42 a.m., Staff B (Nurse Aide) reported worked the night shift prior and assisted Resident #14 to bed and cared for him throughout the night. Staff B reported she assisted Resident #14 at 5:30 a.m. Staff B had the light on in the room and did not observe a bruise at that time. During an interview on 6/26/19 at 10:00 a.m., the Director of Nurses stated she reported the injury to the State Agency. During an interview on 6/26/19 at 1:56 p.m., the Vice President of Patient Services acknowledged Resident #14 had a bruise in an unusual location. However, she did not think to report it.

The following deficiency relates to facility self reports -I and -I: Based on record review, observations, and interviews, the facility failed to provide adequate supervision for 3 residents (Residents #1, #2, #3). On [DATE], Resident #1 fell and fractured her jaw when she exited the front door and her wanderguard alarm failed to sound. Staff interviews revealed the facility staff were unaware of her exit. The facility did not implement/monitor safety provisions to ensure the safety of residents, placing their health and safety at an immediate jeopardy. The facility failed to ensure Resident #2 and Resident #3 received adequate supervision related to falls. The facility reported census of 20 residents. Findings include: 1. According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognitive skills for daily decision making. Resident #1 was independently ambulatory and required limited assistance with physical assist of one staff with dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. Resident #1's plan of care identified a problem with risk for falls and wandering behaviors with interventions which included: a. Wanderguard applied. ([DATE]). b. Wanderguard bracelet will be tested daily and wanderguard doors weekly ([DATE]). In an interview on [DATE] at 1:04 p.m. Staff A, certified nurse aide, stated on [DATE] during lunch, Resident #1 got up and left the dining room. All four staff working that day were in the dining room assisting residents. Staff A stated Resident #1 would usually walk to his/her room after meals and was walking good that day. About 10 minutes later they noticed several people rushing outside with a stretcher. Staff A looked outside and saw someone on the ground, but was unaware it was Resident #1. Staff A stated she later learned it was Resident #1. Staff A stated the door alarm never sounded as it usually does. Staff A stated a couple of months earlier she was walking with Resident #1 through the doors and the wanderguard at the doorway did not sound. Staff A reported this to the Director of Nursing and the bracelet was changed. Staff A stated the nurse checks the wanderguard door alarm with a device and was told the device checks the bracelet as well, but notes she has never seen a nurse check the bracelet. In an interview on [DATE] at 12:53 p.m. Staff B, licensed practical nurse, stated at lunch on [DATE] Resident #1 had got up and left the dining room. Resident #1 was walking good that day. It was not too much longer that Staff B received a call stating Resident #1 was found outside and had fallen. Staff B stated the wanderguard alarm never sounded. Staff B stated the emergency room department cut off the wanderguard bracelet and when it was tested , it did not activate the door alarm. Staff B stated every Friday the charge nurse is responsible for checking the wanderguard door alarms as well as the bracelet. In an interview on [DATE] at 1:19 p.m. Staff C, certified nurse aide, stated she was assisting other residents during lunch on [DATE] and never saw Resident #1 get up and leave the dining room, but noted that was not unusual for Resident #1. Staff C stated she later learned Resident #1 had went outside and fallen. No alarms sounded. Staff C stated each Friday the nurses check the doors and wanderguard doors to ensure they are working. Staff C stated she has never known a nurse to check the bracelet. In an interview on [DATE] at 2:33 p.m. with the paramedic, stated she was returning to the hospital after lunch and as she pulled into the parking lot saw an elderly women walking across the lot. The female made past the second island of grass before falling face first into the pavement. She immediately called (12:23 p.m.) for help and the female was taken to the emergency room . Radiology report [DATE] indicated Resident #1 sustained a left mandibular fracture. Observation of facility video of the front entrance noted Resident #1 was seen walking up the hall towards the front entrance at 12:11 p.m. Resident #1 stopped and sat on a bench at the doorway at 12:12 p.m. and a hospital staff member is seen stopping and talking to Resident #1 and then moving on at 12:13 p.m. At 12:14 p.m. Resident #1 is seen walking out the front entrance. According to the paramedic's cell phone, a call for assistance occurred at 12:23 p.m. In an interview on [DATE] at 10:50 a.m. the Director of Nursing (DON), stated the facility has no policy related to wanderguard use and periodic checking of the bracelet's functioning. The facility purchase 6 month bracelets and the DON marks on her calendar when the next bracelet is due. The DON stated Resident #1's wanderguard bracelet was last exchanged on [DATE] (date in which Staff A noted the bracelet was not activating the door alarms). The DON stated all doors, including the wanderguard doors are checked each Friday. Review of the manufacturer's instructions and the wanderguard bracelet Resident #1 was wearing at the time of the elopement on [DATE]. The bracelet model number was and according to the manufacturer's instructions that model was a 90 day bracelet, not 6 month as the DON had indicated. According to the DON it was activated on [DATE]. The bracelet would have expired its life expectancy by [DATE]. The manufacturer's instructions indicated there were 90 day and one year bracelets. There was no 6 month models noted. The manufacturer's instructions also noted wanderguard bracelets are to be tested daily and results recorded in the resident's record. In an interview on [DATE] at 2:00 p.m. Staff E, licensed practical nurse, stated every Friday wanderguard alarms at door ways are checked to ensure proper functioning. Staff E demonstrated using device and wanderguard door alarms functioned properly. Staff E stated before Resident #1's elopement on [DATE] there was no expectation for staff to check the wanderguard bracelet. Now the bracelet is checked every morning. Staff E demonstrated using the device to check Resident #1's bracelet and the bracelet was working properly and recorded in Resident #1's record. 2. According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9 indicating moderately impaired cognitive skills for daily decision making. Resident #2 was required limited assistance with transfers and ambulation and extensive assistance with dressing, toilet use and personal hygiene needs. Resident #2's [DIAGNOSES REDACTED]. Resident #2's plan of care identified a problem with risk for falls with interventions which included: a. Position change alarm to bed and chair in room. b. Body alarm at all times. ([DATE]) c. Mat with alarm placed on floor. ([DATE]) d. Sensor pad to recliner seat in room. ([DATE]) In an interview on [DATE] at 1:30 p.m. Staff A, certified nurse aide, stated on [DATE] it was very hectic. A water main had busted and they had ordered out pizza to be brought in for supper. Staff A was assisting residents to the dining room for supper, when Resident #2's spouse had escorted Resident #2 into the dining room. The spouse had the gait belt on backwards. Staff A took over and got Resident #2 to his/her chair. The spouse had not brought the tab alarm. Staff A started back to Resident #2's room to get the alarm and as called in to assist with another resident. Once finished, Staff A stated she had forgotten about the tab alarm for Resident #2. Staff A stated she was sitting at a table with her back towards Resident #2 and heard a family member telling Resident #2 to sit down. Staff A turned and Resident #2 was already standing. Staff A moved towards Resident #2, but before she could secure him/her Resident #2 started falling backwards into Staff A's lap and legs. Staff A summoned for help. Resident #2 was complaining of right hip pain. Resident #2 was sent to the emergency room and x-rays confirmed Resident #2 sustained a fractured pelvis. Radiology report dated [DATE] indicated Resident #2 with a mildly displaced fractures through the right superior and inferior pubic rami with normal alignment of hip joint. 3. According to Resident #4's Minimum Data Set (MDS) assessment with assessment reference date of [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognitive skills for daily decision making. Resident #4 requires extensive assistance with transfers, ambulation, dressing, toilet use and personal hygiene needs. Resident #4's [DIAGNOSES REDACTED]. Resident #4's plan of care identified a problem with risk for impaired mobility and potential for injury with interventions which included: a. Baby monitor in room so staff can hear him/her getting up. ([DATE]). b. Sensor pad applied to recliner seat with baby monitor so staff can hear alarm. ([DATE]) c. Sensor pad removed. ([DATE]) d. Sensor pad reinstated. ([DATE] e. Increased restlessness. Raising lift chair up and down with remote increasing fall risk. Continue to educate resident on not raising lift chair all the way or playing with the remote raising chair up and down. ([DATE]) f. Remove resident from recliner and move to wheelchair and bring to supervised area. ([DATE]) g. New non remote recliner brought in by family. ([DATE]) Incident report dated [DATE] at 1:45 p.m. Resident #4 was found sitting on the floor next to his/her recliner. The recliner was tipped over and in the standing position. No injuries noted. Resident #4 had raised the recliner by remote to a standing position. Intervention: Position change alarm reapplied to recliner. Incident report dated [DATE] at 5:15 a.m. Resident #4 raised recliner too high and slid out and pulled chair over on top of him/her. No injuries. Resident #4 had raised lift chair and found sitting on the floor with chair tipped. Sensor alarm and baby monitor in room We have talked with family about a different chair. In an interview on [DATE] at 9:40 a.m. the Director of Nursing (DON) stated Resident #4 had not had any falls in several months and on [DATE] she had the sensor pad alarm removed from his/her recliner. Two weeks later ([DATE]) Resident #4 lifted his/her recliner with the remote causing him/her to slide out of the recliner. The DON stated she reapplied the sensor alarm in his/her recliner. The DON stated they were aware of Resident #4's increased restlessness and his/her continued use of the recliner remote. The DON stated they considered unplugging the chair, but felt the recliner in a reclined position might be considered a restraint. Instead they tried educating Resident #4 to not use the remote. On [DATE] Resident #4 again slid out of his/her recliner when he/she remotely placed the chair in a standing position. The DON stated the family brought in a non remote recliner the following day. On [DATE], the facility abated the IJ when they started routine testing of checking Wanderguard bracelets (daily) ; and added documentation for monitoring on the treatment sheet. The facility educated staff of these changes. These findings lowered the IJ from a J severity level to an G with ongoing monitoring to ensure residents safety/supervision (including falls).

Based on observation, record review, staff interview, and facility policy, the facility failed to assess and provide interventions to prevent a nonstageable pressure ulcer from developing on Resident #4's right heel. Once it developed, staff failed to notify and update the resident's physician/podiatrist regularly and failed to employ infection control measures during a wound dressing change; the resident had already been treated for [REDACTED]. The facility reported a census of 19 residents. Findings include: 1. The Quarterly MDS (Minimum Data Set) assessment, with an assessment reference date of 07/08/2011, indicated Resident #4 had short term memory problems and moderately impaired decision-making capabilities. The assessment documented the resident had no functional limitations of range of motion for the upper and lower extremities. The MDS stated the resident required limited staff assistance for bed mobility and eating; extensive staff assistance for ambulating and transfers, and as totally dependent on staff for dressing, toilet use, and personal hygiene. The documentation identified the resident as at risk for pressure ulcers with an existing non-stageable pressure ulcer. The resident's [DIAGNOSES REDACTED]. A progress note dated 7/13/11 documented the resident scored 13 (low risk for pressure sore development) on a Braden Scale (skin assessment form), however, the resident had a non-stageable (indicating the presence of eschar or necrotic tissue over the wound which inhibits visualization of the wound bed) right heel pressure ulcer at that time. The resident's care plan dated 05/25/2011, identified the resident had potential for skin breakdown due to occasional bladder and bowel incontinence. Interventions included monitoring the resident's skin for redness and breakdown during cares, and the placement of a theraputic mattress. Nurses' notes dated 5/3/11 at 5:05 a.m. indicated staff had faxed the physician that the resident's heels were cracked, dry and sore. Staff requested an order to "stop the process and provide relief." A facsimile communication from the physician dated 5/3/11 at 12:40 p.m. revealed an order for [REDACTED]. (an egg crate overlay provides no pressure relief). The record revealed nothing further regarding the resident's heels until 6/7/11 at 3:30 p.m. That note revealed the resident had 4 black areas smaller than 1 millimeter on the resident's left heel; one of the areas surrounding skin appeared whitish yellow. On 6/7/11, staff took a photograph of the resident's right heel (not left) as documented in the nurses' notes. The accompaning wound assessment indicated the right heel had two blackened areas. One measured 1 centimeter (cm) by 1 cm, and the second area measured 0.5 cm by 0.5 cm. The information indicated the resident had dry cracked heels. There was no evidence the facility had notified the physician regarding the resident's right heel condition at this time. A nurses' note dated 6/27/11 at 3:45 p.m. indicated staff had notified the physician of the resident's dry, cracked right heel with 4 black areas measuring 0.5 cm in size that were tender to the touch. Staff documented requesting a podiatry consult, which the physician ordered, according to a nurses' note dated 6/28/11 at 3:50 p.m. Staff documented on 6/28/11 at 4:00 p.m. having scheduled a podiatry appointment for the resident to take place on 7/8/11 at 3:00 p.m. Staff documented the following interventions on the resident's care plan on 6/27/11: Request podiatrist consult, weekly photo of right heel, keep resident's right heel up off bed, and monitor the resident for pain/discomfort. Staff also documented that they had made the decision not to place a suspension boot on the resident due to a history of the resident getting up out of bed without assistance. A care plan entry on 6/30/11 indicated staff had applied an air mattress to the resident's bed, but had removed it due to fall risk concerns. A nurses' note dated 6/30/11 at 2:15 a.m. indicated the resident had either rolled into the side rails or tried to get up from bed because the air mattress allowed the resident to slide around the bed excessively when he/she tried to reposition self. Staff moved the resident to another bed for the remainder of the night. On 7/8/11 at 3:30 p.m., nurses' notes stated that orders had been received to treat the resident's right heel with mupirocic ointment, covered with an Allevyn cup dressing, from the podiatrist. The podiatrist's orders included an order for [REDACTED]. The podiatrist's progress note stated the resident had muliple wounds on the heel, all with fibrotci based, moderate serosanguinous discharge, and tender to the touch. The podiatrist ordered the wound on the resident's (right) heel to be cultured. Nurses' notes dated 7/9/11 at 1:15 p.m. documented staff had applied a "heels off" cushion on the resident's bed to elevate the resident's heels off the surface of the bed. A note later that afternoon at 3:10 p.m. indicated the resident continued to curl up and lay on his/her side in bed. On 7/10/11 at 1:55 p.m., staff documented the resident refused to use the heels off cushion, and removed the dressing from his/her foot. According to a laboratory report dated 7/11/11, the wound cultured positive [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant stapholoccus aureaus), a virulent pathogen. An earlier laboratory report dated 6/14/11 indicated the resident had an eye infection, also caused [MEDICAL CONDITION]. The facility received physician's orders [REDACTED]. Facility staff photographed the resident's right heel wounds on 7/15/11 at 8:20 p.m. According to the photograph and wound assessment information, the resident now had 3 separate blackened areas on the heel. Wound #1 measured 1.2 cm by 1.1 cm, wound #2 measured3.3 cm by 1.7 cm, and wound #3 measured 1 cm by 1 cm. Nurses' notes dated 7/20/11 at 9:00 a.m. indicated staff had updated the resident's physician regarding his/her heel. The physician examed the resident's heel that day and ordered arterial and venous doppler testing. A report dated 7/21/11 indicated the resident had no venous disease processes present, but did have moderate arterial obstruction in the right leg and mild obstruction in the left leg. On 07/21/2011, an update to the plan of care noted the resident demonstrated moderate arterial obstruction to the right leg according to a doppler study and facility staff concluded the right heel must be a stasis ulcer. According to the MDS manual, stasis ulcers are caused by [MEDICAL CONDITION], not arterial obstructions. Arterial ulcers do not typically present over a bony prominence such as the heels, but can occur on the tops of the toes. Pressure over a bony prominence causes pressure sores/ulcers. The plan of care, dated 7/12/11, described the resident as noncompliant with keeping his/her foot up off the bed and that he/she liked to lay on his/her side. An update on 7/22/11 directed staff to spsend the resident's heels off the bed and wheelchair as the resident will allow. The note indicated the resident removed the positioning devices and preferred to lay on his/her left side with his/her knees bent. The facility did not document any attempts to determine how the resident's right heel ulcers developed. According to orders dated 07/22/2011, the podiatrist discontinued the Mupirocin ointment and directed staff to treat the resident's heel ulcer with Iodosorb gel daily. The order directed the facility staff to suspend the resident's heel off the bed (not to touch any hard surface) and use heel cups. If the heels cups were not available, the podiatrist expected the facility staff to contact him for an alternate treatment/intervention. The same day, the podiatrist instructed the facility staff to place a pillow under the sheet on the resident's bed the facility staff documented the resident took the pillow out. The nursing notes failed to reflect any other interventions tried to keep the resident's feet off the mattress. On 07/23/2011 (8 days after the last wound documentation) the facility staff identified the right heel pressure area as an unstageable stasis ulcer and measured it at 4.0 centimeters by 2,0 centimeters. Staff described the wound bed as dry and red/black in color. A second wound sheet dated 07/23/2011 indicated area #1 measured 0.4 centimeter by 0.2 centimeter and a # 2 area measured 2.8 centimeter by 1.3 centimeter. 07/30/2011 at 9:30 a.m., staff only made out 1 wound sheet for the right heel pressure area. The area measured 1.3 centimeter by 0.3 centimeter and a #2 area measured 4.2 centimeter by 0.2 centimeter, was nonstageable with a wound bed red/black in color. 08/06/2011 the right heel pressure area measured 3.4 centimeters by 7.0 centimeters and no second area noted. On 08/13/2011, staff incorrectly identified the right heel as the left heel with a nonstageable ulcer that measured 8 centimeters by 3.8 centimeters (all the smaller areas had expanded into one heel ulcer that covered the entire posterior heel). During an observation on 08/16/2011 at 9:30 a.m.., Staff C measured the right heel pressure area and verbalized to the surveyor the area measured 7.8 centimeters by 3.7 centimeters. Staff C failed to document the right heel wound measurements anywhere in the resident's chart. The resident's medical record failed to show any notification to the podiatrist or to the physician concerning the constantly enlarging areas since 07/22/2011. During observations on 08/15/2011 at 1:10 p.m., 2:35 p.m., and 4:00 p.m., Resident #4 laid on the bed with nothing between his/her feet and heels and the mattress. The mattress was a plain foam mattress. At 10:20 a.m., the resident sat in a wheelchair in the dining room area. Black foam covered the foot pedals on three sides. Slipper socks covered the resident's feet. An observation on 08/16/2011 at 7:10 a.m. found Resident #4 in bed without any heel protection of any kind between his/her heels and the mattress. During an observation on 08/16/2011 at 9:50 a.m., Staff C and Staff F entered Resident #4's room and donned gloves without first washing their hands. Resident # 4 rested on the bed in a supine position, and still had no heel protection of any kind. Staff F assisted in elevating the resident's right leg/heel off the mattress. Staff C removed the dressing covering the right heel and changed gloves. After wetting a wash cloth with only water, Staff C rubbed the wet cloth around and around the surface of the necrotic heel spreading germs all around the wound area and dried the heel with a towel. Staff C changed gloves and applied the Iodosorb gel with a Q-tip, applying the gel to the end of the Q-tip and wound 3 times, contaminating the gel ointment and the wound. After applying the dressing and slipper sock, Staff C and Staff F removed their gloves and left the room without washing their hands. Both used the hand sanitizer in the hallway. Staff C failed to explain to the resident the need to keep the heels off the mattress during the above observation. **The surveyor observed the resident's left leg around the Achilles tedon. The resident displayed a dry white scabbed area of approximately 1.5 centimeters by 0.5 centimeters. Staff C paid no attention to the area. At 7:20 p.m. on 08/16/2011, the resident laid in bed with no heel protection between the heels and the mattress. An observation on 08/17/2011 at 3:20 p.m., revealed an egg crate mattress now covered the resident's mattress. A circular foam pad (intended to fit around the resident's lower leg) laid on the bed. Observations on 08/18/2011 at 10:35 a.m. and 3:10 p.m., Resident # 4 laid in the bed with his/her heels over the edge of the bed. During an interview on 08/17/2011 at 11:38 a.m., Staff C, licensed practical nurse, confided she had never received any training on assessing and documenting pressure ulcers since working at the facility. Staff C verbalized having worked in the facility for many years and did not really know to stage or identify pressure ulcers. During an interview on 08/18/2011 at 3:20 p.m., Staff B, the long term care supervisor, verbalized not knowing why the left 1.5 centimeter by 0.5 centimeter area on the back of Resident # 4's left Achilles tendon area did not have skin sheets or other documentation/assessments of the area. The facility's Corporate Policy for Pressure Ulcer Prevention, with an annual review date of 06/2011, directed facility staff to complete skin assessments on admission and at defined intervals. The assessment should include the Braden Scale, a nutrition assessment, skin assessment (especially vulnerable points of pressure for bed/chair bound residents, and individual risk factors. Equipment such as a pressure redistribution mattress and chair cushion, heel suspension boots, heel and elbow protectors, positioning devices, and products for moisture management should be considered. Education for the facility staff and the resident should be completed.