Every finding on record at Mississippi Valley

Based on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to complete an informed consent prior to the administration of psychotropic medications for 5 of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #7) residents reviewed for unnecessary medications. The facility reported a census of 54 residents. Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed a list of diagnoses which included anxiety, depression, post-traumatic stress disorder (PTSD), tracheostomy status and dependence on a respirator status. The Medication section of the MDS indicated Resident #1 prescribed high-risk drug antipsychotic, antianxiety, and antidepressant medications. The MDS listed an admission date of 8/21/25. Review of the electronic health record (EHR) Physician Order Report revealed Resident #1 prescribed the following:a. Seroquel (an antipsychotic medication) prescribed daily for PTSD. Start Date: 1/26/26 for 100 mg (milligrams)/1 tab at bedtime; and 2/14/26 for 25 mg/1 tab twice daily.b. Buspirone (an antianxiety medication) prescribed daily for generalized anxiety disorder (GAD). Start Date: 10/2/25 for 15 mg/1 tab three times daily.c. Citalopram (antidepressant medication) prescribed daily for depression, unspecified. Start Date: 3/13/26 for 20 mg/1 tab daily.d. Lorazepam (antianxiety medication) prescribed as needed for anxiety. Start Date: 3/28/26 for 0.5 mg/1 tab every 6 hours as needed. End Date: 4/11/26.During an observation on 5/20/26 at 8:07 AM, Resident #1 in his room, laid on his left side resting in bed. No concerns noted.During an interview on 5/20/26 at 8:34 AM, the Director of Nursing (DON) stated Consent forms are located in the Resident Document section, under consents of the EHR. The DON stated Consent forms may also be on a written form. A review of the Resident #1's EHR Progress Note and Resident Document sections from the admission date of 8/21/25 to current resulted in no Consent forms related to the education of risks and benefits of psychotropic medications found. During an interview on 5/20/26 at 1:15 PM, Staff A, Registered Nurse (RN) stated when a provider ordered a resident new psychotropic medication (antidepressant, antianxiety, antipsychotic), the nurses typically provided education on the risks and benefits to the resident or the legal representative, then documented the education in the Progress Notes. During an interview on 5/20/26 at 1:30 PM, Staff B, Licensed Practical Nurse (LPN) reported nurses provided the education on psychotropic medication risks and side effects when a new order is given. Staff B stated sometimes the Administration or the Infection Preventionist has already provided the education, and they [nurses] just need to inform the resident of the new order. They document the education in the progress notes. During an interview on 5/20/6 at 1:35 PM, the Infection Preventionist (IP) stated that she generally checked the physician orders over for the correct time, medication, and diagnosis. The IP stated that she has done education with the resident/family on risks of psychotropic medications but not that often. She explained the education is documented in the progress notes. The IP stated a lot of times the Social Services Coordinator gets involved. During an interview on 5/20/26 at 1:50 PM, the Social Services Coordinator reported she is not involved in providing education on the benefits and risks of using psychotropic medications. During an interview on 5/20/26 at 2:15 PM, Staff C, LPN explained the nurse's provided education to the resident or the family on what medication the physician ordered, why the medication was ordered, and answer any questions the family may have regarding the medication. Staff C added, the nurses do inform the resident/family if there are side effects and the conversation is documented in the Progress notes. 2. Review of Resident #2 MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The list of diagnoses included adjustment disorder with mixed disturbance of emotions. The Medication section of the MDS indicated Resident #2 prescribed high risk antianxiety and antidepressant medications. The MDS listed an admission date of 3/30/26.Review of the EHR Physician Order Report revealed Resident #2 prescribed the following: a. Clonazepam (antianxiety medication) prescribed daily for circadian rhythm sleep disorder. Start Date: 3/30/26 for 0.5 mg/1 tab at bedtimeb. Escitalopram oxalate (antidepressant medication) prescribed daily for adjustment disorder with mixed disturbance of emotions and conduct. Start Date: 3/30/36 for 10 mg/1 tab daily.c. Mirtazapine (antidepressant medication) prescribed daily for major depressive order. Start Date: 3/30/36 for 30 mg/1 tab at bedtime. During an observation on 5/20/26 at 8:19 AM, Resident #2 laid in bed resting on his right side. No concerns noted.A review of the Resident #2's EHR Progress Note and Resident Document sections from the admission date of 3/30/26 to current resulted in no Consent forms related to the education of risks and benefits of psychotropic medications found. 3. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. The list of diagnoses included anxiety and post-traumatic stress disorder (PTSD). The Medication section of the MDS indicated Resident #3 prescribed high risk antianxiety and antidepressant medications. The MDS listed an admission date of 11/14/23. Review of the EHR Physician Order Report revealed Resident #3 prescribed the following:a. Diazepam (an antianxiety medication) prescribed daily for obsessive compulsive disorder. Start Date: 2/8/25 for 5 mg/1/2 tab daily. Discontinue date: 4/6/26. Start Date: 4/6/26 for 5 mg/1/2 tab daily.b. Paroxetine Hydrochloride (an antidepressant medication) prescribed daily for obsessive compulsive disorder. Start Date: 12/6/24 for 10 mg/4 tabs daily. End Date: 4/6/26. Start date: 4/6/26 for 10 mg/4 tabs daily.During an observation on 5/20/26 at 2:10 PM, Resident #3 in her room with her privacy curtain pulled and stated she didn't want to talk or see anyone. A review of the Resident #3's EHR Progress Note and Resident Document sections from 8/1/25 to current resulted in no Consent forms related to the education of risks and benefits of psychotropic medications found. 4. Review of Resident #4's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. The list of diagnoses included respiratory failure, tracheostomy status, dependence on a ventilator status and dependence on supplemental oxygen. The MDS listed an admission date of 2/25/25.Review of the EHR Physician Order Report revealed Resident #4 prescribed the following:a. Buspirone (an antianxiety medication) prescribed daily for anxiety disorder. Start Date: 5/14/25 for 10 mg/1 tab three times daily.b. Citalopram (an antidepressant medication) prescribed daily for depression. Start Date: 5/14/25 for 10 mg/1 tab daily. c. Diphenhydramine Hydrochloride (commonly used as a sleep aide) prescribed as needed for anxiety. Start Date: 5/14/25 for 25 mg/1 tab every 6 hours as needed.d. Trazodone (an antidepressant medication) prescribed daily for depression. Start Date: 1/23/26 for 50 mg/1/2 tab at bedtime. A review of the Resident #4's EHR Progress Note and Resident Document sections from 8/1/25 to current resulted in no Consent forms related to the education of risks and benefits of psychotropic medications found. During an interview on 5/20/2026 at 2:11 PM, Resident #4 shared she didn't recall anyone talking to her about the risk or side effects of her antianxiety or antidepressant medications and she had taken the medications for a while. Resident #4 stated she gets pretty anxious and short of breath a lot. Resident #4 observed lying in bed on a mechanical ventilator with supplemental oxygen running. 5. Review of Resident #7's MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. The list of diagnoses included of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), tracheostomy status, dependence on a ventilator status and dependence on supplemental oxygen. The MDS Medication section indicated Resident #7 prescribed high risk antianxiety and antidepressant medications. Review of the EHR Physician Order Report revealed Resident #7 prescribed the following:a. Venlafaxine (antidepressant medication) prescribed for generalized anxiety disorder, Start Date: 4/21/26 for 37.5 mg twice daily. b. Ativan (an antianxiety medication) prescribed for generalized anxiety disorder. The Start Date/Discontinue Dates for Ativan in April 2026 were for:1. 4/4/26 go 4/8/26 - 1 mg/1 tab every 6 hours as needed.2. 4/8/26 to 4/16/26 - 1 mg/1 tab every 6 hours as needed.3. 4/16/26 to 4/21/26 - 1 mg/1 tab every 6 hours as needed.4. 4/21/26 to 4/24/26 - 1 mg/1 tab every 6 hours as needed.5. 4/24/26 to 4/28/26, frequently changed to every 3 hours per 4/24/26 Progress noteDuring an observation on 5/20/26 at 8:06 AM, Resident #7 lying in bed resting. No concerns noted. A review of the Resident #7's EHR Progress Note and Resident Document sections from 8/1/25 to current resulted in no Consent forms related to the education of risks and benefits of psychotropic medications found. During an interview on 5/20/26 at 2:44 PM, the DON) reported she had looked in the Progress Notes for each resident (#1, #2, #3, #4 and #7) and had not found any documentation that psychotropic medication education for informed consent had been documented or completed. She explained she had even called the prior DON and wasn't able to find consent information and planned to work on that going forward. The Antipsychotic Medical Renewal Policy and the Psychotropic Drug use Policy, revised 2/2025 lacked direction to the nursing staff to provide education to the resident and/or legal representative regarding treatment, treatment options, benefits and risk factors of psychotropic medication treatment. The Residents' [NAME] of Right, revised 11/16, provided by the facility directed the resident has the right to be informed in advance, by the physician, other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives of treatment options and to choose the alternative or option he or she prefers.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) User's Manual, and staff interview, the facility failed to code diagnoses used of psychotropic medications for 4 of 5 residents (Resident #2, Resident #3, Resident #4, and Resident #7) reviewed for unnecessary medications; and failed to accurately code restraint use for 2 of 2 residents (Resident #19 and Resident #51) reviewed for restraints. The facility identified a census of 54 residents.Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 indicating intact cognition. The list of diagnoses included adjustment disorder with mixed disturbance of emotions. The Medication section of the MDS indicated Resident #2 prescribed high risk antianxiety and antidepressant medications. Review of the EHR Physician Order Report revealed Resident #2 prescribed the following: a. Clonazepam (antianxiety medication) prescribed daily for circadian rhythm sleep disorder. Start Date: 3/30/26 for 0.5 mg/1 tab at bedtime b. Mirtazapine (antidepressant medication) prescribed daily for major depressive order. Start Date: 3/30/36 for 30 mg/1 tab at bedtime. A review of Resident #2's MDS revealed the lack of circadian rhythm sleep disorder and major depressive disorder diagnoses. During an interview on 5/21/26 at 8:40 AM, the MDS Coordinator reported she looked back at the most recent physician visit progress note and coded the diagnoses from the visit in Section I of the MDS. She reviewed Resident #2's MDS and verified the diagnoses were not on the MDS, then stated she would correct all the MDS assessments. When queried on what she used to code the MDS, the MDS Coordinator explained she coded based on how her prior preceptor trained her to code the MDS, but she had a copy of the RAI Manual in her office. 2. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating intact cognition. The list of diagnoses included anxiety and post-traumatic stress disorder (PTSD). The Medication section of the MDS indicated Resident #3 prescribed high risk antianxiety and antidepressant medications. The MDS listed an admission date of 11/14/23. Review of the EHR Physician Order Report revealed Resident #3 prescribed the following: a. Diazepam (an antianxiety medication) prescribed daily for obsessive compulsive disorder. Start Date: 2/8/25 for 5 mg/1/2 tab daily. Discontinue date: 4/6/26. Start Date: 4/6/26 for 5 mg/1/2 tab daily. b. Paroxetine Hydrochloride (an antidepressant medication) prescribed daily for obsessive compulsive disorder. Start Date: 12/6/24 for 10 mg/4 tabs daily. End Date: 4/6/26. Start date: 4/6/26 for 10 mg/4 tabs daily. A review of Resident #3's MDS revealed the lack of an obsessive compulsive diagnosis. 3. Review of Resident #4's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. The list of diagnoses included respiratory failure, tracheostomy status, dependence on a ventilator status and dependence on supplemental oxygen. The MDS listed an admission date of 2/25/25. Review of the EHR Physician Order Report revealed Resident #4 prescribed the following: a. Buspirone (an antianxiety medication) prescribed daily for anxiety disorder. Start Date: 5/14/25 for 10 mg/1 tab three times daily. b. Citalopram (an antidepressant medication) prescribed daily for depression. Start Date: 5/14/25 for 10 mg/1 tab daily. c. Diphenhydramine Hydrochloride (commonly used as a sleep aide) prescribed as needed for anxiety. Start Date: 5/14/25 for 25 mg/1 tab every 6 hours as needed. d. Trazodone (an antidepressant medication) prescribed daily for depression. Start Date: 1/23/26 for 50 mg/1/2 tab at bedtime. A review of Resident #4's MDS revealed the lack of anxiety and depression diagnoses. 4. Review of Resident #7's MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. The list of diagnoses included of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), tracheostomy status, dependence on a ventilator status and dependence on supplemental oxygen. The MDS Medication section indicated Resident #7 prescribed high risk antianxiety and antidepressant medications. Review of the EHR Physician Order Report revealed Resident #7 prescribed the following: a. Venlafaxine (antidepressant medication) prescribed for generalized anxiety disorder, Start Date: 4/21/26 for 37.5 mg twice daily. b. Ativan (an antianxiety medication) prescribed for generalized anxiety disorder. The Start Date/Discontinue Dates for Ativan in April 2026 were for: 1. 4/4/26 go 4/8/26 – 1 mg/1 tab every 6 hours as needed. 2. 4/8/26 to 4/16/26 - 1 mg/1 tab every 6 hours as needed. 3. 4/16/26 to 4/21/26 - 1 mg/1 tab every 6 hours as needed. 4. 4/21/26 to 4/24/26 - 1 mg/1 tab every 6 hours as needed. A review of Resident #7's MDS revealed the lack of an anxiety diagnosis. During an interview on 5/21/26 at 11:20 AM, the Director of Nursing (DON) reported she didn't think the facility had a MDS RAI policy. The facility used the CMS RAI Manual to code the MDS. The CMS LTC RAI User's Manual, October 2025, Version 1.20.1, Page 1-4 documented the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require the assessment accurately reflects the resident's status. The CMS RAI User Manual, Chapter 3, Page I-1 instructs to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Include active diagnosis in the last seven days in the look back period. 5. Review of the MDS assessment dated , 4/26/26, revealed Resident #51 had severely impaired cognitive skills for daily decision making and required dependence on staff assistance for all care tasks and mobility. The list of diagnoses included cerebral palsy, tracheostomy status, gastrostomy status, and dependence on ventilator (respirator). The MDS indicated that no restraints or alarms were used on the bed or on the chair/out of bed. Review of Resident #51's Care Plan, initiated 9/08/25, revealed the Focus area: I have an order for an abdominal binder to protect my P.E.G (Percutaneous Endoscopic Gastrostomy) tube with the goal to have intact skin with no signs of redness or irritation from wearing the binder. An intervention instructed staff to check skin integrity before applying and after removing device and skin checks every 2 hours while in place and as needed. Review of Resident #51's Medication and Treatment Administration Records (MAR/TAR), dated May 2026, revealed an order for: Abdominal binder to be applied to obscure PEG tube to avoid resident pulling on it for safety, start date 4/30/26. The order instructed to document every 2 hours if binder is on or off and perform a skin check every 2 hours when in place. Review of documentation between the dates of 5/01/26 and 5/19/26 revealed daily use of the abdominal binder. During an interview on 5/20/26 at 2:33 PM, Staff M, Certified Nursing Assistant (CNA), stated Resident #51 used the abdominal binder throughout the day shift. During an interview on 5/21/26 at 8:25 AM, Staff I, CNA, stated Resident #51 used the abdominal binder throughout the overnight shift. During an interview on 5/21/26 at 10:37 AM, the DON, stated Resident #51 had utilized the abdominal binder for months to help secure PEG tube and was unable to remove the binder independently. The DON identified Resident #51's abdominal binder as a physical restraint and expectation of assessments to reflect this. 6. Review of the MDS Assessment, dated 4/30/26, revealed Resident #19 had severely impaired cognitive skills for daily decision making and required dependence on staff assistance for all care tasks and mobility. The list of diagnoses included respiratory failure, heart failure, seizure disorder, tracheostomy status, gastrostomy status, dependance on ventilator (respiratory), and conjunctivitis (eye infection) of both eyes. The MDS indicated that no restraints or alarms were used on the bed or on the chair/out of bed. Review of the Care Plan, initiated 2/19/24, revealed the Focus area for Resident #19 behavioral symptoms, can become restless and agitated. Interventions instructed the following, in part: a. Arm immobilizers to bilateral upper extremities. Start date: 4/28/26. b. Staff will monitor my mood if I seem agitated. Redirection will be attempted. Start date: 5/24/24. The Care Plan, additionally revealed the Focus area: I need to have padded hand mitt or sock as needed related to increased agitation, confusion, being fidgety and restless when in bed or chair. This is to keep me from pulling my ventilator circuit, feeding tube, and catheter and keep me from hitting myself. Interventions included the following, in part: a. Encourage participation of therapy department in assessing, re-assessing and determining the least restrictive/appropriate restraint to use. Start date: 5/24/24. b. Fully inform resident/family member of risks and benefits of all options being considered. Start date: 5/24/24. c. Mitts to be removed during periods of one on one. Start date: 5/24/24. d. Monitor, document, and report any negative outcome. Start date: 5/24/24. e. Remove mitts and complete hand hygiene. Range of Motion (ROM) and to check for redness, irritation, or breakdown. Start date: 5/24/24. f. Remove restraint to allow free time at meals or while attending activities (when staff is close by resident). Start date: 5/24/24. Review of Resident #19's MAR/TAR revealed an order, started on 4/15/26, for left and right arm immobilizers which instructed the following: Assess and remove restraint no less than every 2 hours to check resident tolerance and skin integrity; Denote nursing actions during release and reinstatement; Ensure side rail padding is in place over bed rail to prevent injury from resident banging hand on rail; Remove as needed while asleep. T Review of Resident #19's MAR/TARs, between the dates of 4/15/26 and 5/19/26, revealed that the left and right arm immobilizers were utilized daily. During an interview on 5/20/26 at 11:37 AM, Staff L, Registered Nurse (RN), stated that Resident #19 utilized arm immobilizers due to resident biting thumbs and scratching his eyes. Staff L explained that the immobilizers prevented Resident #19 from bending his elbows. Staff L reported that Resident #19 was unable to remove the immobilizers independently and stated that staff removed the immobilizers every 2 hours for skin check and ROM. During an interview on 5/21/26 at 8:45 AM, the MDS Coordinator, denied Resident #19's use of arm immobilizers during MDS assessment dated [DATE], but recalled that resident had an as needed order for hand mitts. During an interview on 5/21/26 at 10:37 AM, the DON stated Resident #19 had utilized arm immobilizers as ordered starting on 4/15/26 until discontinued on 5/21/26. The DON identified Resident #19's arm immobilizers as physical restraints and expectation of assessments to reflect this. Review of the CMS RAI User Manual, Chapter 3, Page P-1 instructed to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7day look-back period. The facility denied having policy and procedure for accuracy of MDS assessments and follows the CMS RAI manual.

Based on observation, record review, staff interviews, the facility policy, and the manufacturer's insulin pen instructions, the facility failed to follow manufacturer instructions for administration of insulin and failed to administer an inhaler and nebulizer treatment at the physician prescribed time for 2 of 6 residents (Resident #22 and Resident #26) observed for medication administration causing a 10% medication error rate. The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set assessment dated [DATE] revealed Resident #26 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed a diagnosis for diabetes mellitus (DM) and that resident received insulin 7 out of 7 days. Resident #26's Care Plan included a problem area dated 4/18/22 for the diagnosis of DM and use of an oral antidiabetic and insulin. The Intervention dated dated 7/12/24 directed staff to administer medications as ordered. Review of the electronic health record (EHR) revealed a Physician Order for Lantus U-100 Insulin solution; 100 units/ml (milliliter)- 35 units daily at 8:00 AM. During an observation on 5/20/26 at 7:38 AM, Staff C, Licensed Practical Nurse (LPN) prepared Resident #26 Lantus insulin pen. Without first priming the pen, Staff C turned the knob to 35 units and then administered the insulin into Resident #26 right abdomen and after the medication injected, kept the insulin pen in place for 2 seconds. During an interview on 5/20/26 at 1:45 PM, Staff C, LPN queried if the Lantus pen had any special instructions and Staff C stated not that she was aware of. Staff C asked about priming the insulin pen and she stated not that she was aware of. Staff C stated the insulin pen needed to be kept in place for at least 10 seconds after injected. Staff C informed the pen left in for only a few seconds, and Staff C stated it felt like 10 seconds. During an interview on 5/21/26 at 9:42 AM, the Director of Nursing (DON) queried on special instructions for the Lantus insulin pen and the DON stated nurses needed to push the air out and hold it in place for 15 seconds after injecting. The DON confirmed the nurse needed to prime the needle prior to administration. Review of the facility policy titled Insulin Preparation and Administration Policy and Procedures dated 4/2019 revealed: Prior to administering an insulin medication, the member of the professional nursing staff who prepared the insulin dose shall verify the insulin dose that was prepared is accurate/correct and is adherent to the Six (6) R's of medication administration. The administration of any insulin shall be done using an administration/injection needle that meets the manufacturer's recommended specifications for administration use.Review of the Lantus Solostar Pen manufacturer's instructions dated 8/2022 revealed: a. Perform a safety check: dial a test dose of 2 units, then hold the pen with the needle pointing up and lightly tap the insulin reservoir so that air bubbles rise to the top of the needle. This will help you get the most accurate dose. Then press the injection button all the way in and check to see that insulin comes out of the needle. b. Inject the dose.use your thumb to press the injection button all the way down. When the number in the dose window returns to zero as you inject slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.)2. Review of Resident #22's MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15, which indicated a moderate cognitive impairment. The MDS list of diagnoses included respiratory failure and asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease. The MDS indicated the resident received continuous oxygen therapy. Review of Resident #22's Care Plan revealed a problem area dated 10/10/22 for resident required oxygen. Interventions, dated 7/3/24 included breathing treatments/medications as ordered. The EMR revealed the following Physician Orders:a. Arnuity Ellipta (fluticasone furoate) blister with device 100 mcg/actuation- 1 puff once a day between 7 am- 10 am.b. Ipratropium-albuterol solution for nebulization; 0.5 mg (milligrams)- 3 ml- 1 vial inhalation four times a day (8 am, 12 pm, 4 pm, and 8 pm)During an observation on 5/20/26 at 7:48 AM, Staff H, Certified Medication Aide (CMA) prepared Resident #22 medications. Resident #22 ipratropium-albuterol foil packet did not have the date it was opened on it so Staff H stated she wouldn't administer it and reordered a new supply. Resident #22's Arnuity inhaler also did not have an open date on it, so Staff H did not administer the inhaler either. The inhaler had 21 doses left on it. Review of the May 2026 Medication Administration Record revealed:a. Arnuity Ellipta not administered: drug/item unavailable on 5/20/26 between 7:00 am -10:00 AM.b. Ipratropium-albuterol solution not administered: drug/item unavailable on 5/20/26 at 8:00 am and 12:00 PMDuring an interview on 5/20/26 at 9:05 AM, Staff H, CMA stated she reordered Resident #22 medications and the pharmacy would send out today and the facility should receive Resident #22 medications around 2:30 PM. Staff H stated Resident #22 inhaler was scheduled daily and his nebulizer treatments were scheduled 4 times a day. Staff H stated Resident #22 would also miss the 12 PM nebulizer treatment, but Resident #22 had a PRN (as needed) albuterol nebulizer treatment the facility could use. Staff H stated if a medication was not labeled with a date it was opened, staff didn't know how long the medication had been used for, so Staff H didn't give it. During an interview on 5/21/26 at 9:42 AM, the DON queried on Resident #22 inhaler and nebulizer vials not being dated when opened and the DON stated the medications were usually labeled and Resident #22 always gets through his medications. The DON stated she wished Staff H would of asked questions before not giving Resident #22 his medications. The DON stated they could of contacted the pharmacy to see when the medications were sent rather than not giving Resident #22 his medication at all. Review of the Medication Administration revised 7/2024 revealed, in part: Unless otherwise specified by the prescriber, medications are to be administered within one hour of the prescribed time of administration.

Based on record review, staff interviews, and the facility discharge to another facility checklist, the facility failed to complete a recapitulation of stay discharge summary for 1 of 1 residents reviewed for discharges (Resident #63). The facility reported a census of 54 residents. Findings include: The electronic health record (EHR) Census Records revealed Resident #63 discharged from the facility on 3/26/26. Review of a Social Services Note dated 3/5/26 at 8:58 AM, revealed SS (Social Services)- Discharge- Called [name redacted] @ [facility name redacted] She stated they have accepted resident. They are currently working on transportation and will let facility know an admit date . [Name redacted] was informed to call DON (Director of Nursing) [name redacted] with update on admit date . DON has been given this information. [name redacted] [facility name redacted] has informed Spouse of accepting resident and working on transportation. (email sent to DON, Admin (Administrator),MDS (Minimum Data Set) about discharge.)Review of a Nurse Note dated 3/26/26 at 1:04 PM, revealed [name redacted], RT (Respiratory Therapy) Director and [name redacted], Transport arrived at 11:34. They brought their own sling and reclining chair that had feces in the creases. Report given to [name redacted]. [Name redacted], RT at bedside along with [name redacted] to switch over to their vent. [Name redacted, Resident #63] will be leaving in their transport van. Vitals WNL (within normal limits) before leaving. Paperwork provided, left behind in room. [Name redacted, Resident #63] left our facility at 12:25. Report given to [name redacted], LPN (Licensed Practical Nurse). Faxed over all paperwork that should have been sent to [phone number redacted].Review of the EHR lacked a Discharge Summary for Resident #63During an interview on 5/21/26 at 8:31 AM, Staff E, Registered Nurse (RN), queried about Resident #63 discharge and she stated the nurses fill out a checklist for the discharge on the things the staff needed to complete for the discharge. Staff E asked if she completed a discharge summary with a recapitulation and Staff E stated from her standpoint Staff E printed off paperwork, completed vital signs, and gave report to the new facility. Staff E thought the recapitulation was completed by the management team. During an interview on 5/21/26 at 9:30 AM, Staff F, RN queried on a checklist for discharges to another facility and Staff F stated yes and pulled a copy out of the cabinet in the nurse's station. The Discharge to Another Facility Checklist provided revealed the following: complete discharge summary in Matrix under observations- discharge/transfer-discharge summary.During an interview on 5/21/26 at 9:54 AM, Director of Nursing (DON) queried about Resident #63 discharge summary and the she stated sometimes the records didn't get uploaded in the EHR and the DON would check medical records for the documentation. The DON confirmed she didn't see a discharge summary completed under the observations and a discharge summary should have probably been completed. During an interview on 5/21/26 at 11:20 AM, the DON reported she checked Resident #63's clinical record and there was no discharge summary completed. She stated it had probably been missed. The facility did not have a policy. They just developed a policy to work on it going forward. During an interview on 5/21/26 at 11:23 AM Staff G, Licensed Practical Nurse (LPN) queried about the process for residents discharging to another nursing facility and she stated she would first pull the policy and procedure book and the facility also had a checklist to complete. Staff G asked who completed the discharge summary and Staff G stated the floor nurses did unless they were busy and then the DON would help or other nursing staff. The Discharge to Home Policy dated 7/2025 revealed the following:Use the Discharge to Home Checklist with steps to follow upon day of discharge. The checklist is in the file cabinet at each nurse desk.

Based on observations, clinical record review, policy review, resident and staff interviews, the facility failed to provide staff with clear resident specific directions for the level of assistance a dependent resident required for repositioning and the use of a bed pan for 1 of 4 residents (Resident #1) who experienced a fall with fracture when assisted with the use of a bed pan. The facility reported a census of 56 residents.Findings include: Review of the Minimum Data Set (MDS) assessment, dated 12/18/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The list of diagnoses included hereditary motor and sensory neuropathy (a progressive disorder damaging peripheral nerves causing muscle weakness, atrophy (loss of muscle tissue) and sensory loss), chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The assessment identified the resident non-ambulatory with the use of a wheelchair for mobility, and dependent to roll left and right and chair/bed-to-chair transfer. Review of an Event Report for a Safety Event - Fall Investigation for Resident #1, dated 12/21/25 completed by Staff C, Licensed Practical Nurse (LPN), revealed, in part:a. The fall occurred in the resident's bedroomb. Fall witnessedc. No adaptive equipment in use at the time of the falld. Description of Fall - see nurse notes. Review of the electronic health record (EHR) revealed the same nurses note entered in the Note section of the Event Report. The Notes section, documented At 11:20 am Called to room per CNA (Certified Nursing Assistant) upon entering the resident [Resident #1] was on floor on his back beside bed. Left leg with external rotation and a visible deformity of outer mid-thigh. Unable to move left leg. Resident was not moved from floor. He states he did not hit his head.Ambulance called at 1130 (AM).then at 1605 (4:05 PM) resident was being admitted with a left knee FX (fracture).Review of the Self Report, submitted on 12/22/25, Incident Summary revealed, in part: The resident is [name redacted, Resident #1]. The issue is a fractured knee cap that occurred on 12/21/2025. Scenario: Nurse was called to the resident's room. Upon arriving, the nurse observed the resident laying on the floor, on his back by his bed. Left leg was observed with external rotation and visible deformity on outer mid-thigh. Resident was observed unable to move his leg. Resident denies his head being hit or injured. Resident was not moved by facility staff. Physician notified and EMS (emergency medical services) was summoned to the facility. The acting DON (Director of Nursing) was notified as was the resident representative, of this event. EMS arrived, transferred resident to gurney and transported resident to hospital, where eventually he was admitted for further evaluation upon his diagnosis and any necessary follow up medical treatment. Scenario Review- The acting DON reviewed the event that occurred. The CNA, [name redacted] that was involved with the incident was questioned about what her role and/or observation was in the event. [CNA name redacted] identified she was in the resident's room and was assisting him off a bed pan and was going to help position him from that. She indicated she requested the resident to turn on his side. She observed the resident attempting to grab the assistance rail to assist himself in moving off the bed pan and, in that process, his legs slid off the bed. She observed that this caused the rest of his body to move also as a result. [CNA name redacted] when realizing the body movement was continuing, did attempt to stop the body movement from continuing by holding onto the resident's gown to stop it, but was not successful. The resident slid off the bed and made contact with the floor involving the left side of his body. [CNA name redacted] then summoned additional staff assistance to the resident's room. It should be noted at that time of this event, only one (1) staff was required for assisting the resident by re-positioning within his bed. Therefore, the care expectations for the resident were being followed by [CNA name redacted] and the facility believes no staff culpability is evident.Review of hospital progress notes for the hospitalization from 12/21/25 to 12/26/25 revealed Resident #1 had a left femur fracture as result of a fall out of bed while at the facility.Review of a Progress Note in the EHR revealed the following ADL (activities of daily living) charting entries:a. On 12/11/25 at 21:05 (9:05 PM), revealed: Thursday ADL Charting: Bed Mobility Resident is an extensive two person assist with bed mobility and lifting BLE into bed. Resident requires staff assistance for repositioning and is offered Q2hrs. Pressure reduction mattress utilized as well as side rails. Pillows utilized per request with no wedges being used. Resident A/O x4 and able to communicate needsb. On 12/16/26 at 20:10 (8:10 PM) revealed, in part: Toileting and Continence: include maximum number of staff assisting, bowel and bladder, use of continence supplies, frequency of toileting or incontinence cares: Utilizes bed pan for bowel movements. Assist X 1-2 (one to two staff assistance) with toileting needs.c. On 12/19/26 at 00:14 (12:04 AM) revealed, in part: Bed mobility: include maximum number of staff assisting, include how resident lifts legs into bed and side rail use (left, right, bilateral, 1/2 or 1/4): Assist x2. Does not lift legs. Bilateral 1/4 side rails. Turning and repositioning: do they need assist, how often are they being repo'd (repositioned) etc. Use of pillows and wedges, how often being repo'd, effectiveness: Independent with repo. Calls when he needs boosted up in bed. Pillows for comfort. Effective. Pressure reducing device for bed: low air loss, scoop mattress, roho etc: n/a.Review of the Care Plan for Resident #1 revealed a problem area, start date 3/31/21 to address I am at risk for falls. Approaches included:a. Implement exercise program that targets strength, gait and balance. Start Date: 7/3/24.b. Increased staff supervision with intensity based on resident need. Start Date: 7/3/24. After the fall on 12/21/26 the approach Ax2 (Assist of 2) in bed for rolling and repositioning with a start date of 12/22/26 added to the Care Plan. The Care Plan also included a Problem area, start date: 3/31/21 to address I am limited in physical mobility and requires assist with ADL's. Approaches included, in part:a. I require assist with all ADLs. Ax2 Hoyer (a brand name of a mechanical lift). Start Date: 7/3/24.After the fall on 12/21/26, the following approach added to the Care Plan: I am aware that I can assist staff when I am being rolled in my bed for positioning purposes which I can use assistance rails to help manage rolling motion, I will now require two (2) staff to assist me with bed roll/positioning with start date of 12/22/25 and an end date: 3/18/26. During an observation on 3/10/26 at 8:38 AM, Staff D, CNA, and Staff E, CNA assisted Resident #1 to reposition by moving him towards the head of the bed. The resident was dependent on staff during the repositioning. During an interview immediately after the repositioning, Resident #1 stated he remembered the fall from his bed in December 2025, but did not remember which staff had assisted him. Resident #1 explained he needed help with rolling side to side, and staff assisted him to reposition. He recalled the staff person pushed him instead of flipping him over and pushed him out of the bed. Resident #1 explained that he had a narrower bed at that time. Resident #1 reported that he thought he tried to help, but the CNA moved him too quickly for him to grab the bed rail. Resident #1 reported before the fall in December 2025, he had either one or two staff that assisted him with repositioning and had never had problems before.During an observation on 3/10/26 at 11:30 AM, the CNA Trainer and Staff F, CNA, assisted Resident #1 with dressing. They assisted the resident with rolling from side to side two times while they pulled up his pants. The resident did not assist.During an interview on 3/10/26 at 10:58 AM, Staff C, Licensed Practical Nurse (LPN) stated she assessed Resident #1 after his fall on 12/21/25. Staff C stated Staff A, CNA, was in the room and told her the resident just slid. Staff C recalled Staff A reported the fall happened when she assisted the resident to reposition. Staff C reported she had worked at the facility for 2 years, and had helped to reposition Resident #1 during this time. Staff C stated that she had tried to put the resident on the bed pan by herself, and explained the resident was stiff, really hard to move and did not assist when repositioned for the bedpan. Staff C stated the resident had shorter quarter rails, and the mattresses on the beds were slick. Staff C explained she tried to use two staff, as the resident would slide on the mattress when trying to turn him. During an interview on 3/10/26 at 12:36 PM, the Restorative Nurse stated he had been in his position since 2015 and had the responsibility of oversight for the safe handling and transfer of residents. The Restorative Nurse reported the facility made sure new orientees received training related to safe transfers and repositioning, and he occasionally trained the staff. The Restorative Nurse explained that Staff C, CNA, received training on safe handling and transfers during her orientation with the CNA Trainer and also at a recent skills fair. He reported doing training with Staff C, CNA, after Resident #1's fall. The Restorative Nurse reported that he had repositioned Resident #1 prior to his fall. He reported the resident had been care planned for use of either one or two staff, and he would have to see documentation in the record that would indicate the resident required 2 staff to place him on a bed pan. The Restorative Nurse reported he heard Resident #1's fall occurred with the assistance of one staff, and after the fall the facility changed the level of assistance to two staff for ADL's. The Restorative Nurse added the facility changed the policy after Resident #1's fall to a mandatory assist of two staff for all paraplegic, quadriplegic or non-responsive residents. During an interview on 3/10/26 at 12:59 PM, the MDS Registered Nurse (RN) stated she had been in her position since September 2024 and had the responsibility of completing all resident MDS assessments and Care Plans. The MDS RN confirmed the MDS assessed Resident #1 dependent on staff for all ADL care with the exception of eating/oral hygiene. The MDS RN explained that the night shift nurses reviewed the resident's ADL needs including toileting, transfers and bed mobility during the seven-day assessment period of each MDS. During a second interview on 3/11/26 at 10:59 AM, the MDS RN explained the use of dependent meant staff did all of the ADL tasks without the resident assisting. The MDS RN reported she added the intervention to Resident #1's Care Plan for two staff to assist with all ADLS on 12/22/25 after the resident's fall. She explained Resident #1 did not have a change in ability, rather she added the intervention to ensure two staff assisted the resident, which clarified direction to staff.During an interview on 3/10/26 at 1:40 PM, the CNA Trainer stated she had provided care and repositioned Resident #1 prior to the fall on 12/21/25, but it had been some time since she last assisted. The CNA Trainer reported she trained Staff C, CNA, and Staff C passed competency skills which included bed mobility on 8/7/25. The CNA Trainer explained she had not specifically trained Staff C on how to assist Resident #1 with ADL's. The CNA Trainer explained communication care cards (also known as a Kardex, a quick reference tool to summarize a residents current ADL needs) are posted above the residents' bed, and the cards direct how many staff were needed to transfer/assist with ADLs. The CNA Trainer stated the Restorative Nurse and Therapy staff kept the Kardex information updated. She explained for bed mobility and use of the bed pan she always used two staff for Resident #1. She added prior to the fall, putting Resident #1 on the bed pan would be the same as repositioning and required 2 staff. During an interview on 3/10/26 at 2:25 PM, Staff E, CNA stated she had provided care to Resident #1 prior to his fall in December 2025. Staff E reported that she had never repositioned the resident by herself, and had always had two staff. Staff E explained staff had to reposition the resident to put him on the bed pan, and when staff rolled him, they needed two people. Staff E reported she knew the number of staff that were needed to assist residents by looking at the Restorative Communication form kept on a clipboard at the nurse's station. Staff E obtained a document titled Restorative Therapy to Nursing Communication dated 2/27/26. The document identified Resident #1 by name. The document directed Transfer w/Hoyer min BID (two times) for lunch and supper. Use caution with LLE (lower left leg extremity), support throughout transfer. Resident should remain up in w/c (wheelchair) 30 min after meals. During a follow up interview on 3/11/26 at 11:53 AM, Staff E, CNA, stated she used the Kardex posted in the residents' rooms to know whether or not one or two staff were needed to assist residents with their ADLs. She explained she also looked at the Restorative Therapy to Nursing Communication form. During an interview on 3/10/26 at 2:30 PM, Staff G, CNA, stated she had worked at the facility for 3 years. Staff G stated Resident #1 had always been a two assist for everything including repositioning, putting him on/off a bed pan and transfers. Staff G explained she looked at the Restorative Therapy to Nursing Communication clipboard for direction.During an interview on 3/10/26 at 2:56 PM, Staff F, CNA, reported she had provided care to Resident #1 prior to his fall in December 2025. Staff F explained that the resident used to be more independent and could assist with repositioning, but that changed about 6 months before his fall. Staff F explained the resident gained weight, had become more frequently short of breath, and wasn't able to help. Staff F stated it was tougher to reposition him, especially if staff was going to put the bedpan under him. Staff F stated one person couldn't do it, because it wasn't safe. Staff F reported one person would need to pull up on the chuck (an incontinence pad placed under a resident), while the other person rolled the resident over and positioned the bed pan under him. Staff F added Resident #1 used a larger bed pan making it more difficult. During a follow up interview on 3/11/26 at 11:58pm, Staff F, CNA, stated she learned how staff assisted a resident with ADLs by word of mouth. She explained she would ask other CNAs for direction, or she would go to either the CNA trainer or a nurse. Staff F stated she did not look at the residents' Care Plans. Staff F reported she would also look at the Restorative Therapy to Nursing Communication form on the clipboard. Staff F explained that prior to Resident #1's fall, she would use her own judgement or word of mouth. During an interview on 3/10/26 at 3:55 PM, Staff B, RN confirmed she completed ADL assessments on Resident #1 during the MDS assessment period, which included assistance for toileting. Staff B confirmed she completed an assessment on 12/16/25 that identified the resident needed one to two staff assistance with toileting. Staff B explained that the resident needed the assistance of one staff to empty his urinary catheter, but needed the assistance of two staff to place him on the bed pan. Staff B explained prior to Resident #1's fall, he was a good roller. At times, the resident had been able to roll with the assistance of one staff, but it might take two staff to get the resident off the bed pan. Staff B explained that it depended on the day and how the resident was doing prior to his fall. The resident had been able to grab the quarter bed rails and help with rolling. Staff B reported that the resident rolled better to the left, and would use his right arm to grab the left rail. During an interview on 3/11/26 at 8:43 AM, Staff A, CNA, reported she had provided care to Resident #1 prior to 12/21/25, which included repositioning and transferring. Staff A reported she utilized the Kardex posted in the resident's room for instruction on toileting, repositioning and transfers. Staff A did not remember the instructions on Resident #1's Kardex. Staff A reported staff helped Resident #1 to roll over, but he helped hold himself by grabbing the bed rail. Staff A reported she had not repositioned the resident by herself, but she had previously put the resident on the bed pan by herself and had never had any problems before. Staff A explained for repositioning the resident, he needed to be pulled up in bed and she always had two staff for that. Staff A reported that on the day of the fall, the resident requested to use the bed pan. Staff A stated she got his bed pan, and asked the resident to roll over. Staff A explained he can't do it himself, and we have to assist. Staff A reported she stood on the right side of the bed (near the window), about mid bed and with the quarter rails near the top of the bed in an upright position. Staff A stated that she went to roll Resident #1 over on the left side and he had grabbed the rail, but his legs swung over the end of the bed on left side. Staff A explained that she tried to reach for the resident, but he slid off the bed and landed on his left side. Staff A reported the resident had a smaller bed then (when he fell). Staff A explained, he's a bigger guy; I had a hard time turning him. She reported Resident #1's Kardex stated two people assist for everything. She stated she couldn't remember if the Kardex in the room identified the number of staff needed for ADLs prior to the resident's fall. Staff A stated during training she was told she could use one or two staff for toileting Resident #1. Staff A denied being instructed that one staff emptied the urinary catheter and two staff were needed to place the resident on a bed pan. During an interview on 3/11/25 at 9:46 AM, the DON reported that either the MDS RN or Restorative Nurse updated the Kardex located in the residents' rooms, but mainly the Restorative Nurse had the responsibility of updating the Kardex. The DON reported at the time of Resident #1's fall in December 2025, she was the interim DON. She reported she was very new at the time, and maybe in the first couple weeks of taking over. The DON reported staff were expected to follow the Kardex located in each resident's room. The DON reported the Kardex stated the resident was a staff assist of one for bed mobility and toileting prior to his fall, and Staff A, CNA, followed the Kardex in the room. The DON reported she was not sure what the MDS assessment meant when the assessment identified a resident was dependent versus max/substantial assist for ADLs. The DON explained staff usually could get by with one staff for Resident #1 for the bed pan, but it depended on the bowel movement amount and consistency on whether or not two staff were needed. The DON explained that staff reported to her that the resident helped to roll himself. The DON provided a copy of resident's #1 current Kardex located in his room.Review of the Kardex from Resident #1's room revealed Transfer status: Hoyer; Ambulation: N/A; Side Rails: Quarter checked and x2 checked; Toilet: Bedpan handwritten and checked; Tubigrips - blank; [NAME] Hose - blank; Special Devices: blank. A handwritten date of 4/8/25 noted in right hand corner of the Kardex. During an interview on 3/11/25 at 11:26 AM, the Restorative Nurse confirmed the current Kardex, dated 4/8/25, did not identify the number of staff Resident #1 needed for assistance with ADLs. The Restorative Nurse then stated the Restorative Therapy Communication to Nursing provided specific instruction to staff. The Restorative Nurse provided the current Restorative Therapy to Nursing Communication form for Resident #1, dated 2/27/26, which instructed staff to transfer with hoyer min BID for lunch and supper, use caution with LLE, support with transfer; Resident should remain up in w/c 30 min. The Restorative Nurse explained that some staff had the ability to turn a resident safely with one staff, and staff had different physical abilities. The Restorative Nurse reported that while it was now mandatory for two staff to assist Resident #1 with ADLs, the resident was previously an assist of one or two staff, and the residents Care Plan would have told staff more specifically what the resident needed. The Restorative Nurse was unaware Resident #1's Care Plan did not specifically address the number of staff persons the resident needed to assist him with repositioning and toileting prior to his fall on 12/21/25. During an interview on 3/11/26 at 12:04 PM, the Restorative Nurse provided a copy of the Restorative Therapy to Nursing Communication form for Resident #1 that was in place at the time of the 12/21/25 fall. Review of the form, dated 9/17/25, revealed Per Therapy: Ensure Resident is up in w/c BID and check skin integrity before and after. Report any refusal or adverse conditions to the nurse for documentation. The form lacked any specific instructions regarding the number of staff need to provide ADL assistance to Resident #1. During an interview on 3/11/26 at 12:17 PM, Staff D, CNA, stated she worked as a contract staff and had worked at the facility a couple of months ago and recently returned. Staff D stated the facility did not have a place to go and look to find out whether a resident required the assistance of one staff or two for ADLs. Staff D denied that she had received any direction from management staff, and reported no one had told her what to do. Staff D reported she used her judgement to determine whether or not she needed the assistance of another staff person to assist residents with ADL tasks. During an interview on 3/11/26 at 1:07 PM, the DON reported CNAs do not conduct assessments, nurses do. The DON reported that CNAs knew how to assist residents with ADLs through verbal report, the Kardex in the residents' rooms, and orientation. The DON reported contract staff are informed of the level of assistance during shift report. The DON stated Resident #1's Care Plan should have identified the amount of staff assistance needed to complete ADL tasks. The DON reported that for the safety of Resident #1 and for staff safety, they made it mandatory for two staff to assist him with all ADLs after his fall.During an interview on 3/12/26 at 7:38 AM, Staff H, RN, confirmed that she completed the ADL assessments associated with the MDS, including an assessment of Bed Mobility, dated 12/19/25. Staff H reported Resident #1 needed staff assistance of two on night shift due to his size. Staff H explained that staff would roll the resident, push him so he could reach the bed rail and then he would hold on to the rail. Staff H stated Resident #1 did not have a good grip on the rail due to contractures on both hands, and only able to use his right thumb and index finger. Staff H stated the resident had better bed mobility on the left side. Staff H reported she assessed Resident #1 required the assistance of two staff for everybody's safety, both the resident and the staff. On 3/12/26 at 11:24 AM, during an interview, Staff I, CNA, reported she had worked 4 years at the facility and provided care throughout that time to Resident #1. When asked if she had repositioned or put Resident #1 on the bed pan by herself, she replied, Not so much. He had gotten harder to do. Staff I reported Resident #1 had gained weight and needed a second aide for all of his ADLs except emptying the catheter, Staff I explained this had been the case for quite some time prior to the fall in December 2025. Staff I reported that she would use her personal judgement to determine if a resident needed the assistance of two staff. She reported she was using the Kardex in the room, but did not realize the it did not identify the number of staff needed to complete ADL tasks. Staff I reported she also utilized the Restorative Therapy to Nursing Communication clipboard. Review of the facility's policy, titled Safe Resident Handling, dated 2/2024, revealed, in part, resident handling tasks would be carried out in accordance with care plans specific to the resident. If a level of assistance changed, staff would immediately communicate the change in status to the supervising nurse and Care Plan Coordinator.Review of the facility's policy, titled resident Pre-admission Screen/Resident Review (PASRR) Care Plan and MDS Care Plan, dated 5/22/23, revealed, in part.The MDS care plan shall also be developed by the facility's care team with resident/resident representative involvement. The MDS care plan shall be reflective of assessment results from the MDS and/or current clinical functioning of the resident. The care plan will identify the potential problems, goals to be achieved, and intervention strategies to be employed (by whom or by when) to meet the goals, alleviate problems and determine if new problems are occurring in order to be addressed by the overall care team.

Based on observation, staff interview, and record review the facility failed to ensure a seizure pad remained present to both sides of the resident's bed while the resident was left unattended in bed and failed to ensure adequate supervision of the resident during this time by a staff member for one of four residents reviewed for accidents (Resident #1). Resident #1 fell from the bed, was found on the floor by staff member, sustained a laceration and hematoma to the back of the head, and was sent to the hospital. The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1 revealed the resident was rarely to never understood. The Care Plan dated 11/18/21 revealed, My family has expressed a desire to have bed rails raised while I am in bed. The Intervention dated 5/31/24 revealed, All four 1/2 rails are to be up and have seizure precaution padding in place while in bed. The Physician Order dated 8/28/20 revealed, Resident is to use fully padded side rails while in bed due to frequent seizure activity. The Progress Note dated 4/2/24 at 8:30 AM revealed, in part, CNA (Certified Nursing Assistant) observed res (resident) on floor next to bed upon return with mechanical lift. CNA had been providing cares and getting ready for res to get up in W/C (wheelchair). Unable to complete full ROM (range of motion) due to contractures but no s/s (signs/symptoms) of shortening or rotation and res was able to move extremities per her usual. Noted res to have a laceration to back of head that was bleeding lightly. Noted to have large hematoma to back of head. Res is non-verbal and just moans per usual. Review of the Incident Report for Event Date 4/2/24 at 8:30 AM revealed the following description: Observed on floor next to bed. Per the Incident Report the event was unwitnessed, and neurological disorder was selected as a possible contributing factor. Review of the Physician Emergency Department (ED) Note dated 4/2/24 at 10:06 AM revealed the following chief complaint: Patient fell out of bed at [Facility Name Redacted], hematoma on back of head that is seeping. The Assessment and Plan section revealed the following: a. Scalp contusion b. Scalp abrasion c. Closed head injury The Physician Note for Resident #1 dated 4/5/24 at 8:10 AM revealed, She (Resident #1) had a fall on 4/2/24, she went to the ER (emergency room ) and CT (computed tomography) brain was negative for acute findings. She has a contusion on her left posterior scalp that has been weeping. She also has extensive ecchymosis (bruising) to her left foot. The Functional Status section revealed, Total care patient, mechanical lift for transfers, dependent for all ADLs (activities of daily living) and iADLs (instrumental ADL's such as cooking, shopping, managing finances). On 6/05/24 at 12:58 PM during a telephone interview with former staff member Staff C, Licensed Practical Nurse (LPN), Staff C explained the following about the event: Staff C explained she was not present at the actual fall and was there shortly after when the resident was found on the floor next to the bed. Staff C explained it was evident the resident had hit their head and had a hematoma and a laceration there. Staff C acknowledged bleeding present. Per Staff C, Resident #1 could roll herself some, and Staff C explained the resident was pretty immobile, and did move themselves in bed. Staff C explained, evidently the resident moved around in bed and rolled out of bed. Staff C further explained the rails were up, and the seizure pad present on one side of the bed and not on the other. Staff C explained staff had gotten the resident ready, and were getting ready to transfer the resident. When queried as to the aide, Staff C identified Staff B, Certified Nursing Assistant (CNA). Staff C explained Resident #1 did not communicate, and felt the resident needed assessment of head injury because the resident unable to communicate. On 6/05/24 at 1:14 PM, Staff B, CNA explained the following about the event: Per Staff B, she went in to do the resident's cares and to get the resident up. Staff B explained she had the resident slung (sling under resident), took the blue seizure mat off as she had trouble reaching over it to get the resident the right way. Per Staff B, she radioed (requested assistance), no one answered her, she radioed again, peeked out, and asked for help with transfer. Staff B explained another staff member said she needed to get trays passed, and Staff B explained it wouldn't take long, just a few seconds, and response given to Staff B was that they needed to get current task done. Staff B explained she ran down, grabbed a tray and delivered it, and grabbed a hoyer lift (mechanical lift that has become known as a brand name, such as kleenex is referring to tissue) and another aide to transfer the resident. Staff B explained when she went back in, the resident had flipped herself out. Per Staff B, other staff came down and she told them what happened. Staff B explained the resident was gotten up with the hoyer, Staff B said the resident got her head and had a good size bump. Staff B indicated to the back of the head. Staff B further explained the resident had bruising around the feet a few days later. Per Staff B, the resident did not have a full rail, and clarified as a split rail and seizure pad. Staff B explained she took the seizure pad off to transfer the resident over to her chair, and the split rails were both up. Staff B explained the following in terms of Resident #1's movement: Resident #1 could move all over the bed, and the resident was able to put both feet over the seizure pads. Staff B explained she did not see the event occur, and when she, Staff B, went in the resident's body and head were towards the bottom of the bed with the resident's whole body on the ground. Staff B acknowledged the event had occurred in a matter of 5 or 7 minutes. On 6/05/24 at 12:12 PM, Resident #1 observed in their room in bed. The resident had bilateral seizure pads (continuous section of padding along side of bed) present inside of the rails while the resident was in bed. On 6/5/24 at approximately 3:55 PM, observation revealed Resident #1 in their room in bed. Observation of rails present to the bilateral sides of the resident's bed revealed the rails were not continuous along the side of the bed, and two separate portions of bed rail present, which allowed for a space in the middle section of the bed where rails would not be present on either side of the mattress. On 6/6/24 at 2:12 PM, the facility's Director of Nursing (DON) queried about the above event for Resident #1. Per the DON, they had just gotten to the facility for the morning, went to do walking rounds, and was informed of the situation. When queried as to the cause, the DON explained per her understanding Staff B was getting Resident #1 ready for the day to get up, which meant removing the seizure pad doing cares. Per the DON, the two half rails on the end of bed were back up, Staff B peeked out to get assist, and in that time the resident's wiggled themselves in between the gap and had fallen through the gap on in the side rails. The DON acknowledged that staff had to leave the room, the seizure pad should have been put back as at the resident could have had a seizure. When queried if the resident could move themselves in the bed, the DON acknowledged the resident could do so. The DON explained she had gone in to check on the resident and the resident had been sideways in bed. When queried if Staff B should have started to pass a tray when she left the room, the DON responded if the staff member started the transfer, would have went back and put Resident #1 back, put the seizure pad back, put the resident's chair in the hallway, then assist with the tray pass, then later asked about going down to get the resident up. The Facility Policy titled Resident Supervision, dated 11/19, revealed, Resident supervision shall involve staff providing observation that is reasonable for the life space event the resident is occupying in the course of their daily activity of living .The intended goal is to provide supervision that promotes a sense of safety for a resident while they resident in the building.

Based on observation, interview, and record review the facility failed to ensure the Care Plan reflected a resident's current liquid consistency order for one of twenty-one residents reviewed for care plan revision (Resident #17). The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The Care Plan, dated 3/23/21, revealed a focus area to address I am at risk for choking and swallowing difficulty. The Intervention dated 3/14/24 revealed, Diet as ordered House Diabetic mechanical soft thicken liquids to nectar small portions. The Diet Order and Communication Form dated 2/27/24 revealed mechanical soft texture for foods and thin drinks. The Physician Order dated 2/29/24 to 4/26/24 revealed, House diabetic diet/mechanical soft texture/thin liquids. The Physician Order dated 4/26/24 revealed, House diabetic diet/mechanical soft texture/thin liquids. On 6/5/24 at 12:14 PM, observation of Resident #17 during the lunch meal revealed Resident #17 in their wheelchair in the dining room. The resident observed to drink from a cup which had a lid and straw. On 6/6/24 at 1:40 PM when queried about the fluid thickness included in the resident's Care Plan, the MDS Coordinator acknowledged she missed it and needed to take it out. On 6/6/24 at 2:10 PM, the facility's Director of Nursing (DON) explained the facility did not have a policy on care plans.

Based on observation, interview, and record review, the facility failed to trim and clean fingernails for 1 of 3 residents reviewed (Resident #62) The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #62 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed resident dependent with personal hygiene and shower/bathing. The MDS listed diagnoses for acute and chronic respiratory failure with hypoxia. The Care Plan, dated 3/28/24, included a focus area for staff assistance with Activities of Daily Living (ADL's). The plan included an intervention for total staff assistance with all ADLs. During an interview on 6/3/24 at 11:02 AM, Resident #62 stated he received a bed bath once a week. He stated he would like them to trim his nails. During an observation on 6/3/24 at 11:02 AM, the fingernails on Resident #62 left hand appeared long with dirt under the nail bed. During an interview on 6/4/24 at 1:22 PM, Resident #62 stated he received a bed bath today but they didn't clean or trim his nails. During an observation on 6/4/24 at 1:22 PM, resident's left fingernails appeared dirty and long. During an interview on 6/5/24 at 12:15 PM, the resident stated they trimmed his nails twice since he had been admitted . During an observation on 6/5/24 at 12:15 PM, fingernails on the Resident #62 left and right hand appeared to be long with dirt under the nail bed. During an interview on 6/6/24 at 9:21 AM, Staff D, Certified Nursing Assistant (CNA) stated they completed bed baths with Resident #62 for his comfort due to his pain. Staff D stated the CNA didn't cut fingernails because the nurses completed that task. During an interview on 6/6/24 at 10:01 AM, Staff A, CNA stated Resident #62 experienced a lot of pain so they only gave him bed baths. She stated she noticed Resident #62 fingernails and they cleaned them when they gave him a bed bath but he scratched his skin so he always had skin under his nails. She stated the bed baths didn't get him as clean but he refused to get into the shower chair. She stated the house supervisor would go to the resident's rooms and trim their nails. During an interview on 6/6/24 at 9:36 AM, Staff E, RN (Registered Nurse) stated the nurses trimmed the nails when they had time. She stated the house supervisor would go to the resident's room and trim them once a month. Staff E stated Resident #62 nails needed done and she didn't have time to get to them but hoped she had time today to do them. Staff E stated she didn't know if Resident #62 fingernails had been trimmed since he arrived to the facility. During an interview on 6/6/24 at 10:32 AM, the Director of Nursing (DON) stated she expected Resident #62 fingernails to be trimmed and cleaned especially because he mainly received bed baths and not showers. The DON stated the house supervisor trimmed nails monthly but last month she took time off and the resident probably missed but she still expected the floor nurses to look and trim and clean his nails if needed. During an interview on 6/6/24 at 2:10 PM, the DON stated they didn't have a policy for nail care. They followed the standard of practice for nail care. During an interview on 6/6/24 at 3:28 PM, Staff F, RN stated she conducted monthly spot audits on the residents for nail care. She stated Resident #62 got his toenails and fingernails cut on the day of admission and again on 4/11/24 and he did not get done in May or audited in May.

Based on observation, interview, and record review, the facility failed to ensure a resident remained free from unnecessary medication when a resident who experienced loose stools was administered a laxative and stool medication for one of six residents reviewed for unnecessary medications (Resident #17). The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The Care Plan dated 9/29/21 revealed, I am incontinent of bowel. Review of Physician Orders for Resident #17 revealed the following: a. 4/26/24: Docusate sodium liquid; 50 mg (milligram)/5 mL (milliliter); amt: 20 mL; oral Once A Day. (This was noted to be a stool softener medication) b. 4/26/24: Gavilax (polyethylene glycol 3350) powder; 17 gram/dose; amout: 17 grams; gastric tube Once A Day. (This was noted to be a laxative medication). c. 5/1/24: Imodium A-D (loperamide) . tablet; 2 mg; amount: 2 1st loose stool then 1; oral Special Instructions: 1st loose stool give 2 then give 1 for each loose after that do not exceed over 8 in 24 hours As Needed. The Progress Note dated 4/28/24 at 1:40 PM documented, Incontinent of bowel. Several loose stools this shift. The Progress Note dated 4/29/24 at 11:20 PM documented, Incontinent of bowel with recent HX (history) of diarrhea. No hand off report to this nurse about diarrhea thus far today. The Progress Note dated 4/30/24 at 7:43 PM documented, Resident had a large projectile emesis and a large foul loose bm (bowel movement) twice. Resident cleaned up small sips liquids given and doctor notified awaiting orders. Head of bed up 35 degrees. Held meds due to condition .Very active bowel sounds through out. The Progress Note dated 5/1/24 at 12:10 AM revealed, Notified DON (Director of Nursing) and HCP (Health Care Provider) on res.(resident) current illness with diarrhea and not eating. HCP ordered 100 mL/hr (milliliter/hour) of fluids through peg tube for 10 hours and to continue the loperamide (Imodium). Advised the DON (Director of Nursing)and put in order. The Progress Note dated 5/1/24 at 1:16 AM revealed, Res. (resident) this shift (early in shift) had projectile vomiting that was reported to his nurse with diarrhea. Res. assessed by myself and other nurse. HCP notified and gave N.O (new order) for loperamide for res. Loperamide was started and was found to not be working. DON and HCP notified for further instructions d/t (due to) res. heart rate increased to 128 bpm (beats per minute). RR (respiratory rate) 22, spo2 (oxygen saturation) 92%. Felt needed treated for dehydration. HCP N.O (new order) for 100 ml/hour of fluids through peg tube for 10 hours and to continue loperamide .continued water hydration 100 ml/hr. resting at this time with loperamide continued for diarrhea. The Progress Note dated 5/01/24 at 6:26 AM revealed, Res. continues to have loose stools, a couple thru the night were small liquidly light brown stools the rest have been large liquidly stools. Loperamide given with no changes in stools. Held res. mirilax and docusate this a.m. med pass. No more emesis just loose stools. The Progress Note dated 5/01/24 at 6:28 AM revealed, total of 5 loperamide has been given and advised nurses on day shift hand off report of this and that res. continues to have loose stools. Review of the resident's Medication Administration Record (MAR) dated Apil 2024 revealed Docusate Sodium 20 ml and Gavilax powder 17 grams administered to the resident daily on 4/28/24 through 4/30/24. On 6/6/24 at 2:20 PM, the DON explained she would have held the medications, called the doctor/ordering provider, explained the resident having diarrhea, and see how they wanted to proceed. The Facility Policy titled Medication Administration, dated 9/17 and reviewed 2/24, did not address holding medications.

Based on observation, interview, and record review, the facility failed to ensure catheter drainage bags were maintained off of the floor for three of three residents reviewed for catheters (Resident #17, Resident #30, Resident #41). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The assessment revealed the resident had an indwelling catheter. The Care Plan dated 3/22/21 revealed, I require a suprapubic urinary catheter. Observation on 6/6/24 at 9:52AM revealed Resident #17 in their room in bed. The resident's catheter drainage bag present to the side of the resident's bed, and the catheter drainage bag touched the floor in the resident's room. 2. The MDS assessment for Resident #30 dated 5/23/24 revealed Resident #30 was rarely to never understood, and further revealed the resident had an indwelling catheter. The Care Plan dated 9/4/19 revealed, Indwelling Catheter I require an indwelling urinary catheter. Observation on 6/03/24 at approximately 2:30 PM revealed Resident #30 in bed. The resident's catheter bag observed on the floor. 3. The MDS assessment for Resident #41 dated 5/23/24 revealed Resident #41 was rarely to never understood, and further revealed the resident had an indwelling catheter. The Care Plan dated 10/13/20 revealed, I have a catheter. Observation on 6/04/24 at approximately 2:54 PM revealed the resident in bed, and the resident's urinary catheter drainage bag and call light were on the floor to the right side of the resident's bed. On 6/6/24 at 10:12 AM during an interview with Staff A, Certified Nursing Assistant (CNA), Staff A acknowledged the catheter bag should be on the bed railing, positioned to not touch the floor, with catheter tubing going down flow. On 6/6/24 at 2:19 PM when queried about catheter bags on the floor, the DON acknowledged the concern, acknowledged it should not happen, and explained it was an infection control issue. The Facility Policy titled Catheter, dated 11/19, did not address the area of concern.

Based on clinical record review, observation and staff interviews the facility failed to identify increased water temperatures during a shower that resulted in second degree burns to one of three residents reviewed (Resident #1). The facility reported a census of 60 residents. Findings include: The Quarterly Minimum Data Set (MDS) Assessment for Resident #1 dated 12/14/23, listed diagnoses including debilitating cardiorespiratory (relating to the action of both heart and lungs) condition, quadriplegia (paralysis of all four limbs) and respiratory failure. The MDS identified Resident #1 in a persistent vegetative state, and dependent on staff for all activities of daily living (ADL). The Care Plan for Resident #1 dated 11/21/219, directed staff as follows: the resident required total assistance of 2 staff with bed mobility, positioning, dressing, grooming, hygiene and transfers with a full body lift. Resident #1's Event Report dated 1/16/24 at 10:25 p.m., documented that a Certified Nurses Aid (CNA) alerted Staff B, Registered Nurse (RN) that he failed to realize as he sprayed water over Resident #1's chest and torso that the water temperature got hot and caused the resident skin to turn red. The Note described Resident #1's abdomen/torso appeared red from the nipple line to just below umbilicus (belly button) and across abdomen, a small intact blister to the left border. Staff applied a normal saline soaked gauze to the area, obtained vitals and assessed pain on a faces scale at 4 out of 10. The nurse notified the Physician, who ordered a wound treatment to start as soon as the pharmacy delivered, ordered to continue saline soaks as needed to cool the area, monitor for blister worsening throughout the night and call with changes. The Medication Administration Record (MAR) dated January 2024, showed on 1/16/24 staff administered an as needed (PRN) Oxycodone 5 milligrams (mg) at 10:44 p.m., and a PRN Acetaminophen 650 mg at 2:42 a.m. The Wound Information for Resident #1 dated 1/17/23 at 8:46 a.m., identified a burn to the mid chest, anterior (front) torso 60 centimeters (cm) long by 47 cm wide. The description reflected a large amount of serous (clear, amber, thin and watery) drainage, and described the burn type as partial thickness: redness, blistered, moist, painful. The Progress Notes included a Wound note dated 1/20/24 at 11:31 a.m., from Staff C, Nurse Practitioner (NP) Chronic Wound Care Nurse (CWCN) documented: Resident#1 recent burn injury to anterior torso from chest to navel. The burn reportedly caused from hot water during a shower. The burns covered with Silvadene cream. The burns classified as superficial partial thickness with blisters that have unroofed (skin rubbed off), moist, red, weeping areas. Some burn areas are dried with dried drainage encrusted wound bed. Planned to continue Silvadene cream and add Xeroform gauze (fine mesh gauze occlusive dressing) over Silvadene, then dry gauze or abdominal (ABD) pad for drainage. The NP started oral antibiotic as the patient is febrile (fever) today. The note confirmed Resident #1 needed a dietary consult and labs checked. On 1/18/24 at 9:01 a.m., Staff E, Maintenance Supervisor, reported both of the water heaters set at 115 degrees, as of the day before. Staff E, stated the water heaters previously were set at 120 degrees. Staff E, revealed management directed the water temperature lowed because someone received a burn. On 1/18/24 at 10:25 a.m., Resident #1's right upper chest appeared like a popped blister, approximately greater than 50% of the torso affected, reddened to the left mid chest underneath the left nipple area extended in the direction of the resident's back, and a blistered left middle chest. Staff D, RN, treated the wounds with cream per the Physician's order. On 1/18/24 at 10:48 a.m., the Director of Nursing (DON) reported the Physician ordered scheduled pain medication, increased free water flushes via tube feeding and ordered labs done. The DON identified the burn as second-degree burns. On 1/22/24 at 2:52 p.m., Staff A, Certified Nurses Aid, (CNA) explained and demonstrated the process of the shower he provided Resident #1 on 1/16/24. He explained at the end of the shift on 1/16/24 about 10:00 p.m. the nurse reminded him of the shower and he thought he'd get it done fast. Staff A, reported he got Resident #1 in the shower chair, took him in the shower room. Staff A, demonstrated he took the hand-held shower head off the mount with his gloved hands and turned the water on. He reported the water temperature felt warm with his gloved hand, but not hot. Staff A reported he held the shower head in one hand, wet the resident and washed the resident with the other hand. Staff A, confirmed he kept the water on Resident #1 as he washed him to keep him warm. Staff A confirmed he failed to notice the water temperature got increased. Staff A, revealed he identified something's wrong as he dried Resident #1 and his skin peeled off. Staff A, stated he immediately reported to the nurse. Staff A reported the whole shower took about 10 minutes. The facility provided a document signed by the DON dated 1/18/24, that included her investigation summary. The document reflected Staff A failed to notice that the temperature of the water changed during the shower he gave Resident #1. The document reflected staff A received and signed a disciplinary action form. The facility Progressive Discipline Notification System for Employees dated 1/16/24, identified Staff A, rushed during care resulting injury. The facility provided the Bathing The Patient Procedure undated, that directed at point number seven, fill the tub half full of water at a temperature of 110 degrees Fahrenheit and check it with a bath thermometer. Or turn on the shower and adjust the water temperature.

Based on clinical record review, resident and staff interviews, the facility failed to provide sufficient staff to meet the needs (bathing)for 4 of 4 residents reviewed. (Residents #1, #2, #3, #4) The facility census was 58. Findings include: In an interview on 12/5/23 at 3:20 p.m. the Director of Nursing (DON) stated staff scheduling is based on census, but notes there is no specific criteria established. The DON stated she would not like to see anything more than a 1:12 to 1:15 aide to resident ratio. Currently with 34 residents on [NAME] they would minimally schedule 2 nurses, 3 aides and 1 shower aide as adequate to meet resident needs on day and evening shifts. In an interview on 12/5/23 at 1:00 p.m. Staff E, staff scheduler, stated staff numbers are dependent on the census. Currently (census 34) they schedule 2 nurses, 4 aides and 1 or 2 shower aides during day and evening shifts. According to daily assignments sheets for October 2023 on [NAME] halls, no shower aide was scheduled on either day or evening shift on the 4th, 8th, 9th, 14th, 15th, 16th, 18th, 19th, 20th, 21st, 22nd and 29th. Additionally there were 10 day shifts (1st, 2nd, 6th, 10th, 11th, 24th, 25th, 27th, 28th and 31st) and 5 evening shifts (3rd, 6th, 11th, 12th and 31st) in which staff scheduling fell below the minimum standard of 2 nurses, 3 aides and 1 shower aide. According to daily assignments sheets for November 2023 on [NAME] halls, no shower aide was scheduled on either day or evening shift on the 4th, 5th, 15th, 25th, 26th and 27th. Additionally there were 12 day shifts (1st, 2nd, 7th, 11th, 12th, 13th, 14th, 16th, 18th 19th, 20th and 30th) and 6 evening shifts (6th, 8th, 9th, 16th, 22nd and 29th) in which staff scheduling fell below the minimum standard of 2 nurses, 3 aides and 1 shower aide. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/30/23, Resident #1 had a Brief Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included acute and chronic respiratory failure with hypoxia, morbid obesity, coronary artery disease, congestive heart failure, diabetes mellitus, ventilator dependent and sleep apnea. In an interview on 12/6/23 at 1:00 p.m. Resident #1 indicated frustration with staff not responding to call lights timely, causing him to be incontinent of bowel and bladder and having to sit in his own excrement for lengthy periods of time. Resident #1 attributes the slow response to call lights to insufficient staffing. Resident #1 stated short staffing has also caused missed shower opportunist, noting there was a period of time a month or so ago in which he only got a shower one time a week for four weeks. According to bathing records, Resident #1 was to receive showers on Mondays and Thursdays. In October 2023, Resident #1 received a shower on October 5th and did not receive another shower until the 20th. Resident #1 did not receive scheduled bathing opportunities on October 9th, 12th, 16th and 23rd. According to a Quarterly Minimum Data Set (MDS) with a reference date of 10/12/23, Resident #2 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #2 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included chronic obstructive pulmonary disease, respiratory failure, coronary artery disease, acute myocardial infarction, congestive heart failure and gastroesophageal reflux disease. According to bathing records, Resident #2 was to receive showers on Wednesdays and Saturdays. During September 2023, he received showers a week apart on 1st, 8th, and 15th, missing scheduled showers on 6th, 13th, 23rd and 30th. In October 2023 Resident #2 missed scheduled showers on the 4th, 11th, 18th, 21st and 28th and in November 2023 he missed scheduled showers on the 1st, 4th, 8th, 15th, 18th, 25th and 29th. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/2/23, Resident #3 had a Brief Mental Status (BIMS) score of 14 indicating an intact cognitive status. Resident #3 required limited assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #3's diagnosis included chronic obstructive pulmonary disease, respiratory failure, coronary artery disease, renal insufficiency, congestive heart failure and gastroesophageal reflux disease. According to bathing records, Resident #3 was to receive showers on Mondays and Thursdays. During September 2023, she missed scheduled showers on the 14th and 25th. In October 2023 she received a shower on the 2nd and not again until the 23rd. Missing scheduled showers on the 5th, 9th, 12th, 16th, 19th, 26th and 30th. In November 2023 Resident #3 missed scheduled shower opportunities on the 16th, 23rd, 27th and 30th. According to a Quarterly Minimum Data Set (MDS) with a reference date of 11/30/23, Resident #4 had a Brief Mental Status (BIMS) score of 11 indicating a moderately impaired cognitive status. Resident #4 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #4's diagnosis included Displaced comminuted fracture shaft right tibia, diabetes mellitus, cerebrovascular accident (stroke) with hemiplegia, Non-Alzheimer's dementia. According to bathing records, Resident #4 was to receive showers on Mondays and Thursdays. During September 2023, she missed scheduled showers on the 11th and 25th. In October 2023 she received a shower on the 2nd and not again until the 23rd. Missing scheduled showers on the 5th, 9th, 12th, 16th, 19th and 30th. In November 2023 Resident #4 missed scheduled shower opportunities on the 16th, 23rd and 27th. In an interview on 12/4/23 at 1:00 p.m. Staff A, Certified Nurse Aide, stated she doesn't believe resident needs can be adequately met with just three aides on the [NAME] hall. Staff A stated three aides on days is typical, but notes they are only able to get the bare minimum done. Staff A stated they are able to get to most call lights promptly. Staff A stated she believes 5 aides would be more appropriate in meeting quality care standards for residents. In an interview on 12/4/23 at 3:50 p.m. Staff B, Certified Nurse Aide, (CNA) stated they currently have three aides and one shower aide working this evening. Staff B stated that was sufficient to meet resident needs if they have quality aides working and if the day shift were able to get their showers completed. Staff B stated the Director of Nursing and CNA trainer do a good job of trying to educate aides to become better aides on the floor and are aware of some of the aides limitations. In an interview on 12/5/23 at 11:45 a.m. Staff C, Certified Nurse aide, stated today with two nurses, three aides and two shower aides on West, they have adequate staff to meet resident needs. However, Staff C stated the staffing today is often not the case, citing it is often two nurses and two or three aides without shower aides. Staff C stated she was hired as a shower aide and will often get pulled to the floor, leaving showers undone. Staff C recalled on September 10th through the 16th she worked with only one other aide and no shower aides. Staff C stated ideally having two aides on each hall (6) and two shower aides would provide the best coverage to meet resident needs. In an interview on 12/5/23 at 12:00 p.m. Staff D, CNA, stated she was hired as a shower aide and works Monday through Friday with days off for school during the week. Staff D stated she often gets pulled to the floor leaving showers undone. Staff D stated they need at least four aides with one to two shower aides during the day to meet resident needs. Staff D stated they have staff scheduled, but often have call-ins. Staff are working a lot of hours and it is sometimes hard to find staff to come in. In an interview on 12/6/23 at 2:15 p.m., Staff F, CNA, stated she was a shower aide from 6:00 a.m. to 2:00 p.m. today and stated sometimes depending on their staffing she may only work until 9:00 a.m. before being pulled to the floor. Staff F stated [NAME] hall is usually staffed with 3 to 4 aides during the day and evening. When they have 4 aides, there is usually a shower aide, but with only 3 aides there is no shower aide. Staff F stated she believes 5 to 6 aides would be ideal to meet resident needs which would include 1 to 2 shower aides during the week.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that two (Resident (R) 21 and R25) of 27 sampled residents were treated in a respectful and dignified manner. Specifically, the facility allowed R21's body to be repeatedly exposed to public view due to ill-fitting pants and/or incontinence briefs. Multiple incidents in which the resident's pants fell down resluted in psychosocial harm, with the resident expressing embarrassment, becoming tearful, and/or expressing fear that she would be sent from the facility in response to the incident. Additionally, staff stood over the R25 while assisting the resident with eating, rather than sitting at the resident's eye level, maintaining face-to-face contact. Findings include: Review of an undated Admission Agreement indicated, The resident has a right to be treated with respect and dignity. 1. Review of R21's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of overactive bladder. Review of R21's quarterly Minimum Data Set (MDS), located in the resident's EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 11/03/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R21 was cognitively intact. This MDS also revealed R21 required limited assistance with toileting and was occasionally incontinent. During an observation on 02/22/23 at 9:55 AM, R21 was observed, by two surveyors, ambulating independently with a walker down the hallway. R21 stopped and spoke with the surveyors and stated she was going to her counseling appointment. R21 was observed by both surveyors to wear pants that were approximately two sizes too large for the resident, and which were hanging nearly over her shoes. During an observation on 02/22/23 at 10:13 AM, R21 was observed, by two surveyors, standing outside the facility, preparing to get into the van to leave for her appointment. At the time of this observation, the Activity Supervisor (AS) was observed adjusting R21's pants and appearing to tuck the waist band of the pants inward. This process lasted for about three minutes. During an observation on 02/22/23 at 12:15 PM, R21 was observed walking down a hallway near the nurses' station. At the time of the observation, R21's pants and incontinence brief were observed to fall down around her ankles, exposing her bare bottom. Staff and other residents were present in the area. In response, R21 was then assisted by staff. At the time of this observation, R21 was wearing different pants from the previous two observations. During an interview on 02/23/23 at 10:05 AM, R21 stated, My briefs fall down about two times a day. I don't know why it happens; I guess because I urinate a lot and they won't stay up. Sometimes hard for me to put them on. They fell two times yesterday while I was at my counseling appointment. It is embarrassing and I don't know what to do. I got some safety pins but those might pop open and scratch me. Do you think that tape will work? R21 further stated, Yesterday when I went to my appointment, it was raining, and my pants and briefs fell right down, and my pants fell right into the puddle and got wet. R21 stated the AS, was nice and she came back here and got me some dry pants and brought them back to the appointment with me. She even helped me put them on. R21 stated, People see my backside all the time and it is embarrassing to be like that in front of people. They told me that they were going to tell the head of nursing for me. During an interview on 02/23/23 at 11:27 AM, the Director of Nursing (DON) stated R21's incontinence brief falling down has been an ongoing issue for the past month. The DON further stated, With the brief coming down, that's embarrassing, and she has said that it is embarrassing. She should not have that happening to her. I can't spend her money for her but I have talked to the Social Services Director (SSD) three times about this issue and buying her some pants. I just talked to her this morning because of the pants and briefs falling down at the appointment yesterday. Today she is wearing a dress but it will still happen. I was thinking about biker shorts or something tight, so the heavy brief won't pull the pants down. The aides have tried tucking her pants into the top of her brief. During an interview on 02/23/23 at 11:44 AM, Certified Medication Aide (CMA) 2 stated R21's brief falls about two to three times a day. CMA2 stated, You are able to see her bare bottom, and this has been happening roughly for the last couple of months. When she soils her brief, it gets heavy and falls. When asked the measures the facility had put into place, CMA2 stated I know we have tried briefs and pull-ups but it keeps happening. She wets so much that they fall. We have tried to put underwear over her briefs, but they still fall. She gets really embarrassed and will say that she is embarrassed. I talked to the nurses about it. Everybody knows that it happens. I guess they are trying to come up with a plan. CMA2 further stated that R21 has been more incontinent lately. CMA2 stated R21 is independent in putting on her brief and we have told her to call for help when she is in the bathroom so that we can make sure that it is pulled up all the way up but I don't know how often she actually calls for help. During an interview on 02/23/23 at 3:26 PM, the SSD stated, R21 has been having stress incontinence and behaviors related to it. The SSD stated, She needs help with putting on her incontinence briefs and they are the kind with the sticky part and I don't think that she is able to get it on tight enough. I keep educating her on how to get it on. We have tried the pull-up kind and she stated those are uncomfortable to her. I think because of the way she is shaped like an apple; we can't get ones to fit her correctly. When she urinates, they fall because she doesn't have them pulled up far enough. Before her incident on yesterday that I was told about, the only other time that I know it happened was a little while back because it happened in my office. She had just left therapy and was coming to my office crying because she had an incontinent episode in therapy and her brief and pants fell down in my office. I made a note about it. This occurred on 12/30/22. The incontinence has been ongoing prior to December. When she had the incident yesterday at the doctor's office, the DON brought it to my attention, and we are going to have to figure something out. I was unaware of it happening before yesterday except for the time that it happened in my office. I was unaware that her bare bottom showed at any time. Review of R21's Resident Progress Notes, dated 12/30/22, written by the SSD, located in the resident's EMR under the Resident tab revealed the following: Res [resident] expressing emotional reaction-Fearful/upset/crying Res came to SS [social services] office in tears and started to become more upset-crying harder. SS encouraged resident to take some big breaths and assisted her to sit-closed doors for privacy. Res was also malodorous. SS notes that Resident attends unit is around her ankles-wet-Resident reported that had an accident in the Therapy room--Res reported that she doesn't want to be taken away. Res expressed that she is fearful that she is going to be placed to another facility due to her accidents-with urine and occasional BM [bowel movement] incontinence. SS provided support and reassurance that she is not being discharged -nor sent anywhere else-as this is her home-till she asks for a referral otherwise. Res started to calm down and appeared to believe that she was safe. Res stated that she doesn't understand why she is having so many accidents. SS talked with resident about going to the restroom more often-changing the type of brief that she is using--Res stated that it is hard to her to put on the other type of briefs and as she continues to use the pull ups. SS reported that we would assist her with attaching the attends unit. Res also shared that she has been missing her son and Nephew and . [son] had reported that he would come down to visit and has not--SS Notes that this had been an ongoing struggle with resident and her family not having strong contact. SS provided assists to resident's room-getting clean clothing-and linens. Resident much calmer-reported that she feels better-Res then walked to lunch. SS to continue to be available-as encouraged to Res. During an interview on 02/23/23 at 3:40 PM, the AS stated, I took her [R21] to her appointment yesterday. When we were getting ready to get on the van, her brief had fallen down inside her pants. The brief was not wet; I think that it wasn't on properly. I was pulling her brief up using the outside of her pants. When were about to get back into the van to go to correct appointment location, her pants and brief fell completely down. You could only see her legs because her shirt covered her backside, and she had on a long jacket. I hurried and pulled them back up because we were in a parking lot but there was no one around. The AS further stated, I used to be a [sic] aide on the floor and I used to take care of her. She has a large stomach and if the brief isn't pulled up over her stomach or up far enough, they fall down. It is hard for her to do it because she has to use one hand to pull up her brief and the other hand is on her walker to keep her steady so she has to keep switching hands back and forth. People think that she is independent, but she really isn't because she can't keep herself steady when putting on the brief. She can't fasten the tape on the brief with one hand. She really needs help and I guess the staff think that she is more independent than she really is. Her incontinence episodes are getting more frequent. It is happening in activities and the residents are talking about her in front of her, but I redirect them but she has started to refuse to leave activities in order to get changed. 2. During a dining observation on 02/21/23 at 8:07 AM, Licensed Practice Nurse (LPN) 2 was observed standing over R25 while feeding the resident. R25 was seated in a wheelchair in the assisted dining room at the time of observation. A chair was available in the assisted dining room for LPN2's use; however, LPN2 was observed for a four-minute continuous period, to stand over the resident while feeding her. Restorative LPN3 was observed to tell LPN2 to sit while feeding the resident. During an interview on 02/21/23 at 8:13 AM, LPN2 stated, I didn't know to sit to feed her before because I have never fed a resident before. Review of R25's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R25's annual MDS, located in the resident's EMR under the RAI tab with an ARD of 02/09/23, revealed a BIMS score of 11 out of 15, indicating R25 was moderately impaired. This MDS also revealed that R25 was independent with eating. During an interview on 02/22/23 at 10:33 AM, the SSD stated, Staff should be seated when feeding a resident for dignity purposes. During an interview on 02/23/23 at 10:16 AM, the Administrator stated, My expectation would be for the staff to be seated and at eye level with the resident so there can be conversations, unless when seated and the resident would not be at eye then they are able to stand. During an interview on 02/23/23 at 10:35 AM, Restorative LPN3 stated, When assisting a resident to eat, the staff should be seated and at eye level. During an interview on 02/23/23 at 10:48 AM, the Dietary Manager (DM) stated, When feeding a resident, the staff should be seated and having conversations with the residents. I see this here all the time and they really just need to take the time to sit down with the residents. During an interview on 02/23/23 at 11:27 AM, the DON stated, I expect for staff to sit when they are feeding residents, unless they are feeding two residents, then they can stand and feed the two residents.

Based on interview, record review, and review of facility policy, the facility failed to provide a written notice of transfer to the resident and/or resident's representative for four (Resident (R) 30, R32, R61 and R116) of four residents reviewed for hospitalization to ensure that the resident and/or their representative were informed of all pertinent information regarding their transfer to another health facility. Findings include: 1. Review of R30's Face Sheet, found under the resident tab in the Electronic Medical Record (EMR), revealed an admitted [DATE], with medical diagnoses that included respiratory failure and dependence on a respirator. Review of the Progress Notes under the resident tab in the EMR, dated 11/25/22 at 12:34 AM, revealed, While performing this resident's vent check, this RT [respiratory therapist] noticed an absence in lung sounds throughout. When asked if he [R30] had any difficulty breathing he said yes. RT called his nurse in to assess . His nurse was unable to detect any breath sounds throughout . Resident appears ashen in skin tone and lethargic. He was sent to the hospital to be further evaluated. Review of the resident's clinical record revealed no evidence that a written notice, which contained all required information including the reason and effective date for the transfer, the location to which the resident was transferred, and information about the resident's appeal rights and how to contact the Long-Term Care Ombudsman, was provided to either the resident and/or their representative. 2. Review of R32's Face Sheet, found under the resident tab in the EMR, revealed an admitted [DATE] with medical diagnoses that included chronic kidney disease (stage 4) and anxiety. Review of the Progress Notes under the resident tab in the EMR, dated 02/20/23 at 4:13 AM revealed the resident was transferred to the hospital for vaginal bleeding. Review of the resident's clinical record revealed no evidence that a written notice, which contained all required information including the reason and effective date for the transfer, the location to which the resident was transferred, and information about the resident's appeal rights and how to contact the Long-Term Care Ombudsman, was provided to either the resident and/or their representative. 3. Review of R61's Face Sheet, found under the resident tab in the EMR, revealed an admitted [DATE] with medical diagnoses that included dependence on a respirator and chronic disease. Review of the Hospital Notes under the resident tab in the EMR, dated 01/23/23, revealed, pt [patient] admitted to hospital from [facility name] pt with hx [history] of anoxic brain injury - vent dependent. She presented with tachypnea pt with sepsis - looking into antibiotics and then may be able to d/c [discharge] back. Review of the resident's clinical record revealed no evidence that a written notice, which contained all required information including the reason and effective date for the transfer, the location to which the resident was transferred, and information about the resident's appeal rights and how to contact the Long-Term Care Ombudsman, was provided to either the resident and/or their representative. 4. Review of R116's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R116's Census Report, located in the EMR under the Resident tab, revealed R116 was transferred to the hospital on 06/24/21. Review of R116's medical record revealed no evidence of a written notice of transfer to the resident and/or the resident's representative. During an interview with Registered Nurse (RN) 2, on 02/22/23 at 10:58 AM, she stated when a resident needed to go to the hospital, the resident's doctor and the resident's responsible party would be notified verbally. RN2 stated she was not aware of any paperwork that was provided to the resident or their responsible party when the resident was sent to the hospital that explained the reason for the transfer to the hospital. During an interview with the Director of Nursing (DON), on 02/22/23 at 11:30 AM, she stated the facility did not complete a discharge or transfer form and was unaware one was required per regulation. During an interview with the Administrator, on 02/22/23 at 12:07 PM, she stated the facility did not use a transfer form when a resident was sent to the hospital and was not aware one was needed. The Administrator stated the facility did not have a policy for this requirement but would be implementing one.

Based on interview and record review, the facility failed to ensure that four (Resident (R) 30, 42, 56 and 21) of 31 residents (27 sampled and four supplemental residents) had Minimum Data Set (MDS) assessments completed in accordance with instructions from the Resident Assessment Instrument (RAI) 3.0 User's Manual. Residents who could communicate and answer questions were not interviewed by facility staff to determine their cognitive and/or mood status. Staff made their own determination in these areas, and inaccurately reflected residents' cognitive status. Findings include: Review of the RAI 3.0 User's manual, dated 10/2019, revealed the following instructions related to Section C (Cognitive Patterns), The RAI assessment process is the basis for the accurate assessment of each resident .Most residents are able to attempt the Brief Interview for Mental Status. A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis. Instructions for C0100 included the statement, Should Brief Interview for Mental Status be conducted? Attempt to conduct interview with all residents. Further instructions for Section C revealed the instruction, Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted, but was not done. Instructions for Section D (Mood) revealed the following information: Should Resident Mood Interview be conducted? Attempt to conduct interview with all residents Do not complete the Staff Assessment of Resident Mood items (D0500) if the resident interview should have been conducted, but was not done. 1. Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. a. Review of R42's Progress Notes, dated 10/01/22 through 10/12/22 and located under the Resident tab of the electronic medical record (EMR), indicated R42 was alert, oriented, and capable of answering questions related to mental status and mood. Review of R42's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/22 and located under the RAI (Resident Assessment Instrument) tab of the EMR indicated staff did not conduct the Brief Interview for Mental Status in the Cognitive Patterns section of the MDS. Although the resident was capable of answering questions, staff instead conducted the Staff Assessment for Mental Status and coded R42 as having modified independence in cognitive skills for daily decision making. In addition, staff failed to conduct the Resident Mood Interview in the Mood section of the MDS, and instead completed the Staff Assessment of Resident Mood instead. b. Review of R42's Progress Notes, dated 01/01/23 through 01/11/23 and located under the Resident tab of the EMR, indicated R42 was alert, oriented, and capable of answering questions related to mental status and mood. Review of R42's quarterly MDS with an ARD of 01/12/23 and located under the RAI tab of the EMR revealed staff did not conduct the Brief Interview for Mental Status in the Cognitive Patterns section of the MDS. Instead, staff completed the Staff Assessment for Mental Status and coded R42 as being moderately impaired in cognitive skills for daily decision making. In addition, it was indicated that staff did not conduct the Resident Mood Interview in the Mood section of the MDS but conducted the Staff Assessment of Resident Mood instead. Review of R42's Progress Note, dated 01/16/23 at 12:33 PM and located under the Resident tab of the EMR, indicated, SS [Social Services] completed MDS based off of Resident progress notes, observations and documentation. During an interview on 02/22/23 at 10:31 AM, the MDS Coordinator (MDSC) stated, Section C is handled by our Social Services Director (SSD). She is the one that actually inputs the cognition data into the system. During an interview on 02/23/23 at 3:39 PM, the SSD confirmed R42 was capable of answering the cognitive and mood interview questions on the 10/13/22 MDS. The SSD stated she attempted to interview R42 and R42 had asked her to come back at a different time, but she could not as the assessment was due on that day. Further interview with the SSD confirmed that R42 was also capable of answering the cognitive and mood interview questions on the 01/12/23 MDS. However, the SSD had completed the staff assessment instead, based on progress notes, observations, and documentation. The SSD stated she did not remember if R42 had been sleeping but she did not document that R42 refused the interview. The SSD stated it was best practice for residents to participate in the interviews and she had not been reporting when residents did not participate in the interviews. During an interview on 02/23/23 at 4:05 PM, the MDS Coordinator (MDSC) confirmed it was her job to monitor the accuracy of the MDS and it was the facility's policy to follow regulations related to MDS accuracy. The MDSC stated staff had six to eight days to complete their sections of the MDS and that allowed ample to conduct resident interviews. 2. Review of R56's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R56's quarterly MDS, located in the resident's EMR under the RAI tab with an ARD of 08/09/22, revealed a BIMS score of 14 out of 15, indicating R56 was cognitively intact. Review of R56's quarterly MDS assessments, with ARDs of 11/03/22 and 02/02/23, revealed these two assessments were not conducted in accordance with instructions from the RAI manual. Although the resident was able to communicate and answer questions, staff failed to conduct the resident interview to determine the BIMS score of this resident. Instead, for these MDS assessments, staff completed their own determination of the resident's mental status. Further review of these MDS, revealed that although the resident had previously been identified as cognitively intact, on both the 11/03/22 and 02/02/23 MDS, staff now documented the resident was moderately cognitively impaired. Review of R56's Resident Progress Notes, dated 11/03/22, written by the SSD, located in the resident's EMR under the Resident tab revealed the following: SS [Social Services] completed MDS based off of Documentation and interactions. Res [resident] was presently unavailable due to an appointment. During an interview on 02/22/23 10:33 AM, the SSD stated that R56 was very talkative and had good memory recall. The SSD further stated that R56 was alert and oriented times three except when he is sick and his cognition lowers. When asked if R56 was sick during the time of the 02/02/23 MDS assessment, the SSD stated R56 was not sick. When asked why R56's BIMS was not assessed on the MDS assessment, the SSD stated, I put 'not assessed/no information' and I did the staff assessment portion. That's what I put in if I didn't get a chance to do the cognitive questions, like if he was asleep or not able to participate. I should have documented how many attempts I made to talk to him so that we could have the BIMS score reflect accurately. I usually attempt three times. The SSD further stated, It [BIMS] should have been completed on him. I didn't document why so not sure why I didn't do it that day. When asked about the 11/03/22 MDS assessment, the SSD stated, That one should have been done also. I put a note in for November that he was at doctor's appointment. The SSD further stated that when the MDSC opens the assessment, they are open for a day or two and that is our timeframe to put in the information. The SSD stated, Just because he was not in the facility at that moment, I should have went [sic] back and checked again in order to complete his BIMS. When asked why the staff assessment portion that the SSD completed reflected R56's cognition to be moderately impaired, (equivalent to a BIMS score of between eight through 12,) the SSD stated, I should have put that he was cognitively intact. His BIMS score is normally a 14 or 15. During an interview on 02/22/23 at 2:13 PM, the MDSC stated, When staff are to assess the residents, I leave the MDS open from Monday - Friday or from Friday - Friday so that the staff can have time to input the data. I expect the sections to be completed accurately and I expect the staff to attempt to see resident at least three to four times in order to get the assessment completed accurately. 3. Review of R21's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS, located in the resident's EMR under the RAI tab with an ARD of 11/03/22, revealed a BIMS score of 15 out of 15, indicating R21 was cognitively intact. Review of R21's annual MDS, with an ARD of 02/02/23, revealed this assessment was not conducted in accordance with instructions from the RAI manual. Staff failed to conduct the resident interview to determine the BIMS score of this resident, who was able to communicate and answer questions. Instead, staff completed their own determination of the resident's mental status. Further review of this MDS revealed that although the resident was previously assessed as cognitively intact on the 11/03/22 MDS, the resident was now documented as being moderately cognitively impaired During an interview 02/23/23 at 3:26 PM, the SSD stated that R21 was alert and oriented times three. When asked why R21's BIMS was not assessed on the MDS assessment, the SSD stated, I didn't put a note why it wasn't done. The SSD confirmed R21 was available at the facility during the time the MDS was due and had no answer as to why the BIMS was not completed. When asked why the staff assessment portion that the SSD completed reflected R21's cognition to be moderately impaired (reflecting an equivalent BIMS score of between eight through 12), the SSD stated, Her BIMS score is normally 15. The SSD stated that although there was no change in the resident's cognition, she scored it lower when she completed her assessment. The SSD was unable to answer why she reflected R21's BIMS inaccurately. 4. Review of R30's Face Sheet, found under the resident tab in the EMR, revealed an admitted [DATE] with medical diagnoses that included respiratory failure and dependence on a respirator. Review of R30's quarterly MDS, provided by the facility, with an ARD of 10/27/22, revealed a BIMS score of 15 out of 15, indicating R30 was cognitively intact. Review of the most recent MDS, with an ARD of 01/26/23, revealed that although the resident could communicate and answer questions, staff failed to interview the resident to complete the BIMS score or mood assessment. Instead, review of the 01/26/23 MDS revealed that staff completed the assessment of these areas with no staff interview. During an interview with the social services director (SSD), on 02/23/23 at 1:47 PM, she stated she was responsible for completing section C, D, E, Q, and Z of the MDS. The SSD stated she would be notified when the MDS needed to be completed, based on the weekly list provided by the MDSC. She stated she would typically try three times to interview the resident in case they were out at an appointment or asleep. She stated she would document in the progress note if the resident was not available for the interview. The SSD confirmed the resident interviews for section C (Cognitive) and Section D Mood) were not completed for the ARD of 01/26/23 and there was no documentation indicating why these portions of the MDS were not completed. She stated R30's cognition had not changed and R30 was interviewable. During an interview with the MDS Coordinator (MDSC), on 02/23/23 at 2:15 PM, she stated she would send out a weekly list indicating which MDS were due the following week. She stated she would leave the MDS open for seven days and would verify all departments had completed their portion of the MDS. She stated she expected the MDS to be accurate but did not verify accuracy of sections that were completed by other staff During an interview with the Administrator and the Director of Nursing, on 02/23/23 at 2:29 PM, they stated they expected all sections of the MDS to be completed accurately. During an interview 02/23/23 at 2:40 PM, the Administrator stated, We do not have a MDS policy. We follow the RAI manual. 25225 37245

Based on interview and record review, the facility failed to ensure Registered Nurses (RN) and/or Certified Nurse Aides (CNAs) with resident responsibilities were involved in the care planning process for three (Resident (R) 42, 56, and 30) of 27 sampled residents. Findings include: 1. Review of R42's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated R42 was admitted with diagnoses that included adjustment disorder. Review of R42's Care Plan, last reviewed and revised 01/23/23 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed no evidence that an RN or CNA with responsibility for the resident was involved in the care planning process. During an interview on 02/23/23 at 9:32 AM, CNA3 stated she worked with R42 frequently. CNA3 stated the CNAs did not attend care plan meetings for R42 or any resident and had never been asked for input into any resident's care. During an interview on 02/23/23 at 9:37 AM, RN1 stated she had been responsible for R42 since 10/2022. RN1 stated she did not attend care plan meetings for R42 or any resident and had not been asked to provide input into the care planning process for any resident. RN1 stated the floor nurses did not attend care plan meetings. 2. Review of R56's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE]. Review of R56's Care Plan, dated 01/20/23 located in the resident's EMR under the RAI tab revealed R56's most recent care conference was on 02/14/23. Review of R56's care plan information revealed no evidence that a CNA or RN participated in the resident's care planning process. 3. Review of R30's Face Sheet found under the resident tab in the Electronic Medical Record (EMR), revealed an admitted [DATE], with medical diagnoses that included respiratory failure and dependence on a respirator. Review of R30's Care Plan, found under the resident tab in the EMR, revealed it was last revised on 01/23/23 by the Minimum Data Set Coordinator (MDSC). Further review of the care plan information revealed no evidence that a CNA was involved as part of the interdisciplinary team who developed/revised the care plan. During an interview on 02/23/23 at 10:48 AM, the MDSC stated the facility held weekly care plan meetings where she and representatives from the activities, dietary, restorative, and social services departments met to review and revise the residents' care plans. The MDSC stated she tried to talk with the CNAs before any care plan meeting, but confirmed the floor nurses and CNAs were not involved in the care planning process for any resident. On 02/23/23 at 4:16 PM, the Administrator stated the facility's policy for the care planning process was to follow the regulations. 35690 37245

Based on observation, interview, record review, and review of facility policy, the facility failed to provide food storage in a safe and consistent manner. Frozen food was not stored at a temperature to ensure that the food remained frozen. Expired perishables were available for use. Opened foods were not securely closed, labeled, and dated. This had the potential to affect 45 of 62 residents who consumed food from the kitchen. Findings include: Review the of facility's undated policy titled, Food Storage (Dry, Refrigerated, and Frozen) indicated, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. This policy also indicated, General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded; c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Review the of facility's undated policy titled, Refrigerator and Freezer Temperatures indicated, 2. The employee ensures that all cold storage units are 41F [degrees Fahrenheit] or below for refrigeration or 0 F or below for freezers. This policy further indicated, 3. The temperature of each refrigeration and freezer unit is checked by the staff member who is closing the department for the day. The temperature is verified to be in the correct range as listed in #2 above. If the unit is not in the correct operating range, the staff member alerts management per facility policy. 1. During an initial kitchen walkthrough with the Dietary Manager (DM) on [DATE] beginning at 9:00 AM, the following was observed: a. The ice machine had some black buildup on the right interior and on edge. The DM stated, The ice machine is cleaned monthly by kitchen staff or as needed. A quarterly flushing/sanitation is completed by an outside company. The DM stated that she would clean the black substance right away. b. In the stand-up meat freezer, immediately upon opening freezer, the temperature gauge read 10 degrees. The temperature affixed to the side of the stand-up meat freezer revealed the most recent temperature of -10 degrees on [DATE]. The DM stated that Dietary Aide (DA) documented the freezer temps this morning. An interview was conducted with the DA at this time. The DA stated, The temperature was 10 degrees, not -10 degrees. I put that number down by mistake. Further review of the temperature log showed the temperature was documented as above 0 degrees for 18 of 19 days in the month of February 2023, with one additional day not being documented. The DM stated she was unaware that there were any issues with the freezer. The DM further stated The freezer temp should be 0 degrees and below. The staff should have informed me of the freezer issue. c. In the stand-up meat freezer, there were 12 packs of Hillshire Farm smoked ham, 32-ounce packages, starting to thaw as evidenced by water droplets in the packages. The DM stated, We are going to remove these immediately and figure out what is going on with the freezer. d. In the dry storage room, there was a 16-ounce carton of corn starch, opened, undated, and unlabeled. The DM stated this item should be dated and labeled. e. In the dry storage room, there was a six-pound carton of rainbow sprinkles opened to air, undated and labeled. The DM stated, I'm going to discard this. f. In the dry storage room, there was a 16-ounce bag of marshmallows, open to air, undated and unlabeled. The DM stated the food should not be opened to air and should also be dated labeled. g. In the dry storage room, there were four bags of coconut flakes with a date printed on each bag of [DATE] and a written date on each bag of [DATE]. The DM stated I am unsure of the dates but the items should be thrown out. h. In the walk-in cooler, there was a container of what the DM stated was icing. The icing was undated and unlabeled. The DM stated the item is required to be dated and labeled. i. In the walk-in cooler, there was a container with an onion and pepper, both cut in half, undated and unlabeled. The DM stated the items is required to be dated and labeled. j. Near the cook's area, there were two 25-pound containers of flour and sugar, undated and unlabeled. The DM stated the items should be dated and labeled. 2. During a tour of the refrigerators outside of the kitchen with the DM on [DATE] beginning at 9:37 AM, there were three eight-ounce cartons of milk with an expiration date of [DATE] in the refrigerator on the West unit. The DM stated, Staff gets all of the items from the kitchen and these should have been disposed of. During an interview on [DATE] at 9:45 AM, the DM stated she expected all foods to be stored properly, including being dated and labeled as required. The DM stated that she expected the staff to check as needed for expired foods. During an interview on [DATE] at 10:16 AM, the Administrator stated she expected the freezer to be in working order, food to be stored appropriately and expired foods to be discarded.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during meal service so as to potentially prevent the development and transmission of communicable diseases for two of two dining observations in the main dining room. Findings include: During a continuous dining observation on 02/20/23 at 12:05 PM through 12:35 PM, the following was observed: 1. Certified Nursing Assistant (CNA)2, Dietary Aide (DA)5, Activity Assistant (AA), Dietary Manager (DM), DA3, and DA4 were observed serving meal trays to residents. These staff were observed to do the following: Remove meal trays from the steam table area. Serve the meal tray to the resident. Set up resident's meal, which included opening creamers, straws, setting up utensils, stirring in creamers. Adjust resident's chairs, wheelchairs, don clothing protectors, and adjust resident's clothing. Return to the steam table area to get another resident's tray and repeat the above steps. During this time, DA4 was also loading the cart for hallway meal trays. a. Throughout the meal process. CNA2, DA5, AA, DM, DA3, and DA4 failed to perform hand hygiene during the above process, as they passed trays and made contact with multiple residents. b. After passing meal trays, CNA2 was observed to begin feeding Resident (R) 31. CNA2 failed to perform hand hygiene between passing meal trays and assisting R31 with eating. c. DA5 was observed serving and setting up meal trays, pouring drinks, and going back and forth between the dining room and the kitchen, bringing resident food from the kitchen, and delivering to the resident. DA5 failed to perform hand hygiene during this observation. d. After passing meal trays, AA was observed to begin feed R27. AA was observed to put on gloves before she began assisting R27 to eat. AA was then observed to remove her gloves, open a condiment packet, and put the condiment on R27's food. AA then began cutting up food for R27's tablemate and went directly back to feeding R27. AA used the same silver to cut up the tablemate's food that the tablemate was already using. AA did not perform hand hygiene prior to feeding R27, after removing her gloves, or after touching the tablemate's silverware. During an interview on 02/20/23 at 12:35 PM, CNA2 stated she was taught to wash hands before serving meals in the dining room. During an interview on 02/20/23 at 12:36 PM, AA stated she taught to wash her hands before serving meals and to wear gloves while feeding. 2. During a second continuous dining observation on 02/21/23 at 8:07 AM through 8:22 AM, the following was observed: 1. DA2, DA4, Restorative Licensed Practical Nurse (LPN)3, and CNA7 were observed serving meal trays to residents. These staff were observed to do the following: Remove meal trays from the steam table area. Serve the meal tray to the resident. Set up resident's meal, which included opening creamers, straws, setting up utensils, stirring in creamers. Adjust resident's chairs, wheelchairs, don clothing protectors, and adjust resident's clothing. Return to the steam table area to get another resident's tray and repeat the above steps. During this time, DA4 was also loading the cart for hallway meal trays. Throughout the above process, DA2, DA4, Restorative LPN3, and CNA7 failed to perform hand hygiene as they touched multiple residents, as well as items such as silverware and glasses used by residents. During an interview on 02/21/23 at 8:22 AM, DA2 stated she was trained to wash hands at the sink before serving meals. During an interview on 02/21/23 at 8:23 AM, CNA7 stated, I was trained to sanitize hands before meal pass and put on gloves when sitting to feed resident. During an interview on 02/21/23 at 8:24 AM, DA4 stated he was trained to sanitize hands before meals. During an interview on 02/23/23 at 10:16 AM, the Administrator stated, I expect hands to be cleaned prior to walking into dining and between contact with residents. Also, after staff take their gloves off, they are supposed to wash their hands. During an interview on 02/23/23 at 10:40 AM, the Infection Preventionist (IP) stated, Staff are to wash or sanitize hands before serving and after contact with residents. Staff are also to wash hands after removing gloves. During an interview on 02/23/23 at 10:48 AM, the DM stated, I expect hand hygiene before coming to serve in the dining room and contact with residents. I also have told them not to wear gloves if they are not touching food because if they put gloves on and touch everything, the gloves are no longer clean. During an interview on 02/23/23 at 11:27 AM, the Director of Nursing (DON) stated, I expect hands to be sanitized before feeding a resident. The staff should have gloves on also. Hands should be sanitized between contact with residents. I worry about that because we have so many residents with MDRO (multi-drug resistant organism) and don't want the organisms to spread.

Based on observation, interview, and record review, the facility failed to determine if self-administration of medication was safe and clinically appropriate for two (Resident (R) 11 and R37) of 27 sampled residents. Findings include: Review of a facility policy titled, Self-Administration of Medication, revised 02/2013, indicated, The facility, in conjunction with the interdisciplinary team, should assess and determine, with respect to each resident, whether self-administration of drugs is safe and appropriate. 1. a. During an observation on 02/20/23 at 1:47 PM, R11 was in her room performing her nebulizer treatment. There were no staff present during this observation. At 1:49 PM, R11 was observed turning off the nebulizer. During an interview on 02/21/23 at 9:09 AM, R11 stated that she does her nebulizer treatment three times a day. R11 stated, The nurse put the solution in and then I do the treatment for about 10 minutes. When asked if she had been assessed by staff to self-administer her nebulizer, R11 stated, No, but I know how to do it. b. During a continuous observation on 02/21/23 at 2:03 PM, R11 was in her room performing her nebulizer treatment. There were no staff present during this observation. At 2:17 PM, R11 was observed turning off the nebulizer. Review of R11's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and asthma. Review of R11's quarterly Minimum Data Set (MDS), located in the resident's EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 01/19/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R11 was cognitively intact. Review of R11's Prescription Order, dated 11/07/22, located in the resident's EMR under the Orders tab revealed, Ipratropium-albuterol solution for nebulization; 0.5 mg [milligrams]-3 mg (2.5 mg base)/3 mL [milliliters]; amt[amount]: 3 mL (one vial); inhalation. Three times a day. Continued review of R11's EMR revealed the absence of an order for self-administration of medication and no evidence that the facility had completed an assessment for self-administration of medication. Review of R11's January 2023 - February 2023 Medication Administration Record, located in the resident's EMR under the Resident tab revealed R11 received the ipratropium-albuterol solution as ordered. During an interview on 02/22/23 at 8:36 AM, when asked about R11's nebulizer treatments, Certified Medication Aide (CMA)1 stated, I set the medicine up into the canister and then she likes to do them after breakfast. So, I have it already prepared in the canister. When she returns to her room, she flips on the nebulizer and does her treatment. It takes about ten minutes complete the treatment. Later, I check on her and look at canister to verify that it is empty. 2. a. During an observation on 02/20/23 at 11:02 AM, R37 was observed seated upright on the edge of her bed with a nebulizer on the bed with the resident. b. During an observation and concurrent interview on 02/21/23 at 2:00 PM, R37 was observed seated upright on the edge of her bed with a nebulizer on the bed with the resident. When asked about the nebulizer, R37 stated, I do it myself. The staff does the medicine and I take it off when the medicine runs out and I turn off the machine. Well, yeah, sometimes they turn it on and sometimes I do, and I always turn it off. When asked how often she is scheduled to receive the nebulizer treatment, R37 stated, A couple of times a day. When asked if staff watched to ensure the treatment was done correctly, R37 stated, No. When asked if staff educated her on the nebulizer treatment, R37 stated, No, they just put in on my bed to make sure that I can reach it and they put the medicine in. c. During an observation on 02/22/23 at 11:12 AM, CMA1 administered R37's nebulizer medication and the treatment began at 11:17 AM. CMA1 proceed to administer medication to R37's roommate and then left the room at 11:17 AM. At 11:27 AM, R37 removed the nebulizer from her mouth, looked at the remaining medication in the holder, and placed the nebulizer back in her mouth. At 11:32 AM, R37 checked the remaining medication, laid the nebulizer on the bed, and turned the machine off. R37 stated she always self-administered her nebulizer treatment. R37 further stated she had not been assessed by the staff to determine if she could self-administer. Review of R37's undated Resident Face Sheet, located in the resident's EMR under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses of congestive heart failure and chronic respiratory failure with hypoxia. Review of R37's quarterly MDS, located in the resident's EMR under the RAI tab with an ARD of 12/29/22, revealed a BIMS score of 15 out of 15, indicating R37 was cognitively intact. Review of R37's Prescription Order, dated 11/07/22, located in the resident's EMR under the Orders tab revealed, Ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1 vial; inhalation. Four times a day. Continued review of R37's EMR revealed the absence of an order for self-administration of medication and no evidence of an assessment for self-administration of medication. Review of R37's November 2022 - February 2023 Medication Administration Record, located in the resident's EMR under the Resident tab revealed R37 received the ipratropium-albuterol solution as ordered. During an interview on 02/22/23 at 8:36 AM, when asked about R37's nebulizer treatments, CMA1 stated, I go into the room, put the medicine into the canister, I start the machine for her or sometimes she starts the machine, she does her treatment, and turns it off when she is done. I go back in later and verify the medicine has been completed. When asked about a self-administration assessment, the CMA stated, I don't know if she has been assessed to do the medication. I think that respiratory therapy would do something with that. I have witnessed her do her treatment before. During an interview on 02/22/23 at 12:07 PM, the Director of Nursing (DON) stated, There are not any self-administration assessments for these residents [R11 and R37]. The DON further stated that she was unaware R37 and R11 were self-administering their nebulizer treatment. The DON confirmed there were no physician orders for R37 or R11 to self-administer medications. During an interview on 02/22/23 at 12:09 PM, the Infection Preventionist (IP) and previous DON stated, I have seen the self-administration assessments before, but we don't do those. The IP also stated she was unaware that R37 and R11 were self-administering their nebulizers.

Based on interview, record review, and facility policy review, the facility failed to promote self determination to support and honor a resident's expressed desire to lose weight for one (Resident (R) 56) of five residents reviewed for nutrition out of a total sample of 27 residents. Findings include: Review of R56's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes. The resident was listed as his own responsible party. Review of R56's quarterly Minimum Data Set (MDS), located in the resident's EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 08/09/22, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R56 was cognitively intact. Review of R56's Weights, located in the resident's EMR under the Resident tab revealed R56 weighed 251 pounds 08/05/2022 and 208 pounds on 02/05/2023, which was a 17.13 % (percent) weight loss in six months. Review of R56's Physician Orders, located in the resident's EMR under the Resident tab revealed the following order dated 01/28/23: Ensure Plus Protein 1 carton Twice A Day. Review of R56's Progress Notes, located in the resident's EMR under the Resident tab revealed the following notes: a. 02/03/23: assessment completed. BMI [body mass index] is 34.9 and is obese. receives a house diabetic diet with regular texture. Wts [weights] stable this quarter. also receives Ensure Pro for healing and hx [history] of wt loss. has 4 wound sites. albumin is mildly depleted. monitor wts monthly and reassess quarterly. b. 02/08/23: has had a significant weight loss in 180 days weight is stable weight 208 BMI 34.61 he is fed by staff started on ensure plus protein for wound care and when not eating as well at time chooses to eat soup at meals will cont [continue] to encourage at meals. c. 02/10/23: wt loss at 180 days. wt is stable for last 30 days. approaches for wound healing and wt loss are liquacell (100 cal[calories]/ and 16 GR [gram] protein/srvg [serving]), Ensure Plus protein (360 calories and protein per srvg). receives a house diabetic diet with regular texture. d. 02/18/23: Noted and Dr. aware of 43# [pound] weight loss in 6 months. Res continues on House Diabetic. Appetite has been good. Meals in dining room. Weight loss had happen [sic] when res was sick and in hospital. Res aware of weight loss. During an interview on 02/22/23 at 8:49 AM, when asked about his recent weight loss, R56 stated, I was 250 pounds. I didn't want to be 250 pounds, so I started eating less. During an interview on 02/22/23 at 8:44 AM, when asked about R56's weight loss, Certified Medication Aide (CMA)1 stated, He had COVID for a while and had weight loss then. He is on Ensure twice a day and he started that on 01/28/23. Sometimes he doesn't eat his entire meal. During an interview on 02/22/23 at 10:33 AM, the Social Services Director (SSD) stated, He always says that he wants to lose weight. I would tell him that he was good as he was. I thought he was teasing and just talking, you know. He didn't say it aggressively but stated he wanted to lose weight, but we were worried with his wounds and the extra protein needs. The SSD stated that she did not document R56's expressed desire to lose weight. The SSD further confirmed she did not inform the nursing staff or the dietary manager (DM) of R56's desire to lose weight. During a follow-up interview on 02/23/23 at 10:01 AM, R56 stated he told the SSD I wanted to lose weight. She told me that I was OK like I was, but I don't want to weigh 250 pounds, so I decided to cut back some. Now I eat soup and eggs and fruit. I lost my leg and decided I needed to do better with eating so I can get well. I don't want to be sick, and I don't want to weigh too much. During an interview on 02/23/23 at 10:16 AM, when asked about R56's weight loss, the Administrator stated, Yes, he has lost weight. He used to eat a lot of sweets, but I noticed that he has been eating more soups and peaches. The Administrator further stated, I was not aware that he wanted to lose weight. I would expect that if he told someone that he wanted to lose weight, it should be documented, and we should assist him in losing weight. He should not have been brushed off. It should have been documented and taken seriously. During an interview 02/23/23 at 10:48 AM, the Dietary Manager (DM) stated, I did not know that he wanted to lose weight. That was not communicated with me. I documented that he was sick and lost a limb and that attributed to his weight loss. I talked with the dietician, and she added the ensure to add the extra calories. He used to love sugar and always ate his desert first. He was always asking for honey buns and such. I would always educate him but that was still his choice. The DM further stated, After he lost his leg, I started noticing that he was asking for different foods and wasn't eating the sweets anymore. I think that, when he had the amputation, that scared him. I saw him eating less sweets but I didn't know that he wanted to lose weight. If I had known, I would have assisted him with his weight loss. During an interview on 02/23/23 at 10:57 AM, the Registered Dietitian (RD) stated, The resident has had a weight loss of over 40 pounds in the last 180 days but stabilized back in November. We have him on Ensure Pro Plus Protein twice per day which adds 720 calories a day. For his wounds, we have him on Liquacel which adds 100 calories per day. The RD further stated, I was not aware that he wanted to lose weight. If I had known, I would not have started him on the Ensure Plus but would have kept him on the Liquacel. The Ensure Plus adds an extra 720 calories. I would have addressed his weight loss differently if I had known that he wanted to lose weight. It's like a catch 22 because we are adding calories and he is eating less trying to lose the weight. During an interview on 02/23/23 at 11:27 AM, the Director of Nursing (DON) stated she was aware of R56's weight loss but was unaware that he wanted to lose weight. The DON stated, When a resident desires to lose weight, I expect this information to be documented and for the dietary department to come up with healthy food choices, taking his wounds into account. I fully expect the facility to assist him in losing weight. I feel like if a resident took the time to speak up for himself and tell someone that he wanted to lose weight, staff should have listened to him. I personally would have been upset if I approached someone with the want to lose weight and they didn't listen to me because apparently I wanted to lose weight and feel better about myself and went to someone expecting them to support me.

Based on observation, record review and resident and staff interviews, the facility failed to provide Resident #2 with an appropriate pressure relieving cushion on the wheelchair seat to prevent the development of pressure ulcers and failed to reposition the resident frequently in the wheelchair to promote healing and failed to apply planned foam boots to Resident #9's feet and legs in order to promote healing of an ankle pressure sore. The sample consisted of 4 residents with pressure ulcers and the facility reported a census of 90 residents. Findings include: 1. Resident #2 had a MDS assessment with an assessment reference date of 6/15/17. The MDS identified a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 indicated the resident had no cognitive problems. The assessment identified the resident as totally dependent on two staff members for bed mobility, transfers, dressing and personal hygiene. The assessment indicated the resident had functional limitations in range of motion of both arms, hands, legs and feet. The MDS listed Resident # 2 with [DIAGNOSES REDACTED]. The Braden Scale (for predicting pressure sore risk) indicated Resident #2 had a score of 13 on 6/19/17. A score of 13 identified the resident at a moderate risk for the development of pressure ulcers. The Care Plan dated 3/21/17 and updated on 6/21/17, identified a problem for the resident at risk for pressure ulcers and had a history of [REDACTED]. The resident had a new motorized wheelchair and able to reposition self and can off load in chair. The staff are directed to encourage the resident to change positions, staff to provide treatment to abrasion to upper right buttock, resident cares to be completed within 30 minutes. Review of the Interdisciplinary Notes dated 05/23/17 at 9:30 am identified an area to the resident's buttock. The area measured 1.5 cm (centimeters) by 2.0 cm. The staff notified the family and physician of the area on the buttock. Review of the Wound/Skin Healing Record dated 5/23/17, indicated the resident had a Stage II pressure ulcer located on the right buttock that measured 1.5 by 2 cm and no depth. On 5/29/17 the Stage II wound measurement was identified as 3 by 3.5 cm and depth 0.1 cm. On 6/5/17 the Stage II wound measurement were 4.5 cm by 4.5 cm with depth undesirables. The resident was referred to the wound clinic. On 6/13/17 the wound identified as unstageable and measured 4 cm by 4.7 cm. (no depth since unable to see wound bed). On 6/19/17 the unstageable wound measured 4 cm by 4.5 cm. On 6/26/17 wound is unstageable, measurements are 4.5 cm by 5 cm with depth 2.5 cm. On 7/3/17 wound unstageable and measured 5.4 cm by 4 cm with depth 2.7 cm. On 7/17 the unstageable wound measured 3.6 cm by 5.9 cm with depth 4.1 cm. On 7/17/17 wound is unstageable, measurements 2 cm by 5 cm with depth 4.9 cm. On 7/24/17 wound is unstageable, measurements 5 cm by 5.4 cm with depth of 4.9 cm. On 7/31/17 wound is unstageable, measurements 4 cm by 5 cm with depth of 6 cm. On 8/7/17 wound is unstageable, measurements 2.8 cm by 3.8 cm with depth 4 cm. On 8/14/17 wound is unstageable, measurements 5 cm by 8 cm with depth 6.3 cm Review of the Interdisciplinary Notes dated 5/31/17 indicated a new order received for treatment to the right buttock area. Review of the Interdisciplinary Notes dated 06/05/17 indicated the area to the buttocks worsening, reported to Resident #2 physicians and received new order to refer resident to the wound clinic. Resident's open area at old pressure injury site had worsened in the last week. Visible slough present in center of wound now unmeasurable depth. Spoke with resident regarding treatment when area was open more than a year ago and surgical repair with bed rest of a year. Discussed with resident the time he/she is up in wheelchair from approximately 10:30 am to 11:00 pm at night. Resident stated he/she repositioned self every two hours in wheelchair and the Roho Cushion (adjustable air-filled, wheelchair support to provide skin/soft tissue protection). Review of the operational manual of the Roho dated 04/2017 revealed warnings that included: Do not use an under-inflate or an over-inflated because the cushions benefits will be reduced or eliminated, resulting in an increased risk to skin and other soft tissue. Intended use included a weight limit of 250 pounds. The MDS with a reference date of 6/15/17 identified the resident's weight to be 284 pounds. Review of the physician History and Physical report, dated 6/19/17, indicated Resident #2 presented for evaluation of the right buttock wound. The resident noted the wound started approximately 4 to 5 weeks ago. The resident believed the wound to be pressure related, as there was an issue with his/her Roho cushion losing air. The Roho cushion was checked in the office today and found cushion to be low with release valve open. Resident educated on placing cushion so valve to the back of the chair to prevent accidental release of air. Resident advised to fill cushion today upon returning to facility. Resident to contact wheelchair representative and to have them come to check cushion for any other causes of air loss, resident to follow-up in 3 weeks. Review of the Wound Center Notes dated 7/13/17 indicated Resident #2 returned for re-evaluation of right buttock wound. The resident had been placing towels in the wheelchair seat for pressure relief and keep pressure off of wound site. Resident averaged 8 hours in the wheelchair during most days. At last visit, the Roho cushion was noted to be deflated with release valve open. Education provided and to have cushion checked for leaks. Resident stated this was performed and that no leaks were identified. Nursing staff at the facility were advised to check cushion daily to insure it is inflated and the release valve is closed. Resident indicated the staff had checked the cushion daily and cushion noted to be inflated in office today. On 8/17/17 at 2:00 p.m. and 8/18/17, Resident #2 was interviewed and stated 3 weeks after the staff noted the wound on the right buttock, he/she along with Staff K, LPN (Licensed Practical Nurse) found the Roho cushion of the wheelchair to be flat. Resident #2 stated Staff K put air into the cushion at the time. Resident #2 stated he/she did not know how long the cushion was flat. Resident #2 stated he/she believed the flat Roho cushion is the cause of his/her current wound to the right buttock. Resident #2 stated the staff do not check the cushion in the wheelchair and he/she has to tell the staff when the Roho is empty. The resident stated he doesn't always know when the cushion is flat. The resident stated the staff are good about repositioning him/her and if not, then will ask and the staff will reposition the resident. On 8/22/17 at 11:30 a.m. and on 8/25/17 at *:40 a.m., Staff K, LPN, stated he never found Resident #2's wheelchair Roho cushion to be completely flat but had found it to be low in air a couple times after his/her wound was noted. Staff K stated he put in more air. Staff K stated there are other residents with the same Roho cushion. Staff K stated he received no training regarding the Roho cushion but had looked up information on the Internet regarding the Roho cushion. Staff K stated Resident #2 stated he/she can reposition self in wheelchair by tilting the back of the wheelchair. Staff K reported Resident #2 did not have the ability to reposition self in wheelchair and staff did not assist him/her. On 8/22/17 at 3:05 p.m., Staff L (nursing assistant) was interviewed and stated he had never attempted to reposition the resident in his/her wheelchair. Staff L stated he repositions the resident in bed every 2 hours or sooner if needed. On 8/25/17 at 12:59 p.m., Staff M (nursing assistant) stated she had taken care of Resident #2 for a long time. Staff M stated the resident will tell you what he wants done. We now check his cushion every day and use a pump in his/her room if needs air. Staff M stated she had offered to reposition the resident in the wheelchair but the resident will refuse and says he/she can do it. Staff M stated after development of the wound, the resident requested a hand towel be rolled up and placed under the thigh (to relieve pressure). Staff M stated she did not think reclining in the wheelchair would reposition the resident off of the buttocks. On 8/25/17 at 10:30 am, the Director of Nursing (DON) stated the wound clinic visit on 6/19/17 was a nursing judgement of the wound clinic regarding resident's wheelchair cushion to be checked daily. The DON stated Resident #2 can reposition self in the wheelchair by the remote control of the wheelchair. 2. Resident #9 had a MDS (Minimum Data Set) assessment with a reference date of 8/17/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 7 out of 15. A score of 7 identified the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and dependent with transfers, eating, toilet use and personal hygiene. The MDS identified the resident had 1 unstageable pressure ulcer. The MDS indicated the resident had a pressure reducing device on the bed, chair seat and a turning/repositioning program. The Care Plan, with a goal date of 8/23/17, identified a problem with a pressure ulcer and directed the staff to use heel protectors to relieve pressure on the heels as needed on 5/23/17. A review of the Admission Note dated 11/14/16 indicated the resident had a pressure area around the feeding tube and no other open areas. A review of the laboratory report from the comprehensive metabolic panel (blood test) dated 6/26/17, identified an [MEDICATION NAME] level of 2.6 g/dl (grams per deciliter) (normal 3.5 to 5g/dl). The test measured the amount of protein in the blood. Observations of the resident lying in bed revealed the resident did not have foam boots on the following dates and times: On 8/21/17 at 10:35 a.m., at 1:24 p.m., at 1:47 p.m. after cares provided by Staff G, CNA and Staff H, CNA and after medication administered by Staff I, LPN. On 8/22/17 at 6:32 a.m., at 6:43 a.m. after Staff I suctioned the resident, at 6:52 a.m., after Staff J, respiratory therapist suctioned the resident, at 7:15 a.m. prior to Staff J changed the dressings to the [MEDICAL CONDITION], at 9:33 a.m., at 10:37 a.m., at 2:03 p.m. and 3:10 p.m. On 8/23/17 at 6:35 a.m., the resident laid in bed asleep and lying on back. The resident had a pillow under the calves of both legs; however, the pillow was flat with the resident's ankle positioned directly on the mattress. The resident had no foam boots on either foot. At 7:18 a.m., the resident continued without foam boots. The form titled Wound/Skin Healing Record described the right ankle as unstageable when identified on 6/19/17. The area measured 1.1 by 0.9. The wound had a purple/red color around the open area which measured 2.2 by 2.7. The last entry identified for the peri-wound area was 6/19/17. On 7/24/17 the area measured 1.1 by 1.1 cm (centimeters) and the resident experienced pain. On 7/31/17 the area measured 1.3 by 1.3 cm and the resident did not experience pain. On 8/7/17, the area measured 1.5 by 1.2 cm and had pain. On 8/14/17 the wound measured 1.2 by 1.2 cm and depth 0.3 and unstageable. On 8/21/17 the wound measured 1.4 by 1.8 cm and showed deterioration. On 8/22/17 at 11:30 a.m., the ADON (Assistant Director of Nursing) reported the possible cause of the pressure sore could be attributed to large doses of [MEDICATION NAME], newly [DIAGNOSES REDACTED]. In an interview on 8/23/17 at 7:38 a.m. and 7:48 a.m., Staff C, RN reported the pressure ulcer may have been caused by the way the resident laid in bed and the resident should have heel protectors on while in bed. Staff C stated she sent the heel protectors to the laundry due to soiled and the resident should wear them when in bed. On 8/23/17 at 8:13 a.m., Staff E, CNA (certified nursing assistant) was interviewed and stated the staff were to ensure no pressure to the resident's right ankle. Staff E stated the staff needed to apply the foam boots while in bed and the boots were in the closet in the resident's room. Staff E stated the resident should have had them on last night and she picked up the boots from the laundry this morning. On 8/23/17 at 8:22 a.m. Staff F, CNA was interviewed and reported the staff should put the heel protectors on while the resident laid in bed and the boots were in the laundry. Staff F stated the resident did not have an extra pair of boots. Staff F stated when the boots are in the laundry, the resident's ankle should be under a pillow and floated. On 8/23/17 at 1:49 p.m., the Director of Nursing reported the resident should have heel protectors on their feet while in bed and if the protectors needed to be washed, the staff should make sure to have another pair for the resident to wear or at least float the area. The Director of Nursing stated the aides do not carry a pocket Care Plan, but do have access to the Care Plan. There are Care Cards in the resident rooms that only address toileting and transferring and thought the Care Card did not address the need to put the heel protectors on. A review of the resident's Care Card revealed documentation that the resident needed assistance with positioning, required a Hoyer (mechanical lift) for transfer and the resident did not have alarms.

Based on clinical record review, staff interview and observation, the facility staff failed to secure wheelchair dependent residents in an appropriate manner in the transport van during an activity outing, resulting in an avoidable injury to one resident of the 8 residents reviewed (Resident #1). The facility reported a census of 99 residents. Findings included: The Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #1 had intact cognitive status as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 (A BIMS score of 13-15 identifies a resident as cognitively intact). The MDS noted Resident #1 required total assist of two staff for transfers and toileting. The MDS listed , Resident #1 required extensive assistance to total dependence of one staff member for bed mobility, locomotion on and off the unit, dressing and personal hygiene. The MDS indicated the resident required a wheelchair for mobility. The MDS indicated Resident#1 ' s active [DIAGNOSES REDACTED]. The MDS for Resident #1 listed a height of 63 inches and a weight of 226 pounds. Resident #1's care plan with a start date of 08/07/14 instructed staff to provide toileting assistance with incontinency care, keep call light in reach at all times, keep personal items and frequently used items within reach. The staff members are instructed to monitor and record complaints of pain, use non-medicated pain relief measures, monitor effectiveness, administer medications as ordered and monitor for effectiveness. The care plan for Resident #1 with a start date of 09/09/14 identified the resident has a fractured ankle and directed staff members to keep right leg immobilized at all times to prevent further trauma, position for comfort with physical support as needed. The incident report dated 09/06/14 at 2:15 p.m. identified two activity staff (Staff B and Staff C) had taken wheelchair dependent Resident #1, and Resident #2 with three ambulatory residents on an outing in the facility transport van. The staff reported one of the securement straps came loose. Resident #1 fell out of the wheelchair causing the resident to receive a fractured ankle. Hospital radiology record review for Resident #1 on 09/06/14 at 5:02 p.m. revealed a complex fracture dislocation at the tibiotalar joint with lateral dislocation of the talus with respect to the distal tibia. The radiology report on 09/06/14 at 7:50 p.m. revealed the ankle fracture and dislocation was reduced and a splint applied. Resident #1 returned to the nursing home with the plan for surgical intervention on 09/10/14. Interdisciplinary notes dated 09/10/14 at 9:00 p.m. revealed Resident #1 prepping for surgical intervention on the right ankle to be completed on 09/11/14. The notation for 09/11/14 at 5:30 p.m. revealed Resident #1 returned from the hospital and the surgery was not completed at this time. Physician facsimile review from 09/15/14 revealed Resident #1 remained undecided on surgical intervention as the pain has decreased and he/she is capable of continuing activities in the nursing home and Resident #1 ' s quality of life has improved. During an interview with Resident #1 on 10/06/14 at 1:30 p.m. Resident #1 stated "we had just gotten ice cream at the Dairy Queen and had just left driving toward the river when Staff C stopped at a red light. The strap holding my wheelchair came undone, my wheelchair tipped forward and I fell forward, sliding out of my chair onto the floor onto my knee". Resident #1 stated that somehow her/his foot got caught under the wheelchair, with the wheelchair over him/her. Resident #1 stated he/she could not see Resident #2 in his/her wheelchair. The resident stated that he/she did not see if Staff C had secured the wheelchair correctly but he/she did know that he/she did not have a seatbelt on. Resident#1 stated that as soon as it happened, both Staff C and Staff B, Activity Director, got out of the van and came around, opened the doors and came into the back. Resident #1 stated the staff had to move Resident #2 out of the van to get to him/her. Resident #1 stated Staff C asked if he/she was okay and he/she stated "hell no, I am not alright". Resident #1 stated staff members contacted fire rescue and it probably took 45 minutes to remove Resident #1 out of the van and to the hospital. During an interview on 10/06/14 at 1:50 p.m. Resident #4 stated when he/she went out in the van for the rodeo parade on 09/06/14 Staff C loaded all five of the residents. He/she stated Resident #3 had been placed in the back position and Resident #4 had been placed in the front position in the van facing the side door/lift platform. Resident #4 stated he/she did not know if Staff C had secured Resident #3 correctly with the seatbelt because his/her wheelchair had rolled forward during the ride. Resident #4 stated his/her wheelchair moved forward toward the lift gate when Staff C stepped on the brake. Resident #4 stated two male residents on the bench seat held onto Resident #3's wheelchair handles to keep it from rolling forward. Resident #4 stated that he/she and Resident #3 both told Staff C they did not feel secure in the van. During an interview on 10/06/14 at 2:10 p.m. Resident #2 stated during the van ride to the park three resident's sitting in the bench seat with seatbelts on. The staff had placed Resident #1 in the van first and staff failed to secure a seatbelt/shoulder strap on Resident #1. Staff C put me in after Resident #1, facing the left side door. Staff C did not put a seatbelt on me but did hook my wheelchair to the floor. Resident #2 identified the van was headed to the river when Staff C had to step on the brake pretty fast. The wheelchair behind me came forward and Resident #1 fell out of his/her wheelchair causing his/her leg to end up between the two wheels of Resident #2 ' s wheelchair. Resident #1 started yelling, Staff C pulled the van over. The fire rescue arrived and helped move Resident #2 ' s wheelchair out so the fire rescue staff could remove Resident #1 out of the van. During an interview on 10/06/14 at 3:45 p.m. with Staff B, activity director stated that he had not been at the van when Staff C loaded the residents onto the van. Staff B stated he had been making arrangements for another activity. Staff B stated upon arriving to the van the five residents had already been loaded and arranged in the van. He stated when he asked Staff C if everyone was ready Staff C stated yes, so Staff B got into the passenger side with Staff C driving. Staff B stated he had not been trained on securing residents into the van and assumed the activity aide (Staff C) knew to do it correctly because Staff C usually drove the activity van. Staff B stated they drove to the Dairy Queen (approximately a mile from the facility) with no problems. He stated the van left Dairy Queen and headed toward the river and approximately around fifth and Main street the traffic light changed and Staff C stepped on the brake. Staff B stated he noticed movement from the corner of his eye and saw Resident #2's wheelchair tipping toward him almost leaning on his shoulder. Staff B stated he told Staff C to put the van in park. Staff B stated he heard someone screaming, when he looked around could not see Resident #1 at all because Resident #2's chair was obstructing his view. Staff B instructed Staff C to hold Resident #2 ' s wheelchair so it would not tip further. Staff B exited the van opened the side door and lowered the ramp to get to the back of the van. Staff B stated he looked into the van to see if it was safe to straighten Resident#2's wheelchair back onto four wheels. Staff B stated he observed Resident #1's wheelchair tipped over with the resident on the floor of the van. Staff B stated after Resident #2was removed from the van over to the sidewalk, instructed Staff C to call for assistance. Staff B stated he stayed with Resident #1 in the van and Staff C remained with Resident #2 on the sidewalk until other facility staff got there and fire rescue arrived at the scene. On 10/07/14 at 8:00 a.m. Staff B stated the activity department did not have a policy and/or procedure regarding outings for staff to use as guidelines. He acknowledged the staff received no formal training on using the equipment in the van to secure the residents. During an interview on 10/06/14 at 4:35 p.m. Staff V, Activity Aide stated when placing a resident in the van, she would roll the resident onto the lift platform place the brakes on, stand behind the wheelchair to hold onto the handles. She stated she would then raise the lift platform to the doorjamb. Staff V stated she would turn the resident to face the front of the van. She stated the largest person would be placed in the back wheelchair area with a second smaller person in the front area. To secure the wheelchair, Staff V stated she would set the brake on the wheelchair, pull the hook apparatus, and place the hooks on the chair crossbar on each side front and back, then wiggle the chair to see if it is tight. Staff V stated she would pull the seatbelt and shoulder harness over the resident and chair. After getting the residents secure will take the lift down, raise the lift and secure the doors. On 10/07/14 at 9:30 a.m. Staff U, CNA, transporter aide had been asked to demonstrate the procedure for placement of a wheelchair dependent resident into the facility transport van. The facility administrator participated in the demonstration acting as a resident. Staff U placed the wheelchair on the lift platform, using the control raised the lift platform to the doorjamb of the van. Staff U placed the wheelchair into the back area, where Resident #1 had been placed during the outing. Staff U secured the wheelchair facing forward in the back wheelchair area facing toward the front. Staff U locked the wheelchair wheels, pulled the hook apparatus around the wheels and hooked the apparatus to the wheelchair frame securing the chair to the floor of the van. Staff U pulled the straps tight to ensure the wheelchair did not move. Staff U then attempted to place the seatbelt and shoulder strap on the "resident" pulling it through the arms of the wheelchair and across the resident's lap. Staff U discovered the seatbelt/shoulder strap apparatus had been connected improperly and would not connect properly. When asked if she had the problem before, Staff U stated that she never uses the back area when she transports residents because she usually transports one resident at a time and secures them in the front area. Staff U placed the wheelchair into the front wheelchair area, securing the wheelchair using the hooking apparatus, locked the wheels, then pulled the seatbelt/shoulder strap between the arms of the chair and connected the two seatbelt parts together. Staff U wiggled the wheelchair to make sure it was secured. The wheelchair did not move. On 10/07/14 at 10:00 a.m. the facility administrator (after the demonstration had been completed) stated that as far as she could tell from the facility investigation, the resident's had not been secured properly in the van and staff had not placed the seatbelt/shoulder strap around the resident correctly. The administrator acknowledged had Resident #1 been secured in the wheelchair with the seatbelt, he/she would not have fallen from the wheelchair. During an interview on 10/07/14 at 10:25 a.m. Staff C stated the procedure for loading the van for outings is to start with the ambulatory residents first placing them into the back bench seat and buckle the seat belts, taking up to three residents there. Staff C stated would then place the first wheelchair dependent person in the back, locking the brake and secure the chair with the hooks, tighten the straps and make sure the strap is tight using the button on the apparatus. Staff C stated they would then bring the second wheelchair in and repeat as they did with the first one. Staff C stated there are no seatbelts for the wheelchair passengers. Staff C said she had been shown how to put the residents in the van by the former activity director two years ago. She stated she had never seen the manufactures directions for securing the resident in the van. Staff C stated the day of the incident, she and the Activity Director were the staff taking the five residents to the Dairy Queen and then to the park by the riverfront. Staff C stated she loaded the residents into the van, placing the three ambulatory residents in first and securing them in the seatbelts. Staff C stated she then placed Resident #1 in the back position, facing the front of the van and secured the hooks but no seatbelt. She stated she then placed Resident #2 in the front position after Staff D brought the resident up on the lift. Stated she positioned Resident #2 facing the side door/left platform and secured the wheels with the hook apparatus. Staff C stated Staff B came out and got into the van after she and staff D finished loading the passengers. Staff C stated she was driving the van, going toward Main Street to the Dairy Queen with the residents. Staff C stated she drove the van back to main street driving toward the river when she reached fifth and main where the traffic light changed. Staff C stated she had to stop rather quickly. Staff C then heard a scream. Staff C identified she placed the van in park, set the emergency brake, and Staff C and Staff B opened the side door and got into the van. Staff C stated she did not see Resident #2's wheelchair tipped but did see Resident #1's leg up against Resident #2's wheelchair. Staff C stated she got behind Resident #2's wheelchair and rolled it on the lift platform and she and Staff B took Resident #2 off the van so they could get to Resident #1. Staff C stated Resident #1 was out of the wheelchair on the floor between his/her chair and Resident #2's chair. Staff C stated Staff B told her to call 911 for assistance. Another facility employee was driving on main street and stopped to see if she could assist. Staff C stated she stayed with Resident #2 on the sidewalk as Staff B assisted Resident #1. Staff C stated that earlier in the day she had taken another five residents to the rodeo parade. Staff C stated she does not recall having any problems with the wheelchairs, nor does she remember any of the residents calling out. During an interview on 10/07/14 at 11:15 a.m. Staff D, Activity Aide stated the procedure for loading resident's in the van is to take the ambulatory residents in first, one at a time up on the lift, and place them into the bench seat and strap them in with the seatbelt. Staff D stated the van can accommodate 3 or 4 ambulatory residents and two wheelchair dependent residents. Staff D stated they will put the largest wheelchair in the back position in front of the bench seat facing toward the front. Staff D stated staff secure the wheelchair with the hooks, then will place the second resident in the front area sideways facing the lift door and secured. Staff D stated the only activity outing she had been involved with was when she and Staff C took five residents to the Rodeo parade on 09/06/14 in the morning. Staff D stated that Staff C had placed the residents in the van because she (Staff D) had not been trained yet. Staff D stated that Staff C had placed two male residents and one female resident in the bench seat. Staff D stated of the two wheelchair residents, Resident #3 had been placed in the back position facing the front window and Resident #4 in the front area facing the side door and lift platform. Staff D stated Staff C had been driving the van with Staff D riding in the front passenger seat. Staff D stated during the ride to the parade everything went smoothly, but on the way back Resident #4 told staff that he/she did not feel strapped in securely. Staff D stated Resident #4's wheelchair started to slide forward and the resident started to grab at Staff D for support. Staff D stated she told Staff C but Staff C did not respond. Staff D stated she did not recall if the resident's had seatbelts on. During an interview on 10/07/14 at 11:30 a.m. Resident #3 stated during a van ride on 09/06/14 Staff C failed to secure Resident #3 and Resident #4 ' s wheelchairs properly and during the ride Resident #3 commented other residents had to hold onto Resident #3 ' s wheelchair to keep it from rolling and moving. According to Resident #3, the wheelchair for Resident #4 was not secure and moved during the ride. The residents commented to Staff C about the wheelchairs and movement and Staff C failed to respond or adjust the wheelchair tie downs to better secure the wheelchairs. On 10/07/14 at 4:03 p.m. The facility administrator stated the activity staff had no formal training on the transport van equipment. She stated after the incident the facility did have their sister facility's maintenance supervisor demonstrate the correct procedure for placing the residents and securing the wheelchairs. She stated they had immediately taken the van out of service and sent it to a specialty garage to check for any malfunctions. When returned the facility was told the van could be used, saw no mechanical reason for the malfunction. The invoice for the van check dated 09/16/14 noted that actions taken were: an inspection of all downs and tracts, cleaned tracts to ensure locks will engage properly. Recommendations were: replacement of all downs to ensure the safety of passengers. Dispose of the old ones and recommend that all staff operating the vehicle is properly trained in the operation of the tie downs and restraints. On 10/08/14 at 2:50 p.m. Staff C, activity aide had been asked to demonstrate how she had placed the resident's in the van for the activity on 09/06/14. Staff C stated she had loaded the three ambulatory resident first to the back bench seat securing them with the available seatbelts. Staff C stated then she loaded the largest wheelchair with Resident#1 into the van, facing the resident toward the front, locked the wheels, then placed the two hooking apparatus on the back to the lower frame of the wheelchair(did not pull the apparatus through the wheels as demonstrated by Staff U). She then attached the two front hooks to the vertical bars on the curved section above the small front wheels, again not pulling them through the wheels. Staff C loaded the second smaller wheelchair facing the side loading door and lift platform. Staff C then attached the hooking apparatus in the same manner as the first one, again not securing the seat belt. When the wheelchair was wiggled the front hooks slipped down the curve of the front vertical bar. The wheelchair had not been secured and moved when wiggled. The manufactures operation instructions for the Sure-Lock combination occupant restraint system stated: 1. Grasp the buckle connector and pull the webbing out of the retractor. While holding onto the snap hook slide the buckle connector up the webbing a full arms-length. 2. Take the snap hook on the end of the retractor strap and thread it down and through the gap between the wheelchair back and seat, or between the side panel and seat. Connect the snap hook to the D-ring provided on the wheelchair securement rear strap. 3. Grasp the buckle connector again and slide it up the webbing another arms-length. 4. Take the snap hook on the end of the retractor strap and thread it down and through the wheelchair back and seat or between the side panel and seat (on the opposite side of the chair). Connect the snap hook to the D-ring on the wheelchair securement rear strap. 5. Snap the Buckle Connector into the push button buckle. Ensure the lap belt in worn low across the front of the pelvis, bearing upon the bony structure of the body and that the push button buckle is located near the occupant ' s hip. 6. Always ensure that the shoulder belt portion in properly extended over the shoulder and across the upper torso of the occupant. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By 09/08/14 the facility had implemented measuresthat adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The administrator removed the transport van from use and sent it out to a specialty garage for evaluation and repair. The facility after the 09/06/14 incident received training from a sister facility maintenance staff member on the proper use and procedures for transporting residents in the van seats and wheelchair designated areas. The van returned to the facility on [DATE] after inspection with recommendations to replace all tie downs to ensure the safety of the residents. Dispose of the old tie downs and recommend that all staff operating the vehicle for transport receive training on the proper operation of the tie downs and safety restraints. As of 10/14/14 exit conference the facility had failed to monitor staff compliance with proper use of the transport vehicle, restraint devices and transportation of residents.

Based on record review, and staff and resident interviews, the facility failed to provide a safe environment for one resident (Resident #9) and adequate supervision for a resident with known behaviors (Resident #8). The sample consisted of 10 residents and the facility census was 104 residents. Findings include: According to the Minimum Data Set (MDS) assessment, the facility admitted Resident #8 to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed the resident had intact cognition and memory. The MDS identified the resident exhibited psychotic delusions and signs and symptoms of fatigue and depression. Resident #8 needed extensive supervision of one staff member for transferring and ambulation, and used a self-propelled wheelchair as his/her main mode of mobility. The resident's admission care plan dated 9/3/11 indicated the resident had a history of [REDACTED]. The same care plan noted the resident received antipsychotic medications. Interventions included monitoring for behavioral changes, providing psychological evaluation as needed, encouraging the resident to participate in activities, social interaction with other residents, and monitoring the resident for medication side effects. The facility admitted the resident from another facility; paperwork from the transferring facility identified the resident refused cares and food, and documented an incident when the resident "yelled, cussed, kicked and swung" at staff and other residents. The transferring facility also documented a second incident when the resident wheeled to the front door of the facility, threw a planter at a window causing the glass to splinter, and held the door so no one could enter or leave the facility. A social services evaluation dated 8/19/11 revealed the resident had a history of [REDACTED]. On 8/30/11, a second entry revealed the resident had not exhibited mood or behavior problems during the seven day evaluation period. Skilled nurses' notes revealed the facility didn't document any behavioral episodes, regarding the resident, from 8/15/11-8/27/11. On 9/2/11, the facility implemented a Behavorial Tracking Tool and staff documented episodes in which the resident exhibited significant verbal abuse to staff/others on 9/2/11, 9/3/11, 9/8/11, and 9/9/11. The entry on 9/8/11 noted the resident had been physically abusive to staff and was resistive of cares in addition to verbal abuse. Attempted interventions documented on the tracking tool included redirection, 1:1 counseling, and toileting. Facility staff kept a separate notebook, with an initial entry dated 9/2/11, in the back of Resident #8's chart which documented descriptions of his/her abusive contacts with staff. Fourteen episodes were entered by various staff members. On 9/7/11, an unknown staff member documented that dietary staff "gave in to Resident #8's demands for fear of his/her abusive reaction." Resident #10 was Resident #8's original roommate. Resident #10's MDS assessment dated [DATE] revealed he/she had intact cognition with no memory deficits and no behaviors noted. A written statement (found in the separate notebook of incidents involving Resident #8) from Resident #10's daughter revealed that she had concerns regarding Resident #8's behaviors (cursing, threatening staff, and screaming ) that occurred in front of her parent, her aunt, and herself. She stated her parent felt threatened by Resident #8, but that he/she would "never say that" to staff. An interview with Resident #10 on 9/28/11 at 1:30 p.m. revealed that he/she witnessed the roommate verbally abuse, and swear crudely, at staff. He/she stated the roommate was never abusive towards him/her, but that he/she was distressed by Resident #8's behaviors. Resident #10 and his/her daughter requested that Resident #8 be removed from his/her room due to Resident #8's offensive behaviors. On 9/8/11 Resident #8 was moved into Resident #9's room. Resident #9's MDS assessment, dated 9/19/11, noted the resident had intact cognition with few memory limitations. The MDS did not note any behaviors for the resident and revealed he/she as independently ambulatory in his/her room. Nurses' notes dated 9/8/11 at 9:35 p.m. documented an incident involving Resident #8 and an unidentified Certified Nurse's Aide (CNA) in the resident's bathroom. The nurses's notes documented Resident #8 yelled at the CNA because he/she handed the "wrong" amount of toilet paper to him/her and the resident subsequently pushed the CNA. An incident report submitted to administration from Staff A, dated 9/8/11, identified her as the CNA and noted that at 9:00 p.m. she assisted the resident to the bathroom. While seated in the bathroom, the resident asked the CNA if her stomach hurt when she was standing. She replied "no" and stated the resident punched her in the stomach and said, "Well, now it does you rotten b----." The CNA notified her charge nurse of the incident who notified the administrator of the incident. During an interview on 9/29/11 at 4:30 p.m., Staff A revealed she was 8 1/2 months pregnant when the resident punched her in the abdomen. She stated she had a prenatal appointment with her obstetrician the next day and recounted the episode to her physician. Staff A stated she did not suffer any injuries from the punch in the stomach. She stated the resident needed assistance to the bathroom and would routinely ask the staff to hand him/her toilet paper. She stated the resident apparently thought she had handed him/her too much toilet paper and this was the catalyst for his/her physically abusive behavior towards her. Nurses' notes on 9/10/11 at 1:30 a.m. revealed the resident refused to go to bed because he/she did not like his/her bed. The note stated the resident began cursing and threatened to throw things at staff. At 8:30 a.m., Staff B, Licensed Practical Nurse (LPN), documented Resident #8 approached her at the nurse's station and began "yelling and cussing" at her because his/her room was cold. Staff B noted she wheeled the resident back to his/her room and attempted to turn the air conditioner down. Resident #8 began to yell at his/her roommate, Resident #9, who was present in the room. Resident #8 stated, "F--- you old man" to Resident #9, and threatened to "beat the h-- out of" him/her. Resident #8 doubled his/her fist at Resident #9. Staff B noted she then removed Resident #8 from the room. Nurses' notes timed at 8:35 a.m. stated that Staff B was called back into the resident's room. Resident #8 was yelling at Resident #9 who then told the nurse, "He hit me." Staff removed Resident #9 from the room a second time, and when asked by Staff B how he/she got back into the room the resident replied, "I went back in." Staff B documented the incidents with Residents #8 and #9 at 8:35 a.m. in the separate notebook as well. The separate notebook indicated the nurse instructed Resident #8 to "stay out of the room" until she called the on-call administrator to find out what to do the first time she removed him/her from the bedroom. While on the phone, Staff B documented she saw another nurse (Staff C) running into the room. When Staff B reached the room, Resident #8 was cursing at Resident #9. Resident #9 stated Resident #8 hit him. Staff removed Resident #9 from the room. Staff B documented when she asked Resident #8 how he/she got back in the room he replied, "I went back in." During an interview on 9/28/11 at 11:30 a.m., Staff B stated her nursing note and the entry she made in the separate notebook regarding the incident on 9/10/11 weren't accurate. She stated before she wheeled Resident #8 from the nurse's station at 8:30 a.m., the resident picked up a bottle of wound cleanser and threw it down the hallway. She wheeled the resident to his/her room, and left the resident in the room with his/her roommate and there was no confrontation between the two of them at that time. She stated that later when she saw Staff C run into the resident's room, she followed, and Resident #9 was yelling, "He kicked me!" Resident #8 stated, "He hit me!" referring to Resident #9. Staff B stated this was the only confrontation between the two roommates and indicated staff removed Resident #9 from the room. After the interview, Staff B recounted the events of 9/10/11 in a written statement dated 9/28/11. The written statement confirmed the resident threw the bottle of wound cleanser in the hall and Staff B wheeled the resident to his/her room after 8:00 a.m. The statement revealed Resident #8 yelled, "F--- you old man. I will beat the h--- out of you," and the nurse left both residents in the room to go call the administrator. When Staff B returned to the west hall after calling the administrator, she saw Staff C running to the room where both residents were yelling at each other and Resident #9 yelled, "He hit me." The nurse wrote she removed Resident #8 from the room and asked him/her to stay out of the room until she figured things out. She had Staff C and Staff D take Resident #9 to another room. When asked to explain the differences between the descriptions she had documented in the nurse's notes, separate notebook, written statement dated 9/28/11, and her verbal statement on 9/28/11, Staff B stated she documented the series of events in a hurry, shortly after the incident occurred because the resident was going to be transferred to the hospital. She stated this was why she mixed up the sequence of events. During an interview on 9/28/11 at 2:45 p.m., Staff D, C.N.A., stated she worked the day shift on 9/10/11, and sometime after 8:00 a.m., she heard yelling coming from a room. She went to the room and saw Staff B and Staff C in the room with Resident #8 and Resident #9. Staff B told the CNA to take Resident #8 out of the room, so Staff C pushed the resident to the lobby. The CNA stated Staff B followed them and told the resident to stay right there while she called the on-call administrator. Staff D left the resident in the lobby and went back to work in a different room. When she returned to the hallway, she heard yelling from the same room as earlier. She entered the room and saw Resident #8 back in the bedroom. Resident #9 was sitting on his/her bed yelling, "He kicked me, he kicked me!" When Staff B returned to the room, Staff D returned to her work assisting residents to breakfast. During an interview on 9/28/11 at 10:30 a.m., Staff C stated she could not clearly recall the events of the morning on 9/10/11. She stated she recalled hearing yelling coming from a room. Upon entering the room, she saw Resident #8 and Resident #9 yelling at each other. She stepped in between the residents and Staff B entered the room. Someone removed Resident #8 from the room and Staff C remained with Resident #9 to calm him/her. She then went back to work passing medications and did not recall what transpired next. She did not recall any physical contact occurring between the two residents and said she thought Resident #9 was moved to another room until Resident #8 left the facility. Nurses' notes dated 9/13/11 revealed Resident #9 had a 6 by 14 (measurement dimensions were not recorded) bruise on his/her upper left thigh that was purplish/blue in color. The nurses' notes documented the resident stated, "I got it from the guy who kicked me." An addendum to the incident report (dated 9/13/11) stated the resident had a bruise measuring 6 by 14 centimeters and the resident stated, "I got it from the guy who roomed with me." An interview with Resident #9 (no time or date, but observation dates are noted to be 9/26-28, 2011) revealed he/she remembered the incident that occurred the morning of 9/10/11. He/she was in his room listening to the radio when Resident #8 entered the room. Resident #8 shook his/her clenched fist at Resident #9 and threatened to "tear my face off." Resident #9 stated he/she informed staff of this and they removed Resident #8 from the room. Resident #9 stated Resident #8 returned to the room a few minutes later, came up to him/her, and kicked him/her in the thigh. Resident #9 stated he/she kicked Resident #8 in the leg to "get him back." Resident #9 stated he/she was afraid of Resident #8, but was so angry he/she struck back at him/her after being kicked. An interview with the Administrator on 9/28/11 at 8:30 a.m. revealed Resident #8 had been verbally and physically abusive to staff and another resident. The facility served an involuntary discharge to Resident #8 and transferred him/her to the emergency roiagnom on [DATE] at 10:10 a.m. The administrator stated it was her understanding the resident (Resident #8) had kicked his/her roommate (Resident #9) and was removed from the room following only the one confrontation. She stated Staff B did not document the incident accurately and needed to correct the entries in the nurses' notes. The administrator stated Resident #9 was a credible witness and could be relied on to recount the incidents accurately.

The following deficiency relate to Complaint # -C Based on clinical record review and staff interview, the facility failed to provide the necessary provisions to ensure residents were protected from resident to resident altercations (between Resident #14 and #18); and failed to fully assess the residents after the altercations; and failed to notify residents' physicians and families of the incidents and or injury. The facility reported a census of 117 residents. Findings include: According to annual Minimum Data Set (MDS) assessment tool dated 5/19/10, Resident #14 had [DIAGNOSES REDACTED]. The assessment determined Resident #14 had short term memory problems and had poor decision making skills. The assessment identified Resident #14 did not need assistance from staff with bed mobility, transfers, and ambulation, however s(he) required the assist of one staff member when dressing, eating, using the toilet, and for personal hygiene. The MDS identified the resident had a swallowing problem. The MDS identified the resident at 70 inches in height (5 feet and 8 inches tall) and weight at 213 pounds. The RAP (resident assessment protocol) dated 5/19/10, identified Resident #14 had threaten to hurt him/her(self) which resulted in a prior hospitalization in April 2010. Resident #14's care plan dated 5/21/10 identified s(he) had cognitive deficits and impaired decision making skills. The care plan directed staff to assess the resident for contributing factors (situations, medications, infections or diagnoses). The care plan also included the following interventions. a. Offer the resident simple choices to reduce the stress of decision making. b. Provide a calm, therapeutic environment and structured routine. c. Avoid changes in resident's environment. Review of the facility's Resident/Other Incident Report dated 7/10/10 at 9:00 p.m. revealed Resident #14 had been assaulted by Resident #18 in their room. According to annual Minimum Data Set (MDS) assessment tool dated 6/1/10, Resident #18 had [DIAGNOSES REDACTED]. The MDS assessment indicated Resident #18 had short and long term memory problems and had poor decision making skills. The assessment identified Resident #18 required assistance of one staff member for transfers, ambulation, dressing, toilet use, and personal hygiene. The assessment revealed the resident exhibited persistent anger towards others and with him/her(self). The assessment established Resident #18 had socially inappropriate/disruptive behavioral symptoms. Resident #18 MDS identified his/her height at 71 inches (5 feet and 9 inches tall) and weight at 170 pounds. Review of Resident #18's Interdisciplinary Notes dated 7/10/10 at 9:00 p.m. documented s(he) attempted to leave the room to elope. The notes documented the resident's roommate (Resident #14) alerted staff of the attempted elopement by putting on the call light. The notes documented when Resident #18 had seen that Resident #14 put on the call light to alter staff, Resident #18 started to choke Resident #14. The notes documented that when Staff A arrived in the room, she/he had to pull Resident #18 was pulled away from Resident #14. The notes documented Resident #18 kept yelling "he/she is a squealer" along with other foul names. The notes documented Staff A spoke with Resident #18 alone and explained that he/she could not have these behaviors. The notes identified Staff A talked with Resident #18 about not touching staff and or residents and then left the room. The nurse (Staff A) documented she heard Resident #14 yelling out. The notes documented when Staff A went back into the resident's room, he/she found Resident #18 punching Resident #14 on top of the head. The notes documented the nurse talked with Resident #18 again about his/her behaviors and moved Resident #14 to another room. The notes documented the Administrator had been informed of the incident and staff would continue to monitor. Review of Resident #14's Interdisciplinary Notes dated 7/10/10 at 9:00 a.m. revealed Resident #14 in bed resting when roommate, Resident #18 assaulted him/her. The note documented Resident #14 caught Resident #18 attempting to elope and alerted staff. Resident #18 attacked Resident #14 punching him/her several times on top of the head. Resident #14 was assessed and given Tylenol and ice applied to the resident's head and knots were noted on top of Resident 14#'s head. Staff moved Resident #14 to another room. Staff contacted the Administrator and the notes documented the Administrator instructed staff that he/she will take care of it on Monday 7/12/10. Review of Resident #14 Interdisciplinary Notes dated 7/11/10 at 12:00 p.m. revealed resident needed much emotional support and reassurance that he/she was safe. The notes documented the resident concerned that staff would put him/her into the same room as Resident #18. Interview on 10/14/10 at 2:16 p.m., Staff A indicated on 7/1/10 that he/she had been assigned to Resident #14 and Resident #18. Around 9:00 p.m. Staff A was summoned to the resident' room by a C.N.A. Staff A revealed when he/she entered the residents room Staff A witnessed Resident #18 choking Resident #14. Staff intervened and pulled Resident #18 away from Resident #14. Staff A stated it was difficult to get the resident away from his/her roommate as Resident #18 was yelling "she/he's a (expletive) squealer." Staff A stated Resident #14 left the room and went to the nurse's station, visibly upset and scared. Staff A remained in the room and talked with Resident #18. Staff A indicated Resident #18 verbalized what he/she did to Resident #14 and then promise to not do it again. Staff A stated Resident #14 remained at the nurse's station upset and scared, then returned to his/her room. Staff A knew Resident #18 was already in the room when Resident #14 returned, and positioned him/her(self) in the hallway right outside the room. Staff A stated he/she heard Resident #14 yelling, and entered the room to see Resident #18 punching Resident #14 two times on the head. Staff A stated Resident #14 had a red mark on his/her top of head on the hair line. Staff A separated the residents at that time. Staff A further stated it took a long time to settle Resident #14 down as the resident was scared. Staff A reported he/she did not separate the residents after the first altercation because Staff A felt that after he/she talked with Resident #18 that no further altercation would happen. Staff A acknowledged he/she should have separated the residents immediately. Staff A revealed that he/she did not notify the physician and thought that he/she had attempted to notify family but not sure. Resident #14's record lacked any physical assessment after he/she had been choked. Resident #14's clinical record lacked a complete assessment after the resident had been repeatedly punched on top of the head; or any vitals taken; or any assessment for a head injury. Resident #18's clinical record lacked any assessment after he/she repeatedly punched the resident. Resident #14's clinical record lacked any documentation the facility staff separated the two residents (Resident #14 and Resident #18) after the first incident when Resident #18 attempted to choke Resident #14. Resident #14's clinical record lacked and indication the resident's family or physician had been notified of the altercations and the injury that occurred. Resident#18's clinical record lacked indication that the resident's physician or family had been notified of the altercation. Review of the facility's Policy Number: HR-21 included the following: a. In the event of a resident-to-resident altercation, the residents will be separated immediately and removed to separate areas of the building until incident is investigated and corrective actions instituted. b. The injured person's account of the incident; c. The time the injured person's physician was notified as well the time the physician responded and any instructions. e. The date and time the inured person's next of kin was notified and by whom. f. The condition of the injured person, including vital signs. g. The investigation report must be submitted to the Director of Nursing services no later than twelve (12) hours after the occurrence of the incident. Records reviewed and interviews with staff lacked the indication that the above policy was implemented. Interview on 10/14/10 at 1:30 p.m., Administrator gave surveyor the incident report of the altercations between Residents #14 and #18. Administrator stated that the date of the report that indicated it was reviewed by the Interdisciplinary Team on 7/10/10 is incorrect the actual date the incident had been reviewed by the Interdisciplinary Team is 7/12/10. The facility failed to separate the two residents after the first altercations. The facility allowed the residents to remain in the same room until the second altercation. Resident #14 received injuries to his/her head which would not have occurred had the residents been separated. The facility failed to fully assess the residents after the altercations. The facility failed to notify residents' physicians or families of the incidents or injury. The facility failed to follow their policy regarding resident to resident altercation.