Every finding on record at Montrose Health Center

Based on review of clinical record review, hospital record review, facility policy and staff interviews, the facility failed to ensure sufficient nursing staff available to meet the needs of a residents readmission after a hospitalization, delaying the residents return to the facility by three day for 1 of 3 residents (Resident #3) reviewed for hospitalizations. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS indicated medical diagnoses for chronic obstructive pulmonary disease with acute exacerbation, pneumonia, and respiratory failure.Review of the electronic health record (EHR) Census Report revealed Resident #3 status STOP BILLING effective 1/21/26, and as of 1/26/26 Active. Review of progress notes revealed a Health Status Note entered on 1/21/26 at 8:15 AM which documented this nurse was called to the resident's room. Resident observed lying in bed with labored respirations and use of accessory muscles. Resident stated he was feeling better since receiving a breathing treatment earlier this morning. Respiratory rate noted at 25 breaths per minute; resident diaphoretic. Oxygen saturation measured at 85% on room air. Wheezing noted. Oxygen applied at 3 L/min via nasal cannula. Oxygen saturation improved to 96% after approximately 5 minutes. Head of bed elevated; however, resident continued to exhibit labored breathing with no significant improvement in respiratory effort. Resident requested to be sent to the hospital. Provider notified, and order received to transfer resident to the hospital. Review of hospital records revealeda. A Discharge Summary note, dated 1/23/26 at 11:52 AM documented, in part: admission Date: 1/21/26; discharge date : [DATE].Patient is discharged on stable condition. I discussed medications, side effects and need to seek medical attention for any side effects. I also discussed the care plan and follow up appointments. To return to ER (emergency room) or contact PCP (primary care provider) to seek medical attention if symptoms return or worsen.b. A Progress Note, dated, 1/24/26 at 10:01 AM, that documented, in part: Subjective: Patient planned to be discharge yesterday, due to timing issues, patient not accepted to the facility. Will be staying here over the weekend. discharge on Monday.c. A Progress Note, dated, 1/25/26 at 2:43 PM, which documented, in part: Subjective: No acute overnight events.Patient medically ready to discharge to rehab. c. discharge instructions, dated [DATE], signed by [name redacted, Resident #3].d. A Discharge Note-Nursing, dated 1/26/26 that documented, in part.Pt (patient) is discharging back to [facility name redacted] he came from. Report was called to [name redacted] and all questions were answered. Pt was transported via wheelchair van. e. A CM/SW (Case Manager/Social Worker) note, dated 1/16/26 at 5:05 PMThe Hospital Admit/Discharge/Transfer Note (Transition Planner Comments) dated 1/26/26 at 5:05 PM that documented, in part.Comment: SW confirmed [facility name redacted] can take pt today.Review of the EHR revealed an admission Summary note, dated 1/26/26 at 4:43 PM which documented, in part.Resident [Resident #3] arrived from [name of hospital redacted] ambulance. Resident was admitted back to his room.During an interview on 3/24/26 at 1:44 PM, Resident #3 stated went to the hospital and found out he was having a heart attack and spent 3 days there before he was able to come back to the facility.During an interview on 3/25/26 at 11:54 AM, Staff A, Registered Nurse (RN) queried on how late the facility accepted admissions and Staff A stated they tried not to do admissions on the weekends because the nurse had to put the medications into the computer. Staff A stated the facility didn't want admission after 2 pm so the nurses could get the admissions done. Staff A stated if the nurse put medication changes into the computer between noon and 2 PM, the facility would receive the medications that night from the pharmacy. Staff A stated if a resident admitted on a Friday evening, residents would not get their medications ordered on time.During an interview on 3/26/26 at 10:00 AM, the [NAME], MDS Coordinator queried on the situation with Resident #3 not getting readmitted to the facility for 3 days and the MDS Coordinator stated the facility liked to have residents readmitted to the facility before 2 PM so the facility could get their medications in. The MDS Coordinator stated the hospital informed them, Resident #3 would not be back until 5:30- 6 PM and the MDS Coordinator stated she left the facility at 4 PM. The MDS Coordinator stated the facility needed 2 nurses in the building for admission and the biggest issues was getting Resident #3 medications. The MDS Coordinator asked if the facility could get Resident #3 medications from another pharmacy and the MDS Coordinator did not know, because the facility never ran into that. The MDS Coordinator stated the resident didn't have family that could go and pick up medications at another pharmacy. The MDS Coordinator stated the facility did not do admissions on the weekends either.During an interview on 3/26/26 at 10:33 PM, the Assistant Director of Nursing (ADON) queried on Resident #3 not getting readmitted back to the facility 3 days after discharged from the hospital and the ADON stated she wasn't here that day, and the facility cut off time wasn't followed by the hospital. The ADON stated the pharmacy cannot activate the medications until the medications are in the EMR. The ADON stated the nurses needed time to do the admission assessment and that day they didn't have any extra nurses and readmission was not feasible with one nurse later in the day and not getting his medications. The ADON stated they wanted to send Resident #3 back at 6 PM. The ADON queried if the facility could of received Resident #3 medications from another pharmacy and the ADON didn't know. The ADON stated some family members bring medications in for other residents, but she didn't think his family would of been able to do that. The ADON stated a readmission and taking care of all the other residents in the facility would of been too much for one nurse to handle. The ADON asked if the facility could of transported the resident back to the facility and the ADON stated the facility shared their transport van with another facility and the driver's schedule was usually pretty full.During an interview on 3/26/26 at 11:20 AM, the DON queried on Resident #3 discharge from the hospital and the DON stated the hospital called and said they wanted to discharge Resident #3, but didn't have transport until 5 or 6 that night and the hospital was never on time. The DON stated the admission would of been in the evening and the facility didn't accept admissions in the evenings for the safety of the residents. The DON stated the hospital was very upset that the facility would not take Resident #3 on Friday, but the DON wouldn't accept the resident for safety reasons. The DON asked if the facility could readmit Resident #3 on Saturday and the DON stated the facility didn't do admissions on Saturday because of all the admission paperwork that needed to be completed. The DON stated the pharmacy might of been able to deliver on Saturday morning, but the night nurse would of had to do all the paperwork and it wasn't safe to have one nurse during a readmission and taking care of the rest of the building especially if a fall happened. The DON asked if any other nurses could of came in and helped and the DON stated the facility had on-call nurses and the DON didn't think anything was wrong with not taking him back until Monday. The DON stated if the resident would of returned at 7 PM on Friday, the resident wouldn't of had medications for a time period. The DON asked if the provider notified of resident getting discharged back to the facility and the DON stated no because the facility only had one nurse in the facility that evening and then the medications not getting here comes into play. The DON asked if the hospital could of sent medications with the resident and the DON stated the hospital never offered to send medications back with him. The DON stated the pharmacy usually delivered medications around noon or 1 PM on Saturday. The DON asked if the facility could of transported resident back to the facility instead of waiting on the hospital transport and the DON stated the facility shared transport with another facility and the driver was packed between both facilities.During an interview on 3/26/26 at 11:48 PM, the Administrator stated she was on maternity leave when Resident #3 went to the hospital. The Administrator stated if the hospital would of got earlier transport, the facility would have taken him back, but with only one nurse at the facility, a readmission was not doable.Per Administrator email on 3/26/26 at 12:09 PM, the facility did not have transportation or readmission policies and followed CMS (Centers for Medicare and Medicaid Services). The facility also did not have a policy for resident rights and followed the Resident [NAME] of Rights.The Facility Residents' [NAME] of Rights revised 1/2023 revealed:Resident Rights. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State Plan for all residents regardless of payment source.Review of the undated Resident Handbook, revealed a Care & Clinical Services, which declared, in part. Residents receive individualized, 24-hour nursing care, medication management, and access to rehabilitation services such as physical, occupational, and speech therapy.

Based on record review, observations, and staff interviews, the facility failed to administer the correct amount of fluid and liquid nutrition to a resident dependent on tube feeding for 1 of 1 residents (Resident #1) reviewed for tube feedings. The facility reported a census of 36 residents. Findings include: Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored a 13 out of 15 on the BIMS exam, which indicated cognition intact. The MDS list of diagnoses included transient ischemic attack, malnutrition, and dysphagia (difficulty swallowing) following cerebral infarction (stroke). The MDS indicated eating not attempted due to medical condition or safety concern. The MDS indicated resident utilized a feeding tube. Review of the Care Plan, Date Initiated 7/29/25, revealed a Focus area to address The resident requires PEG (a percutaneous endoscopic gastrostomy tube is a feeding tube inserted through the skin and stomach wall with an endoscope to deliver nutrition, fluids, and medications directly to the stomach for those who cannot swallow normally) tube feeding. Date Initiated: 7/29/25. Interventions included, in part:a. The resident needs assistance with tube feeding and water flushes. See MD (medical doctor) orders for current feeding orders. Date Initiated: 7/29/25. b. The resident is dependent with tube feedings and water flushes. See MD orders for current feeding orders. Date Initiated: 7/29/25. A review of Physician Orders revealed the following;a. Strict NPO (nothing per mouth) diet order. Revision Date: 7/17/25.b. Flush PEG tube with 120 mL(milliliters) of water before and after feeding administration. Start date: 9/15/25.c. Osmolite 1.5 Cal Oral Liquid (Nutritional Supplements) - give 270 mL 4 times a day. Start date: 9/12/25.During an observation on 10/1/25 at 12:09 PM, Staff A, Registered Nurse (RN) administered 60 mL of water through Resident #1 PEG-tube, followed by 235 mL of Osmolite 1.5 calories through the PEG-tube, followed by an additional 60 mL of water. During an interview on 10/1/25 at 12:24 PM, Staff A, RN queried on Resident #1 orders for flushes and liquid nutrition and she stated the other liquid nutrition order was 270 mL and they didn't change it. Staff A stated she would double check the order. Staff A then stated she read the order for the 120 mL water flushes before and after feeding as 60 mL before and then 60 mL after the feeding. During an interview on 10/1/25 at 12:33 PM, the Advanced Registered Nurse Practitioner (ARNP) queried on the nutritional and flushing order for Resident #1 and the she stated she ordered the facility could switch the formula but the facility should follow the dietician recommendations. The ARNP confirmed the order for flushing before and after feeding indicated 120 mL before and 120 mL after the feeding, not for the 120 mL to be split in half. During an interview on 10/1/25 at 2:23 PM, Staff A, RN queried about the flushing order and liquid nutrition order and Staff A stated flushing with 60 mL before and after feeding was a nursing call. Staff A confirmed the liquid nutrition should have been 270 mL not the 235 mL that Staff A administered. Staff A stated she thought the 120 mL before and after the feeding would of been too much for Resident #1 tummy and Staff A was taught to flush with 60 mL before and 60 mL after. Staff A stated the previous order for liquid nutrition was 235 mL and when Staff A returned on Monday, Staff A should have noticed the new order. Staff A confirmed she had only been giving Resident #1 the 235 mL at each of the feeding Staff A administered. During an interview on 10/1/25 at 3:11 PM, the Dietician queried on Resident #1 orders for the flushes and the liquid nutrition and the she stated she documented 270 mL for the Osmolite. The Dietician stated the she changed the milliliters of the feeding to equal the calories of the previous liquid nutrition and added a protein supplement since Resident #1 previously lost weight. The Dietician stated she wanted the 120 mL water flushes before and after the feeding for Resident #1 to meet her fluids needs. During an interview on 10/2/25 at 12:12 PM, the Director of Nursing confirmed Staff A should of followed the order for the liquid nutrition and water flushes before and after feeding administration. Per email on 10/2/25 at 12:44 PM from the Administrator, the facility didn't have a policy for tube feedings and they followed doctor's orders.

Based on observation, interview, and record review the facility failed to ensure a resident with severely impaired cognition remained free from a burn from hot liquids when the resident sustained a second degree burn (involving the first two layers of skin) to the thigh from a hot beverage believed to have occurred on 7/8/24, and had a second hot liquid spill from a beverage on 9/17/24 resulting in redness to the skin for one of four residents reviewed for accidents (Resident #11). This deficient practice resulted in tenderness of burn area and documented voiced discomfort during treatment. The facility reported a census of 36 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 5/28/24 revealed the resident scored 06 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident required set-up or cleanup assistance with eating. The Care Plan dated 2/9/22, revised 5/29/24, revealed the following: The resident with potential for altered nutritional status r/t (related to) PMH (past medical history) of bradycardia, hypothyroidism, weakness, HLD (hyperlipidemia), CKD (chronic kidney disease) stage 2, HTN (hypertension), depressive episodes, CAD (coronary artery disease), hx (history) of significant weight loss. Interventions per the above Care Plan did not specifically address hot liquids. The Care Plan dated 9/13/24 revealed, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs d/t Cognitive deficits, Physical Limitations. The Intervention dated 9/13/24 revealed, Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: (solitaire cards, a cup of hot tea with a lid). The Health Status Note dated 7/9/2024 at 8:58 AM revealed, CNA (Certified Nursing Assistant) called this nurse to res (resident) room to report a reddened area to res (resident) right anterior thigh. Res believes she may have spilled some hot tea on herself at supper last noc (night). Area is light to medium pink, no open areas noted. No c/o (complaints of) pain voiced unless area is palpated, then res states it's a little tender. All necessary persons notified including provider. Verbal orders rec'd (received) to apply Medihoney et (and) cover with gauze et tape BID (twice a day) daily u/h (until healed). Review of the Incident Report dated 7/9/24 for Resident #11 revealed, resident will not have any styrofoam cups in room and kitchen will dilute hot tea with ice or <sic> tape water. Review of the Progress Note dated 7/9/24 at 11:07 PM revealed, Resident continues to be provided cups with lids, resident removes lids at times. Education provided about need for lids on cups and resident voices understanding. The Progress Note dated 7/10/24 at 4:26 PM revealed, Resident continues to be provided cups with lids; however, resident removes lids at times. Education provided about need for lids on cups and use for safety. Resident with short term memory only and needs reminded frequently. The Encounter Note dated 7/12/24 at 12:00 AM revealed the following per Chief Complaint / Nature of Presenting Problem: Burn. History Of Present Illness: Patient being evaluated today for a wound that has developed after she spilled her hot coffee on herself. Patient was drinking her coffee does not know how she spilled it but it hit her right thigh, she did develop a blister like wound. This occurred on Tuesday 7/9. We have been applying Medihoney to the area. Patient denies any discomfort. There is minimal redness and the blister is almost completely gone. No other reports of illness including fever, cough or other ill symptoms. Per the Encounter Note Resident #11 had second-degree, partial-thickness burn to the right anterior thigh. The Plan section documented, in part, Decreased coordination: Continue to monitor patient's coordination especially with sharp utensils, hot liquids and so forth. Educated patient about safety possibility of needing to cool hot liquids due to tolerance over time. The Health Status Note dated 7/22/24 at 4:34 PM revealed, Burned areas to right upper thigh observed. No intact blisters, pink, blanchable borders. Medihoney treatment continues. Voices discomfort to area during tx (treatment) but resolves with rest. Observation conducted on 9/16/24 of Resident #11 in the dining room revealed the following: a. 12:01 PM: Resident #11 took the tea bag out of cup, stirred, and Resident #11 had the cup in their hands with the cup lid on the table. b. 12:02 PM: Cup on the table without a lid on it. c. 12:04 PM: Cup on the table without a lid on it. d. 12:19 PM: Resident #11 present in wheelchair at the table, and fluid in the cup without the lid on it. Observation conducted on 9/17/24 at 11:28 AM revealed the following: a. 11:28 AM: Resident #11 was delivered a drink cup with a lid and a glass of a beverage as well. The resident observed in her wheelchair at a table in the dining room. b. 11:35 AM: Resident #11 observed with puddle of liquid underneath the resident and resident's cup (cup that previously observed with lid) on the floor. Director of Nursing (DON) alerted by State Agency. Staff then heard to say resident spilled. Staff were asked about contents of the beverage and was identified by Staff A Dietary Staff as hot tea. The Health Status Note dated 9/17/24 at 12:00 PM revealed, DON (Director of Nursing) was walking towards the dining room when resident was observed to have spilled her hot tea onto the floor table and on her pants. Resident was then removed from the main dining hall by DON. DON and MDS nurse assessed resident in her room. Resident is noted to have a reddened area to her lateral posterior thigh. No blisters noted. Area is intact. Resident denied pain and discomfort to the area. Provider notified at this time. The Health Status Note dated 9/17/24 at 12:01 PM revealed, reddened area is to right lateral posterior thigh. Review of the Incident Report dated 9/17/24 revealed the following description: I'm not sure what happened, I was drinking my tea. Review of a Note per the Incident Report revealed, Redden area to right lateral posterior thigh measuring 0.4 cm (centimeter) x 15cm. Review of the Other Info section revealed, Resident was observed attempting to remove lid from hot tea. Observation on 9/19/24 at approximately 8:00 AM revealed Resident #11 in the dining room with a cup with a lid on it. The cup had a tea bag inside with the string part of the tea bag on the outside of the cup. On 9/19/24 at 8:22 AM during an interview with the Dietary Manager (DM), the DM queried about what kind of drinks Resident #11 liked, and responded hot tea and water. When queried about the cup with the lid, the DM explained the resident normally had a regular cup and she was spilling and didn't want her to get burnt. Per the DM, dietary staff put in two pack of sugar substitute. Per the DM, Resident #11 couldn't get the lid off to spill it. The DM explained the resident left the tea bag in cup per her preference. When queried if there were issues with spilling since the resident got the cup with the lid, the DM responded nope. Per the DM, if the resident was in the dining room the tea was sent hot. The DM explained the flap was placed over the cup handle. When queried if the DM heard of the resident getting burned in the last couple of months, the DM responded not to my knowledge. When queried about interventions for this resident, the DM responded just the lidded mugs, and if the resident went to her room a few ice cubes added so not as hot. The DM explained the hot water came from the coffee machine from the spout. When queried if she took the temperature of it, the DM responded she had but it had been awhile. A hot water temperature was requested from the DM. On 9/19/24 at approximately 8:30 AM, the DM reported hot water temperature was 168 degrees. On 9/19/24 at 2:44 PM Staff B, Registered Nurse (RN) explained the resident had treatments where had to monitor the right thigh for redness/blistering. When queried what the wound looked like, Staff B responded it blistered up and was kind of like white discoloration kind of thing that eventually faded. When queried if he was told how it had happened, Staff B responded the resident had hot tea at the table and it spilled. Staff B explained he knew they implemented that Resident #11 was to have the cups with the lids now instead of open cup and that she needed to drink liquids in the dining room. Staff B further explained if the resident went back to her room, then cold liquids only for safety. Per Staff B, he thought it was a regular coffee cup with hot tea in it for July incident. When queried if the facility did hot liquid assessments, Staff B responded he was not for sure. Staff B further explained many of the assessments were done by the Care Manager. When queried if the resident was known to spill liquids prior to July, Staff B responded he was not sure, and he hadn't heard of a lot of spills before hand. Per Staff B, that was the that was the first time Staff B had heard of. When queried if he had ever seen Resident #11 with the lid off her cup, Staff B responded he hadn't seen it but did know the resident was physically able to remove the lid. When queried about the incident which occurred 9/17/24 (when Staff B not present at the facility), Staff B explained he was made aware and it was on the resident's chart to monitor for any types of changes/skin issues, and on the TAR (Treatment Administration Record) to check off. Staff B explained he did not see any redness or anything on 9/19/24. On 9/19/24 at 3:16 PM during an interview with Staff C, Certified Nursing Assistant (CNA) and the Director of Nursing (DON), Staff C explained Resident #11 had a lidded cup that is stuck on the top and has a straw that comes out to keep the resident safe, and that is what she drank out of. Staff C further explained with cool liquids used a regular cup, and if hot used a lidded cup. When queried if she had ever seen the resident take the lid off, Staff C responded yes indeed and explained tried to tell the resident not appropriate and tried to explain instructions. Per Staff C, sometimes could not get through to the resident. The DON explained the resident loved her hot tea and was something wanted the resident to keep. The DON explained following the recent incident, the resident was ordered a elderly spill proof twist cup so the resident could not take the top off. When queried about the tea bag, Staff C explained the resident usually left the tea bag in when she liked to drink. Staff C explained when the kitchen staff made the tea they took the tea bag out of it. On 9/19/24 at 3:28 PM during an interview with the MDS Coordinator and Nurse Consultant, the MDS Coordinator explained she was present for the resident's spill (second spill which occurred week of survey) and explained the resident had a small reddish s shaped area on the side of the leg. The MDS Coordinator explained she was the one that assessed and measured. The MDS Coordinator was unable to recall whether she had been at the facility in July when the resident had spilled. The MDS Coordinator further explained an intervention had been put in place to not allow hot tea in resident's room, and to encourage resident to sit out here and socially and have a lid on it. Per the MDS Coordinator, kitchen put ice cubes in it. When queried if that went into the resident's care plan, the MDS Coordinator responded they would have to look. The MDS Coordinator explained the resident used to drink with a different cup, and the cup was changed completed with lid put on it. Per the MDS Coordinator, the original cup was styrofoam, and the resident always used to have a styrofoam cup. When queried if she had ever seen the resident take the lid off, the MDS Coordinator responded no, and the MS Coordinator further explained she would say a little harder to get off hence the intervention for the resident. Per the MDS Coordinator she had never seen the resident with the lid off, and explained it was not the easiest to take off. On 9/19/24 at 3:47 PM during an interview with the Administrator, the Administrator explained the resident very much enjoyed hot tea, had one incident a couple months ago where spilled hot tea, resident was in her room, and addressed not being in her room, being in the main dining room. Per the Administrator, resident also not to have it hot, hot, and would have a couple of pieces of ice. The Administrator further explained the resident spilled a couple days ago and facility decided to get the spill proof cup. The Administrator acknowledged needing to do something to protect the resident. On 9/19/24 at 4:24 PM during an interview with the Director of Nursing (DON), the DON explained the facility was trying to find something for resident to have hot tea and be safe also. When queried if hot liquid assessments done, the DON responded not that she was aware of. On 9/19/24 at 4:04 PM, a Facility Policy pertaining to accidents and hazards requested via email from the facility's Administrator. On 9/19/24 at 4:07 PM, the Administrator responded via email the facility did not have a policy to address, and followed CMS (Centers for Medicare and Medicaid Services) guidelines.

Based on clinical record review and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were submitted per required regulatory timeframe's for one of one resident reviewed for Resident Assessment Instrument Task (Resident #33). The facility reported a census of 36 residents. Findings include: Review of the Resident Assessment Task indicated Resident #33 had an MDS record over 120 days old. Review of the resident's MDS history revealed not all assessments documented as accepted and/or submitted. Review of Resident #33's census revealed the resident initially admitted to the facility 5/8/24, and discharged on [DATE]. On 9/18/24 at 3:50 PM, the Nurse Consultant explained did not think got submitted, and was an oversight. The Nurse Consultant explained although assessment completed, did not change a question to yes (in system) which had auto-populated from a previous assessment, and now the assessment export ready and would be late to federal. Continued review of the resident's MDS assessments revealed the following Assessment Reference Date (ARD) and date submitted: a. Review of the resident's Quarterly MDS assessment (ARD 8/6/24) was submitted 9/18/24. b. Review of the resident's MDS assessment completed for death in facility (ARD 8/19/24) was accepted 9/18/24. On 9/19/24 at 4:04 PM, a Facility Policy pertaining to guidelines for submitting was requested via email from the facility's Administrator. On 9/19/24 at 4:07 PM, the Administrator responded via email the facility did not have a policy to address, and followed CMS (Centers for Medicare and Medicaid Services) guidelines.

Based on interview, record review, and policy review, the facility failed to ensure resident care plans were revised following a resident's hot liquid spill with burn, failed to address a diagnosis of diabetes mellitus, and to accurately reflect insulin use related to steroid-induced hyperglycemia for three of twelve residents reviewed for care plans (Resident #11, Resident #26, Resident #139). The facility reported a census of 36 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 5/28/24 revealed the resident scored 06 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident required set-up or cleanup assistance with eating. The Care Plan dated 2/9/22, revised 5/29/24, revealed the following: The resident with potential for altered nutritional status r/t (related to) PMH (past medical history) of bradycardia, hypothyroidism, weakness, HLD (hyperlipidemia), CKD (chronic kidney disease) stage 2, HTN (hypertension), depressive episodes, CAD (coronary artery disease), hx (history) of significant weight loss. Interventions per the above Care Plan did not specifically address hot liquids. The Care Plan dated 9/13/24 revealed, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs d/t Cognitive deficits, Physical Limitations. The Intervention dated 9/13/24 revealed, Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: (solitaire cards, a cup of hot tea with a lid). The Health Status Note dated 7/9/2024 at 8:58 AM revealed, CNA (Certified Nursing Assistant) called this nurse to res (resident) room to report a reddened area to res (resident) right anterior thigh. Res believes she may have spilled some hot tea on herself at supper last noc (night). Area is light to medium pink, no open areas noted. No c/o (complaints of) pain voiced unless area is palpated, then res states it's a little tender. All necessary persons notified including provider. Verbal orders rec'd (received) to apply Medihoney et (and) cover with gauze et tape BID (twice a day) daily u/h (until healed). On 9/19/24 at 3:28 PM during an interview with the MDS Coordinator and Nurse Consultant, the MDS Coordinator explained an intervention was put in place and explained different interventions implemented for the resident. When queried if went into the care plan, the MDS Coordinator explained would have to look. On 9/19/24 at 4:11 PM when queried about care plan interventions if accident with injury, the Nurse Consultant responded should be, and explained would open risk management, do immediate intervention, and would have been done with [Resident #11] with spills. 2. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident had a diagnosis of diabetes mellitus. Review of Resident #11's Medical Diagnoses in the Electronic Health Record (EHR) included the following: Type 2 diabetes mellitus with other specified complication, noted to be assigned during the resident's stay versus on admission. Review of the Care Plan for Resident #26 did not address diabetes. The Physician Order dated 2/13/24 revealed, empagliflozin Tablet 10 MG (milligram) with instructions to give 1 tablet by mouth one time a day for DM2 (Diabetes Mellitus Type 2). On 9/19/24 at 3:28 PM, the MDS Coordinator explained if resident diabetic and on insulin got a care plan. On 9/19/24 at 4:19 PM when during an interview with the Director of Nursing (DON) and Nurse Consultant, queried if resident with diabetes not on insulin should be care planned. The Nurse Consultant acknowledged she would care plan it. On 9/19/24 at 4:04 PM, a Facility Policy pertaining to guidelines for care plan revision requested via email from the facility's Administrator. On 9/19/24 at 4:07 PM, the Administrator responded via email the facility did not have a policy to address, and followed CMS (Centers for Medicare and Medicaid Services) guidelines. 48888 3. The Minimum Data Set (MDS), dated [DATE], revealed Resident #139 received insulin injections on 7 out of 7 days reference period. The MDS listed diagnoses included: disorder of bone, unspecified, cerebral infarction without residual effects (stroke with no ongoing effects). The MDS did not list diabetes mellitus as a diagnosis for Resident #139. The Care Plan, initiated 9/16/24, revealed Resident #139 had insulin-dependent diabetes mellitus with the goal that Resident #139 would have no complications related to diabetes through the review date. The Medication Administration Record (MAR), dated September 2024, revealed an order for Insulin Lispro Injection Solution 100 units per milliliter (mL) following sliding scale parameters for diabetes mellitus. A Hospital Discharge Note, dated 9/04/24, revealed Resident #139 had diagnosis of steroid-induced hyperglycemia (high blood sugar) and utilized sliding scale Insulin Lispro. On 9/19/24 at 4:10 PM, the Nurse Consultant for the facility, stated that Resident #139 did not have diagnosis of diabetes mellitus and that the Care Plan had been incorrect. The Nurse Consultant stated she would expect the Care Plan list the use of insulin related to diagnosis of steroid-induced hyperglycemia with interventions appropriate for the diagnosis. On 9/07/24 at 4:07 PM, Facility Administrator revealed the facility had no written policies or procedures related to Care Plan revisions.

Based on clinical record review, interview, and facility policy review the facility failed to ensure digoxin administered per Physician Order adhering to established parameters for one of six residents reviewed for medications (Resident #26). The facility reported a census of 36 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Physician Order dated 2/13/24 revealed, Digoxin Tablet 125 MCG (microgram) with instructions to give 1 tablet by mouth one time a day for heart failure hold if pulse below 60. Review of Medication Administration Records (MARs) revealed the following dates and documented pulse rate when the resident received the medication outside of parameters: a. On 7/8/24 for 6:00 AM scheduled dose: pulse of 59, and medication documented as administered. b. On 8/14/24 at 6:00 AM scheduled dose: pulse of 55 and medication documented as administered. On 9/19/24 at 2:43 PM during an interview with Staff B, Registered Nurse (RN) explained standard would be if a pulse less than 60 hold it [digoxin]. When it was explained about parameter present with the order, Staff B responded if in there would go by that. On 9/19/24 at 4:20 PM, the Director of Nursing (DON) acknowledged should hold the medication and call the provider. Review of the Facility Policy titled Medication Administration effective 2/17, revised 8/24, revealed the following: Policy: Medications shall be administered per physician order.

Based on clinical record review, resident interview, staff interviews, and facility policy review, the facility failed to appropriately provide assessment and interventions for the necessary care and services during a change in condition for 2 of 3 residents (Resident #3 and #6) reviewed for condition change. The facility failed to promptly identify change in respiratory condition and intervene in a timely manner for a resident with known history of chronic obstructive pulmonary disease (COPD) and respiratory failure. (Resident #6) found unresponsive with no palpable carotid or radial pulse and required emergency transport to the hospital. Resident #6 diagnosed with respiratory distress, respiratory syncytial virus (RSV) and respiratory failure with hypercapnia at hospital. Additionally, the facility failed to appropriately provide assessment and interventions for the necessary care and services following an unwitnessed fall (Resident #3). Clinical record review and interviews revealed Resident #3 had fallen on [DATE] without nursing assessment or documentation completed. On [DATE], an x-ray of left hip obtained due to Resident #3 complaints of pain, results revealed nondisplaced left sub-capital hip fracture. Resident #3 admitted to the hospital between [DATE] and [DATE] for surgical repair of left hip fracture. The facility reported a census of 36 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] at 03:00 AM on [DATE] at 10:24 AM. The facility staff removed the Immediate Jeopardy on [DATE] at 03:49 PM by implementing the following actions: 1. Education provided to all staff nurses within 24 hours or before next working shift, whichever is first on the following topics: -Documentation in real time. -When to notify the provider via phone call. -Acceptable notifications to be left in the provider binder. -Physician notification as soon as acute change is noted. 2. A review of respiratory assessment parameters and when to notify the provider completed with staff nurses, which included the development of respiratory assessment guidelines to notify the provider of any of the following that aren't resolved with interventions already in place: -Respiratory rate greater than 22 respirations/minute with complaints of shortness of breath. -Oxygen saturation less than 90%, unless otherwise specified in orders. -Acute lung sound changes, including: wheezing, rhonchi, rales, and crackles. 3. Audits of the provider binder to be completed by Director of Nursing each working day for 90 days. Findings include: 1. The Admission Minimum Data Set (MDS), dated [DATE], for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. Diagnoses included: chronic obstructive pulmonary disease (COPD), asthma, anxiety disorder, and morbid obesity. This initial MDS revealed no shortness of breath or respiratory treatment noted upon admission. The Quarterly MDS that followed hospitalization , dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. Diagnoses included: COPD, acute respiratory distress, asthma, anxiety disorder, and morbid obesity. Quarterly MDS revealed Resident #6 required oxygen therapy and had shortness of breath with exertion, when sitting at rest, and when lying flat. The Care Plan, initiated [DATE], revealed Resident #6 required oxygen therapy, and informed staff to monitor and report to the Medical Doctor (MD) for signs and symptoms of respiratory distress which included the following changes: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color ([DATE]). The Care Plan revealed that Resident #6 utilized supplemental oxygen via nasal cannula and frequently refused to wear bipap ([DATE]). The Medication Administration Record (MAR), dated [DATE], revealed the following orders in place for Resident #6: -Supplemental oxygen kept between 2 to 4 liters to maintain an oxygen saturation above 88% for COPD, started on [DATE]. -Antibiotic orders for Cefdinir 300mg twice per day for 5 days, started on [DATE] and Azithromycin 500 milligrams (mg) daily for 3 days, started on [DATE], both indicated for a lower respiratory infection. -Ventolin (albuterol sulfate) inhalation aerosol solution 108 micrograms (mcg) per actuation (act), 2 puffs inhaled orally every 4 hours as needed for shortness of breath related to COPD, initiated upon admission [DATE], had been utilized 9 times between the dates of [DATE]-[DATE], and utilized only once between the dates of [DATE]-[DATE]. -Guaifenesin liquid 100mg/5 milliliters (mL) to be given every 4 hours as needed for cough, started on [DATE], and utilized 6 times between [DATE]-[DATE]. A review of Nursing Progress Notes for Resident #6, between the dates of [DATE] to [DATE], revealed the following: a.) [DATE] at 04:51 AM: Resident #6 had increased shortness of breath, cough, and dyspnea noted. Oxygen saturation 90% on 2 liters of oxygen via nasal cannula (NC). Resident utilized inhaler and noted to have increased anxiety when nurse attempted to take inhaler out of resident's room. Lung sounds diminished and resident complained of difficulty breathing. Noted increased twitching of extremities. Resident #6 refused to wear bipap. Nursing indicated they would make a request for inhaler to be kept at bedside. b.) [DATE] at 06:38 PM: Resident #6 requested to wear bipap mask, respirations were heavy at 20 respirations per minute, audible rales noted throughout lungs. Nursing provided reassurance and one on one with Resident #6 due to increased anxiety. c.) [DATE] at 09:59 PM: Resident #6 complained of shortness of breath, nursing increased oxygen to 4 liters/NC due to oxygen saturation of 82% on 2 liter of oxygen. Lung sounds had rales noted throughout, Resident #6 continued to have frequent cough and complained of increased anxiety due to wearing bipap mask. Nurse informed resident that they would call the doctor, Resident #6 stated, Good, if I go to the Hospital, maybe I will get my Xanax (anti-anxiety medication). Nursing notified the on-call Provider and received orders for Lorazepam 0.5mg every 6 hours as needed and albuterol nebulizer every 4 hours as needed for shortness of breath, only if resident will give up her inhaler, which had been kept at bedside. d.) [DATE] at 11:32 AM: Resident #6 requested to go to the Hospital, when nursing questioned why, resident stated, I just don't feel good. Resident noted to have mouth breathing at intervals, nurse encouraged resident to breath in through nose and out through mouth. On-call Provider notified and instructed nursing to utilize the as needed anti-anxiety medication and continue to monitor. e.) [DATE] at 02:53 AM: it is noted that Resident #6 had complained of shortness of breath throughout the evening hours, vital signs included 22 respirations per minute and a temperature of 100.2 degrees Fahrenheit. Nursing reported that administration of as needed medications did not provide relief as Resident #6 continued to express increased restlessness. Nursing also noted that Resident #6 intermittently sat upright in recliner, resident's skin had been warm, dry, and dusky per norm for resident. Lung sounds had scattered congestion and an occasional moist cough continued. According to documentation, nursing provided an FYI for MD in the communication binder for evaluation upon rounds to the facility. f.) [DATE] at 03:03 AM: an addendum had been added to correct the documentation in previous note to inform that respirations had been 26 per minute, not 22 per minute as recorded and indicated that respirations were also slightly labored but subsided through the night. g.) [DATE] at 05:50 AM: Resident #6 stated, I just feel wiped out. It's the Ativan, it makes me feel drugged. Nursing noted that resident had occasional twitching of arms, an overall generalized increased weak appearance, and continued to voice that she didn't feel good. According to documentation, nursing provided an FYI for the MD and next shift nursing staff for continued monitoring. h.) [DATE] at 02:30 PM: Provider saw Resident #6 on facility rounds and ordered to obtain chest x-ray related to COPD. i.) [DATE] at 03:37 AM: Resident required increased assistance due to weakness and dyspnea with activity and expressed malaise. Nursing noted an overall general weak appearance and random involuntary twitching of extremities. Lung sounds continued to have scattered congestion and respirations slightly labored at times between ,d+[DATE] respirations per minute, temperature of 99.2 degrees Fahrenheit, pulse of 102 beats per minute, and oxygen saturation between ,d+[DATE]% on 3.5 liters of oxygen/NC. According to documentation, the Provider had been aware of resident decline as resident was to have chest x-ray in waking hours, and further orders pending. Nursing noted resident monitoring and encouragement continued. j.) [DATE] at 05:44 AM: Resident #6 complained of shortness of breath, nebulizer treatment administered and oxygen saturation following treatment had been 82% on 3.5 liters of oxygen/NC. Nursing increased flow of supplemental oxygen to 4 liters per NC and oxygen saturation increased to 89%. Resident #6's respirations slightly labored but calmed after one on one and encouragement, no Provider notification documented. k.) [DATE] at 02:55 AM: Resident #6 noted to be anxious with increased shortness of breath sporadically throughout the evening hours and Resident #6 intermittently yelling out, Help me, I can't breathe. Nursing reported respirations moderately labored during these events and oxygen saturation had been between ,d+[DATE]% on 3.5 liters of oxygen/NC. Nursing indicated Resident #6 utilized bipap for approximately 15 minutes, education provided with encouragement for resident to utilize bipap, resident stated, I can't do it. I can't breathe with this mask. Noted Resident #6 continued to have frequent involuntary twitches of extremities and slept in a straight upright position in recliner. Supplemental oxygen had been increased to 4 liters of oxygen/NC with oxygen saturations between ,d+[DATE]%, pulse ranged from ,d+[DATE] beats per minute, and respirations between 24 to 32 per minute. According to documentation, an FYI continued to be provided on nursing communication sheet and MD binder for continued monitoring/treatment as needed. Provider had not been called at this time. l.) [DATE] at 12:31 PM: Nurse had been called to Resident #6's room by Certified Nursing Assistant (CNA) when resident stated she felt like she wasn't getting air. Noted resident slightly rocking back and forth and had pursed lip breathing. Resident #6 had stated, There must be something wrong with my oxygen concentrator, I'm not getting any air. Nursing provided education for resident to attempt to hold mouth closed and inhale through nose and exhale through mouth. Oxygen saturation 91% on 3 liters of oxygen/NC. Nurse reported resident had dusky appearance per norm, lung sounds had rhonchi heard in bilateral lower lobes and diminished sounds throughout upper lobes. Resident #6 also noted to have twitching and stated, I feel cruddy. Nurse documented they would notify the Provider. m.) [DATE] at 12:51 PM: received order from Provider to obtain labs and urinalysis. n.) [DATE] at 10:25 AM: CNA called nurse to Resident #6's room due to resident not responding. Nurse reported Resident #6 sat in recliner with head tilted down and Bipap on, resident's lips colored blue and had forced air coming out of lips which caused lips to flutter. Resident #6 not responsive to verbal stimuli or sternal rub performed. Nurse reported increasing the oxygen flow to 5 liters via NC and requested Director of Nursing (DON) to be present, noted resident's status was for full code, and unable to palpate carotid or radial pulses. DON entered room and called 911, additional staff entered to assist with placing resident on the floor to start Cardiopulmonary Resuscitation, Resident #6 then opened eyes and gasped for air, eventually became more alert and breathing became more stable. Resident #6 assisted to bed with mechanical lift, staff performed cares due to bowel incontinence that occurred during non-responsive episode and prepared resident for transport in ambulance to the Hospital. o.) [DATE] at 11:00 AM: Nurse and DON gave report and assisted Emergency Medical Technicians (EMTs) with transfer of Resident #6 to stretcher for ambulance transfer to the Hospital. The hospital History and Physical Note, dated [DATE], revealed that per EMS, facility stated patient lost consciousness twice but never lost a pulse. Patient is full code and presented with worsening shortness of breath for ,d+[DATE] days prior, and had equivocal fever. H&P informed that Resident #6 presented to outside of emergency room (ER) hypoxic and hypercapnic, worse than baseline. Resident #6 tested positive for RSV. Upon physical exam, Resident #6 had been in moderate respiratory distress with decreased breath sounds and minimal wheezing. Resident #6 assessment included admission and treatment plan for respiratory distress, RSV infection, and urinary tract infection. On [DATE] at 12:15 PM, Resident #6 reported that leading up to the recent hospitalization she had experienced coughing and trouble breathing. Resident #6 reported that she had been found passed out, but unable to recall details from the day she had transferred out to the hospital. On [DATE] at 01:20 PM, Staff D, Registered Nurse (RN), recalled that Resident #6 had respiratory infection prior to an unresponsive episode and that her baseline had been on supplemental oxygen without respiratory distress at rest. On [DATE] at 01:45 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident #6's baseline had been mild respiratory distress with activity and sometimes at rest dependent upon how much the resident would get worked up or anxious. She stated Resident #6's baseline oxygen saturation usually in the 90's or upper 80's and improved with position change and or treatments. Staff E indicated that prior to hospitalization , Resident #6 started to have a new moist cough, followed by no energy, sleeping more, then continued to decline with increased cough and dyspnea for a few days before being transferred out. Staff E stated the twitching extremities had also been new. Staff E noted that Resident #6 had started antibiotics prior to transfer and that symptoms of respiratory infection never totally resolved. Staff E stated Resident #6's cough and shortness of breath had been hard to assess because the resident always had some respiratory distress. Staff E did not recall any requests from Resident #6 to go to the hospital prior to the unresponsive episode, and stated the resident did not ask her. Staff E stated she would notify the provider if Resident #6 had a change to see if something else would be ordered or notify the provider if Resident #6 wasn't getting better. On [DATE] at 04:00 PM, Staff B, LPN, stated a provider should be notified of any change in resident condition or vital signs. Staff B stated that with a decrease in oxygen saturations for a resident who required supplemental oxygen to call the provider, if after hours, nursing had a number for an on-call provider. Staff B revealed that most of the oxygen orders informed staff to keep oxygen saturations above 88% and stated that if oxygen saturation is under 88% to call the provider and stated it would not be okay to put this information in communication binder only. Staff B stated facility utilized communication binder for providers who visit the facility, that is to include non-emergent items which may include orders that the facility had already received. Staff B confirmed working during Resident #6 unresponsive episode on [DATE] and recalled that Resident #6 woke up saying she wanted CPR and to go to the Hospital. Staff B assisted CNA to prepare resident for hospital transfer. On [DATE] at 09:28 AM, Staff F, RN, confirmed responding to Resident #6's unresponsive episode on [DATE], recalled performing sternal rubs and attempting to locate pulses. Staff F called for the DON to enter resident's room, took the bipap mask off, put oxygen nasal cannula on and increased the flow of oxygen. Staff F stated staff had prepared to assist Resident #6 to the floor, to perform CPR, when resident had gasped and started to respond. Staff F stated that upon waking, Resident #6 had requested CPR and wanted to go to the hospital. Staff F stated that for oxygen saturations in the 80's it would depend on the situation and how fast saturation returned to normal for this information to be put as an FYI in communication binder for Provider. Staff F revealed that a Nurse Practitioner visited the facility twice per week and the Physician visited the facility twice per month. On [DATE] at 01:33 PM, the Nurse Practitioner (NP) for the facility, revealed the expectation that non-emergent notifications would be placed in the communication binder, gave examples such as: itchy skin, didn't sleep the greatest one night, fever resolved with Tylenol, sometimes family concerns, a fall without injury, labs if normal results unless I ask them to contact me, and pharmacy recommendations. The NP revealed the expectation that facility calls with acute respiratory changes and depending on the patient with history of COPD and chronic respiratory disease to give treatment to see if that helps, if not, or symptoms continue for ,d+[DATE] hours, NP would like to be notified. On [DATE] at 10:02 AM, the Facility Administrator stated the facility lacked policy for resident change of condition. The facility document titled, Things to be Placed in Communication Log, not dated, instructed staff to place the following non-emergent patient issues in binder: seasonal allergy symptoms, skin tears, falls without injury, insomnia, family member meeting requests, if as needed medications have been initiated, non-emergent labs, tests, or x-rays, refusal of medications or medications given for other reason, medication errors without adverse effects. The facility document titled, Call Immediately For, not dated, instructed staff to immediately call Provider for the following issues: any unstable patient, falls with injury, unstable vital signs, any new findings on imaging studies, chest pain, fever, hypoxia, heart rate greater than 110 beats per minute, shortness of breath, etc. 2. The MDS, dated [DATE], revealed a BIMS score of 13 out of 15 indicating intact cognition. Resident #3 had no impairment of upper or lower extremities and utilized walker. Resident #3 independent with bed mobility, transfers, toileting, and ambulation at time of this assessment. Diagnoses included: non-Alzheimer's dementia, anxiety disorder, fibromyalgia, hypothyroidism, and history of falling. Resident #3 received scheduled pain medication for almost constant pain. The MDS, dated [DATE], revealed Resident #3 utilized both a walker and wheelchair during the assessment period and required partial to moderate staff assistance with bed mobility, transfers, and toileting. The MDS documented Resident #3 non-ambulatory during reference dates. Diagnoses of fracture of unspecified part of neck of left femur subsequent for closed fracture with routine healing included. Resident required scheduled and as needed pain medications, and non-medication interventions for almost constant pain. The Care Plan, revised on [DATE], revealed a risk for falling related to low back pain, fibromyalgia, and history of falls. Interventions informed staff to keep personal items and frequently used items within reach ([DATE]), refer to fall intervention plan (FIP) at Nurse's Station ([DATE]) and refer to resident's care card in room ([DATE]). An Incident Report, dated [DATE], completed by the Director of Nursing (DON), documented that there was no documentation of the incident. Resident #3 interview revealed that she had fallen when attempted to get into bed and hit head on a pile of soft clothes and notified that her head had still been sore where she landed. Resident recalled yelling for help and her roommate pulled the call light. Resident #3 reported that a few CNA staff came into room and checked her out, then the nurse came to room and checked her out. The Incident Report revealed that the immediate action taken had been to obtain an order for a x-ray immediately after DON was notified of fall (3 days following fall) and resulted in post incident injury of left trochanter (hip) fracture. Review of Nursing Progress Notes that followed fall on [DATE], revealed the following entry information: a.) [DATE] at 08:38 AM: Resident received new order for anti-anxiety medication Alprazolam (Xanax) scheduled three times per day. b.) [DATE] at 04:39 PM: Provider ordered x-ray of left hip for resident complaints of increased pain. c.) [DATE] at 01:59 AM: Resident more lethargic in mood, appeared to have increased generalized weakness, and fatigued appearance. Resident stated, I'm just tired. I'm just not me anymore. d.) [DATE] at 02:29 PM: Resident self-reported a fall on [DATE] and complained of left hip pain. e.) [DATE] at 02:30 PM: Obtained x-ray as ordered for left hip ,d+[DATE] views unilateral with pelvis. f.) [DATE] at 04:00 PM: Results received from mobile x-ray for non-displaced left sub-capital hip fracture. Nursing notified Provider of results. g.) [DATE] at 04:40 PM: Resident transferred to Hospital. h.) [DATE] at 05:03 PM: Director of Nursing completed investigation, found that Resident #3 had attempted to get into bed, call light had been pulled by Resident #3's roommate and Certified Nursing Assistant (CNA) answered light. Resident #3 found on the ground near her bed. CNA notified Nurse of fall. Nurse in another resident's room performing cares instructed CNA to obtain Resident #3's vital signs. CNA assisted Resident #3 off the floor and into bed. Nurse arrived to assess the resident between ,d+[DATE] minutes following incident. i.) [DATE] at 08:10 PM: Facility notified that Resident #3 had been admitted to Hospital and scheduled to have left hip surgery. The hospital History and Physical (H&P), dated [DATE], revealed that Resident #3 presented with complaints of left hip pain since falling on Saturday ([DATE]). New left hip fracture noted on outpatient x-ray. Resident stated she fell backwards when using her walker, hit her head, has been ambulatory since fall, and progressive left sided pain without radiation. The H&P also revealed that Orthopedic Surgeon had been consulted by Emergency Department and plan for surgical intervention on Thursday ([DATE]). On [DATE] at 01:45 PM, Staff E, Licensed Practical Nurse (LPN) stated that prior to falling Resident #3 had been independent using walker throughout the facility and following the fall required assist of one staff to stand pivot transfer and ambulate short distances with wheelchair to follow. Staff E revealed the facility fall process is for nursing to assess the resident before they are moved, check vital signs, look at their skin, check range of motion, and assess for head injury. Staff E stated if acute pain is assessed with a fall, call the provider and ask about evaluation at ER, call family, notify the DON and Administrator if resident needs sent to the hospital. Staff E also stated that staff involved with a fall complete a fall packet which includes a diagram, an immediate intervention to prevent it from happening again, then discussed in all staff huddle the following day. Staff E revealed that a fall assessment and 3 day follow up assessments are completed in the Electronic Health Record. On [DATE] at 04:00 PM, Staff B, LPN, stated that when residents fall, nursing staff is expected to assess the resident as soon as notified. The nurse is to check vital signs, check skin, range of motion, assist resident to a safe position and fill out fall paperwork which involves intervention appropriate to fall, staff education, resident education, and notify the Director of Nursing, Administrator, provider, and family. Staff B informed that if a resident's BIMS is lower than 13 neuro checks are automatically initiated for an unwitnessed fall. On [DATE] at 01:33 PM, the Nurse Practitioner (NP) for the facility revealed the expectation that resident fall assessment is completed immediately and indicated that there are times residents should not be moved because this may cause more harm. The NP expected that for cognitive deficits or functional decline the provider be notified immediately of the fall or if they hit their head, have injury, or pain to be notified within the hour. The NP stated that a hip fracture could be exacerbated with movement, and gave the example that a hairline fracture could be made worse. The NP expected that nurses assess resident following a fall to document change and establish a baseline. The NP stated CNA staff could check and report vital signs. On [DATE] at 02:31 PM, Staff G, Certified Nursing Assistant (CNA), confirmed working [DATE], on the date that Resident #3 had reportedly been observed on the floor. She stated that she told another CNA to notify the nurse that Resident #3 had fallen, while Staff G waited with the resident in her room. Staff G recalled that Resident #3 had been in a kneeling position on one knee and informed that after waiting 15 minutes with Resident #3 for the nurse, had assisted resident to stand up from the floor and then lay on the bed, due to resident trying to get self up and complaints of pain in her back. Staff G reported that another CNA returned to Resident #3's room with vital signs equipment and recalled that vitals looked okay and everything seemed okay when resident laid in bed, with no more pain than usual. Staff G stated a nurse entered the room and also assessed the resident. On [DATE] at 04:36 PM, the Director of Nursing (DON), stated she had not been notified that Resident #3 fell on [DATE] until Monday [DATE] when a CNA informed her that Resident #3 had fallen over the weekend. DON revealed having concern that there was a lack of documentation related to fall and completed investigation with staff who worked, as well as Resident #3, and resident's roommate. DON revealed that the nurse had been terminated due to lack of fall documentation and revealed the expectation that the nurse would do a proper fall assessment and notify the DON. The facility document, titled Fall Checklist, not dated, instructed nursing staff to complete the following tasks when a resident falls: 1. Obtain vital signs and safely position resident 2. Complete fall huddle sheet with staff 3. Call Medical Doctor (MD), Physician's Assistant (PA), or Nurse Practitioner (NP) for EVERY fall 4. Call Power of Attorney (POA) 5. Text to Administrator, DON, and on-call nurse, if injury that requires higher level of care, the Administrator and DON must be called. 6. Complete fall investigation form 7. Initiate neurological assessment (if applicable) 8. Initiate skin sheets (if applicable) 9. Complete risk management in Electronic Health Record (EHR) 10. Add intervention to CNA intervention list 11. Complete Morse Fall Scale assessment in HER

Based on clinical record review, observations, and staff interviews the facility failed to prevent pressure ulcer development, failed to ensure accurate assessment of a pressure ulcer, and failed to implement timely interventions to prevent the development and worsening of a pressure ulcer for one of one resident reviewed for pressure ulcers (Resident #4). The facility reported a census of 36 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 11/16/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Per this assessment, the resident was at risk for pressure ulcer development, did not have one or more unhealed pressure ulcers, and did not have any venous or arterial ulcers. Review of census information for Resident #4 revealed the resident initially admitted to the facility on [DATE] and was hospitalized on [DATE]. Review of Resident #4's Care Plan and Care Plan revision history for skin revealed the following: a. The Baseline Care Plan for the resident's admission 11/9/23 documented the resident had a left fibular fracture and wore a cam (controlled ankle movement) boot. The Baseline Care Plan lacked guidance as to the schedule when the cam boot applied and removed. Per the Baseline Care Plan, the resident had no open areas per the skin section. b. The Care Plan dated 11/21/23 documented, the resident has potential impairment to skin integrity. (This Care Plan focus was initiated after the resident had a blister present to the left heel). c. The revised Care Plan dated 1/23/24 documented, the resident has potential impairment to skin integrity and has an actual pressure ulcer. Location: left lateral foot Stage: DTI (deep tissue injury-persistent non-blanchable deep red, maroon or purple discoloration). d. The revised Care Plan dated 2/20/24 documented, the resident has potential impairment to skin integrity and has an actual pressure ulcer. Location: left lateral foot & heel Stage: DTI. e. The revised Care Plan dated 2/20/24 documented, the resident has potential impairment to skin integrity and has an actual pressure ulcer. Location: left heel Stage: Blister. f. The revised Care Plan dated 4/15/24 documented, the resident has potential impairment to skin integrity and has an actual pressure ulcer. Location: left heel Stage: Pressure Unstageable. Review of the resident's Nursing Admission Screening/History V2 Report dated 11/9/23 documented reason for admission as therapy due to fall and broken ankle. The assessment noted the resident had a left fractured tibia, and noted edema present to the feet and hands, increased to the left ankle. The Skin section of the assessment did not address any areas present to the resident's feet or toes. Review of a SNF (Skilled Nursing Facility) Fracture Documentation form dated 11/9/23 explained the resident had no bruising or skin issues and boot present to the left ankle. Review of the resident's Treatment Administration Record (TAR) dated November 2023 lacked an order to monitor skin underneath Resident #4's boot. Review of the resident's Braden Scale dated 11/9/23 revealed the resident at moderate risk for pressure ulcer development, with a score of 13 on the assessment. The Provider Progress Note dated 11/11/23 documented, this is a new admission to the nursing home post left fibular fracture. Per the Progress Note, the resident used a cam boot and weightbearing as tolerated. Review of Bathing Documentation and Skin Check sheets dated 11/11/23 and 11/14/23 lacked documentation of any skin issues. Review of SNF Fracture Documentation forms dated 11/10/23 through 11/15/23 documented presence of the boot. The Provider Progress Note dated 11/15/23 documented, left fibular fracture: continue with stabilizing boot. Review of the resident's Braden Scale dated 11/16/23 revealed the resident at risk for pressure ulcer development, with a score of 15 on the assessment, which indicated at risk. The Physician Order dated 11/16/23 revealed, Per Dr. [Name Redacted]-Cam boot on at all times while in PT/OT (physical therapy/occupational therapy). May keep Cam boot off when in bed or recliner or for hygiene. Review of Physician Orders, Skin and Wound Evaluations, Progress Notes, and Provider Progress Notes for the resident's left heel and/or ruptured blister revealed the following: The Health Status Note dated 11/16/23 at 10:58 AM documented, resident received shower today and nurse noticed blister to left heel and areas of discoloration and previous scabbed areas to left foot. Skin prepped areas. Mepilex applied to blister on left heel and remove after 5 days. The Communication with Physician Note dated 11/16/2023 documented, Fluid filled grayish blister 6.9 x 4.8 cm (centimeter) to left heal. Skin prepped and applied Mepilex. Area noted to left side of foot discolored and deterioration under area 3 x 0.6 cm will apply skin prep daily along with areas that were visible on admit of scabs to toes. The Nutrition/Dietary Note dated 11/17/23 at 10:38 AM documented the resident's skin as intact, following documentation of a blister to the resident's left heel the day prior. The Skin/Wound Note dated 11/17/23 at 12:06 PM documented, measurements on 11/16/23 for new areas. No pictures available at this time due to dressings intact and fragility of skin requires extended periods between dressing changes. The Physician Order dated 11/17/23 to 11/18/23 documented, Skin Prep Wipes Miscellaneous with directions to apply to left heal topically every day shift every 5 day(s) for blister, cover with bordered foam dressing. The Skin/Wound Evaluation dated 11/18/23 revealed the following: The following areas left blank per assessment: Type of wound, wound location, in-house or present on admission, and how long wound was present. The assessment noted a ruptured blister which measured 3.1 cm (centimeter) length (L)by 2.5 cm (W). The wound bed documented epithelial, granulation, and slough present. Per the assessment, progress documented improving with notes of blister opened and drained. The Provider Progress Note dated 11/18/23 documented the following per the Plan section for EXT (extremities): 1+ edema CAM boot in use. The note did not address wounds to the left heel. The Provider Progress Note dated 11/21/23 documented the following per the Physical Exam Integumentary section: Dry. Left heel red with blisters. The Health Status Note dated 11/22/23 documented, Resident left for his ortho appt at 1330 (1:30 PM) today and returned at 1600 (4:00 PM). Orders from the doctor received. Orders: Will continue to only wear the boot when getting up to transfer, otherwise boot off due to pressure sores. okay to weight bear with transfers. Review of the resident's Pressure Sore Risk assessment dated [DATE] revealed the resident scored 15 on the assessment which indicated at risk for pressure ulcer development. The Skin/Wound Evaluation dated 11/24/23 revealed a blister to the left heel which was in-house acquired. The date the wound present had been left blank, with wound documented as 4.0 cm L x 2.7 cm W. The wound described as an intact blister, documented as blister intact but fluid has decreased. The Physician Order, start date 11/24/23, documented, Mepilex Border Flex External Pad with directions to apply to left heel topically every day shift every Friday for protection. This order had been left blank on the resident's MAR for the date 11/24/23. The Health Status Note dated 11/25/23 at 1:46 PM documented, in part, Drsg's to LLE (left lower extremity) changed. Review of the resident's Braden Scale dated 11/29/23 revealed the resident scored 15 on the assessment which indicated at risk for pressure ulcer development. The Skin/Wound Evaluation dated 12/1/23 revealed an intact blister to the left heel which was in-house acquired. The date the wound present had been left blank, with wound measurements documented as 4.3 cm L x 3.4 cm W. The Health Status Note dated 12/2/2023 at 1:04 PM documented, Changed Mepilex order to be changed every 3 days due to preference to have nurses' monitor how wound looks throughout week. The Skin/Wound Evaluation dated 12/8/23 revealed an intact blister to the left heel which was in-house acquired. The date the wound present had been left blank, with wound measurements documented as 3.5 cm L x 2.8 cm W. The Skin/Wound Evaluation dated 12/15/23 revealed an intact blister to the left heel which was in-house acquired. The date the wound present had been left blank, with wound measurements documented as 3.6 cm L x 3.7 cm W. The Skin/Wound Evaluation dated 12/22/23 revealed an intact blister to the left heel which was in-house acquired. The date the wound present had been left blank, with wound measurements documented as 2.2 cm L x 2.8 cm W. The Provider Progress Note dated 12/22/23 documented, in part, [Resident #4] does have two wounds that nursing is doing management with dressing changes. Left heel DTI with black stable eschar. Tissue still present over wound. The assessment of the resident's left heel wound revealed a pressure DTI, which measured 2.21 x 2.82 CM, with tissue/wound bed 100% eschar. The Plan section for Pressure Injury of Deep Tissue Injury of Left Heel documented to continue to elevate area to limit pressure. Monitor for s/s (signs/symptoms) worsening condition. Current treatment for Mepilex to area and change weekly. If develops moisture will change to Betadine BID (twice a day) and keep OTA (open to air). On 12/27/24, Resident #4 sent to the hospital to address a different concern. Review of a Consultation Note dated 12/28/23 from hospital records revealed the resident had a consultation done for ulcers to the left heel and foot. The History of Present Illness section documented, in part, on admission, it was noted that he had several wounds to his left foot. Patient states these are the result of wearing a boot from his recent leg fracture. States the areas are painful to palpation. The Wound Assessment section documented, The ulcer on the left heel measures approximately 2.5 x 1.0, completely covered with thick necrotic tissue. Minimal serosanguinous drainage. No erythema. The area on the top of the left first toe wound measures approximately 0.5 cm in circumference. Large amount of yellow necrotic tissue present, small amount of serosanguinous drainage. The area on the left lateral foot measures 0.6 cm in circumference. Completely covered with yellow necrotic tissue. No erythema or induration. Pulses were not palpable due to 2+ edema. Observation on 4/22/24 at 8:14 AM revealed Resident #4 in a wheelchair in the common area. The resident moved themselves from the dining area to towards the television area in the common area by the entrance to the facility. The resident had gray socks to their feet, and their left foot observed to rest on the wheelchair pedal. Observation on 4/22/24 at 8:28 AM and 9:03 AM revealed Resident #4 in the common area, with their feet resting directly on the wheelchair pedals. Observation of wound care conducted 4/22/24 revealed Resident #4 present in their recliner chair in their room, with the resident's left foot elevated on pillows. Wound care to the resident's heel performed by Staff C, Registered Nurse(RN). On 4/17/24 at 4:10 PM during an interview with Staff B, Licensed Practical Nurse (LPN)/Wound Nurse, Staff B explained the area to the heel was a blister that was present when the resident was admitted . Per Staff B, it was a blood blister that turned necrotic. Staff B explained she thought the heel wound was currently set for an unstageable because it was all necrotic at present time. On 4/22/24 at 2:43 PM, Staff C, Registered Nurse (RN) queried if the resident came into the facility with the heel wound or acquired at the facility, and explained they were not sure without looking at the records. When queried if the resident had a boot when the resident initially came into the facility, Staff C explained the resident had a black cam boot that they believed the resident came with from the hospital. Staff C acknowledged an initial skin would be done on admission. On 4/24/24 at approximately 4:40 PM, Staff H, Consultant #1 acknowledged she would expect an order to be put in to remove the boot each shift and inspect skin. Staff H also acknowledged she did not see notification completed to dietary. On 4/24/24 at 10:02 AM, the facility Administrator explained via email on 4/24/24 at 10:02 AM that the facility did not have a pressure ulcer policy.

Based on observation, resident interviews, provider interview, staff interviews, and clinical record review, the facility failed to identify and adequately treat pain related to an open ulcer on a residents right ankle during wound care for 1 of 2 residents (Resident #8) reviewed for pain management. The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Diagnoses included: atherosclerosis of native arteries of right leg with ulceration, non-pressure chronic ulcer of right ankle with fat layer exposed, and arthritis. MDS revealed Resident #8 had one stage II pressure ulcer. The Care Plan revealed a focus area, initiated 03/27/23 for pressure ulcer to right lateral ankle and the goal that ulcer will heal without complications. Interventions instructed staff to report any further skin breakdown, such as sore, tender, red, or broken areas. Report signs of cellulitis such as localized pain, redness swelling, tenderness, drainage, or fever. Report signs of osteomyelitis, such as, pain, redness, swelling, muscle spasms in affected joint, and fever. The Care Plan revealed a focus area, revised on 01/23/24 that resident receives scheduled and PRN (as needed) pain medications. Interventions instructed staff to monitor for any complaints of pain and to administer medications as ordered. The Medication Administration Record (MAR), dated April 2024, revealed current orders for the following medications and wound treatments: 1. Gabapentin 300 milligrams (mg) twice a day related to osteoarthritis, started 01/05/24. 2. Tylenol Extra Strength 1000 mg daily at bedtime for pain, started 01/05/24. 3. Tylenol 650 mg every 4 hours as needed for pain/fever, started 01/05/24. No doses administered in month of April, 2024. 4. Ibuprofen 600 mg every 6 hours as needed for pain, started 01/22/24. No doses administered in month of April, 2024. 5. Aquacel-Ag Extra Hydrofiber (Silver- Carboxymethylcellulose sodium) external pad, applied to right heel topically every 2 days for wound, started 03/10/24. 6. Mupirocin External Ointment 2%, applied to right dorsal foot topically every other day for right dorsal foot wound, cover with foam and secure with tape, started 02/07/24. Review of Nursing Progress Notes, revealed the following entry information: a.) 04/25/23: Provider visit noted Resident #8 had concerns about right ankle wound, present for over a month, that is getting dressed by nursing. Resident #8 with history of arterial ulcers in this area is at increased risk of recurrence due to significant contraction present to right ankle from surgical fixation. Resident #8 had discomfort with dressing changes and when laying in bed. b.) 05/10/23: Resident #8 reported and showed signs of increased pain with dressing change. Right lower extremity noted to be red with pitting edema present. c.) 06/10/23: Provider visit noted wound had gotten wider and Resident #8 had a great deal of pain when area is cleaned to redress ankle. A referral made for Wound Clinic to follow for proper numbing for mechanical debridement of wound. d.) 08/30/23: Resident #8 voiced continued discomfort at right ankle wound site. e.) 09/14/23: Resident #8's wound to right ankle had deteriorated, measured bigger, had a majority of slough to wound bed, and noted to be red and inflamed. Resident #8 complained of pain with treatment change. f.) 09/30/23: Provider visit informed that Resident #8 had discussed a need for more pain management regarding ankle wound. Physician's Assistant (PA) wrote order for Tramadol dosage at bed time. g.) 10/01/23: PA ordered for nursing to discontinue Tramadol order due to Resident #8 diagnosis of Stage 4 Renal Disease and to give Tylenol 650 mg three times per day. h.) 10/18/23: Resident #8 returned from Hospital with order for Tramadol; PA discontinued order and indicated to complaints of discomfort would be addressed if it comes up. i.) 03/13/24: Resident #8 stated her wound hurt, she continued on oral antibiotics. j.) 03/16/24 at 3:59 PM: Resident #8 voiced concerns about pain in her foot and stated she has been asking for pain mediation to help. A Hospital Wound Consultation Note, dated 10/07/23, revealed Resident #8 had been seen for ulceration of right lateral ankle and complained of pain when the bandages are being changed. Noted pain of area with palpation during assessment of peri-wound. Wound cultures showed Pseudomonas as well as Staph bacterium from both culture taken at Hospital and Wound Clinic. A Hospital Computed Tomography (CT) Report, dated 10/07/23, revealed no clear signs of osteomyelitis, however, it is reported that osteitis and early phase osteomyelitis cannot be excluded without concordant evaluation with more sensitive imaging such as Magnetic Resonance Imaging (MRI). A Podiatry Consultation Note, dated 10/09/23, revealed Resident #8 Power of Attorney (POA) stated that the patient has had problems with pain control in the past and she feels that this is a concern the patient has with potentially performing wound debridement surgery. A Wound Clinic Note, dated 10/17/23, revealed Resident #8 stated she had pain when bandages are being changed and noted to have pain with palpation to wound site within the subcutaneous tissue visibly. On 04/22/24 at 09:45 AM, observed wound care performed by Staff C, Registered Nurse (RN), to Resident #8's right ankle ulcer. Old dressing removed from Resident #8 right ankle, utilized wound cleanser spray to loosen tape and bandage, noted moderate amount of serosanguinous drainage on old padded dressing. Ulcer to right ankle had red, raw appearance in wound bed, surrounding skin appeared dark pink with flaky, scaly skin. Ulcer actively dripped bright red blood onto a bed pad placed underneath wound. Throughout wound treatment, as Staff C cleaned wound and applied ointment to wound bed, Resident #8 gasped, screamed, squeezed her eyes shut, and bit tongue, staff had not stopped for a break or offer pain medication. A Certified Nursing Assistant (CNA) assisted with keeping Resident #8 right leg elevated during treatment, attempted to console resident and stated to Resident #8, it's okay, just think happy thoughts. Right ankle wound treatment is scheduled every other day and wound measurements are completed by Wound Nurse every Friday. On 04/22/24 at 10:00 AM, Resident #8 reported the pain she experienced in ankle/wound site is frequent in occurrence and described pain as shooting type. Resident #8 stated facility does not give her anything except Tylenol for pain, stated she had previously reported to facility staff that Tylenol does not help, but they will not give her anything else for pain. On 04/22/24 at 02:44 PM, Staff C, RN, stated Resident #8 has had an open ulcer to her right ankle as long as she can remember. She reported the wound had more leakage lately and wound easily irritated with wound cleanser which caused wound to bleed. Staff C, stated Resident #8 has always had pain with dressing change, reported no narcotics ordered for Resident #8 but thought she utilized Gabapentin and Baclofen for nerve pain. Staff C stated that Resident #8 could be given dosages of as needed Tylenol or Baclofen oral medication in response to pain, and stated staff should give medication some time to see if it helped, and then go back and attempt to finish. Staff C revealed that the provider should be notified for change in wound drainage or if the resident had increased pain. On 04/22/24 at 04:00 PM, the Nurse Practitioner (NP) for the facility, stated Resident #8's wound is very chronic and stated the resident recently had an exacerbation of inflammation. NP reported Resident #8 had scheduled Tylenol for pain and that her pain often resulted from wound cares and positioning of right lower extremity. NP also noted that Resident #8 had not consistently complained about pain but would be good about telling staff, and felt overall Resident #8 had been fairly comfortable except during her dressing changes. NP stated she would encourage pre-medication for wound treatment utilizing an as needed pain medication a half hour to an hour prior to treatment to see it it helps Resident #8 tolerate procedure better. NP revealed the expectation that nursing staff notify provider for increased pain and stated, if it's once with increase pain that improves an FYI may be okay, if resident has no pain relief, staff are expected to call the provider. On 04/24/24 at 04:35 PM, the Director of Nursing (DON) stated signs of pain observed during wound cares would not have been voiced by Resident #8 if cares had not been observed and that the signs of pain displayed by the resident were a character thing. The DON stated if Resident #8 needed pain medication she would voice it. The DON stated Resident #8 had only utilized as needed pain medication once in the last month and felt that staff would not need to offer pain medication, and the resident would know to ask if she needed it. The DON stated the scheduled and as needed medications had provided effective relief of pain for Resident #8. On 04/24/24 at 04:55 PM, Resident #8 reported she never knows when her pain is going to start or how long it's going to last, and again described pain as shooting up her lower extremities. Resident #8 stated pain is sometimes with wound cares and sometimes resulted from putting her leg up. Resident informed that she had requested pain medication to help, all the time, and stated she's even begged to have something stronger to help, but all they will give is Tylenol 500. Resident unaware of any additional medication she may have as needed or prior to wound treatment and asked, What would they give me?. Resident revealed that NP had visited on 04/23/24, spoke to resident about pain, and planned to observe wound dressing change to be completed on 04/25/24. On 04/24/24 at 10:02 AM, Administrator revealed the facility lacked policy or procedure related to pressure ulcers/injuries.

Based on observation, staff interviews, clinical record review, and facility policy review the facility failed to ensure residents remained free from resident to resident altercations including one resident running their wheelchair over another resident's foot, and multiple instances of one resident hitting another resident and/or mutual hitting between residents for three of six residents reviewed for abuse (Resident #1, Resident #5, Resident #18, Resident #141). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Diagnoses included: non-Alzheimer's dementia, depression, and cancer. The MDS revealed that both physical and verbal behaviors occurred on 1 to 3 days of the 7 day reference period. Resident #18 required anti-anxiety, anti-depressant, and antibiotic medications. The Care Plan, initiated 11/08/23, revealed a focus area for Resident #18's potential to be physically aggressive, related to dementia diagnosis, with the goal that resident will not harm self or others though the review date. Interventions included: administer medication as ordered; monitor/document side effects and effectiveness of medications; assess and anticipate resident's needs, such as: food, thirst, toileting, comfort, body positioning, and pain; provide physical and verbal cues to alleviate anxiety; assist with verbalization of source of agitation; assist to set goals for more pleasant behavior; encourage resident to seek out staff when agitated; give resident choices. Review of Nursing Progress Notes, revealed the following entries: 12/18/23 at 9:53 AM: Male resident put arm around Resident #18's shoulder and smacked her left buttocks. Nurse redirected male resident and Resident #18 thanked the nurse and stated she didn't know what to do at that point. 02/07/24 at 1:05 PM: Resident #18 had a verbal altercation with another resident, pointed finger at other resident, tried to take another's sandwich, staff moved other resident to another area in dining room as Resident #18 had refused to move or leave. Request from provider for UA. 03/31/24 at 4:44 PM: Observed by staff making physical contact with another resident. The two residents were immediately separated. The note lacked any other intervention attempted by staff. 04/22/24 at 4:30 PM: Staff overheard resident rasing voice. Resident #18 slapped another resident's leg. The other resident sitting in a recliner in the living room. Staff intervened and separated the two residents. Review of facility Incident Reports revealed the following interventions initiated in response to physical altercation: 12/17/23: Male resident moved rooms to another hallway. 03/31/24: Resident #18 purposely ran over Resident #141 foot in wheelchair, stated because Resident #141 would not move. Resident #18 and #141 then proceeded to hit each other. Intervention put in place for Resident #141 to be assisted to recliner between meals and Resident #141's husband to notify facility when leaving to prevent further issues. 04/22/24: Resident #18 hit Resident #141 on left leg, Resident #141 then kicked Resident #18. Facility planned to have a Care Conference with Resident #18's family to discuss other placement for resident's own and other's safety. On 04/17/24 at 01:45 PM, Staff E, Licensed Practical Nurse (LPN), reported Resident #18 gets antsy at times and that behaviors had been discussed with Provider the previous day (04/16/24). Staff E revealed interventions for Resident #18 behaviors included check her for Urinary Tract Infection (UTI), keep her out of common area or away from other residents when agitated. 2. The MDS, dated [DATE], revealed Resident #141 had moderately impaired cognition with short term and long term memory problems, signs of delirium, and inattention. Diagnoses included: anxiety disorder, dementia, and major depressive disorder (MDD). Resident #141 had both verbal and physical behaviors during 1-3 days of the 7 day reference period, as well as other behaviors not directed at others and rejection of cares. Resident #141 required anti-psychotic, antianxiety, and antidepressant medications. The Care Plan, revised 04/08/24, included a focus area for impaired cognition and directed staff to provide the resident with necessary cues, stop and return if agitated, and to monitor/document/report any changes in cognitive function. The Care Plan revealed Resident #141 had behavioral symptoms both directed and not directed towards others with goals that Resident #141 will not exhibit socially inappropriate or disruptive behavior and Resident #141 will not threaten, scream at or curse at other residents, visitors or staff. Interventions included: a.) Allow resident to have control over situations if possible. b.) Assess whether the behavior endangers the resident and/or others and intervene if necessary. c.) Avoid over-stimulation; maintain a calm environment and approach to resident. d.) Remove resident from group activities when behavior is unacceptable. e.) When resident becomes socially inappropriate or disruptive, move to a quiet, calm environment and provide for comfort measures. f.) If resident has delusions or hallucinations, do not try to reason with or confront resident, offer reassurance. g.) Refocus conversation when resident becomes verbally abusive. h.) Provide adequate distance or remove resident when she is overstimulated by other residents when engaging in activities in the Main Living Room. i.) Provide consistent staff and routines as much as possible. j.) When resident becomes physically abusive, keep distance between the resident and others (staff, other residents, visitors) k.) When resident becomes physically abusive, stop and try task later, do no force resident to do task. Review of facility Incident Reports revealed the following interventions initiated in response to physical altercation: 1.) 10/17/23: Resident #141 bumped wheelchair into back of another resident's wheelchair while trying to pass. Both residents became verbally upset and Resident #141 hit Resident #1 on the right shoulder 3 times. Staff responded and immediately separated residents. Interventions initiated for Certified Nursing Assistant (CNA) responsible for assisting Resident #141 to eat will assist Resident #141 to her room or recliner to lay down. 2.) 01/31/24: Resident #141 observed by staff member self propel wheelchair to Resident #5 who sat in wheelchair and called out. Resident #141 told her to shut up, and hit Resident #5's right leg twice. The two residents were immediately separated. Intervention again initiated for CNA responsible for assisting Resident #141 to eat will assist Resident #141 to her room or recliner to lay down. 3.) 03/31/24: Resident #141 in wheelchair in main living room area following a visit with significant other. Resident #18 rolled over Resident #141's foot with wheelchair, Resident #141 became upset and hit Resident #18. The two residents were immediately separated. Intervention initiated for Resident #18's significant other to notify staff when done with visit so that Resident #141 may be assisted to a stationary chair. 4.) 04/22/24: Resident #141 sat in recliner in main living room, Resident #18 showed agitation and self propelled in wheelchair to Resident #141. Resident #18 hit Resident #141 on the left leg one time, Resident #14 became upset and kicked at Resident #18 without making contact. The two residents were immediately separated. Intervention initiated for facility to have Care Plan Conference with Resident #18's family to discuss other placement options for her and other resident's safety. On 04/17/24 at 01:45 PM, Staff E, Licensed Practical Nurse (LPN), informed that Resident #141 has sporadic behaviors and informed that staff assigned to resident are to assist her to bed or recliner between meals On 04/24/24 at 04:55 PM, Director of Nursing (DON) revealed the expectation that staff assigned to Resident #141 are to assist her to recliner or bed between meals to increase supervision and decrease altercations. Informed that Resident #141 is able to notify staff of needs when sat in living room recliner. DON stated facility is trying to create less stimulus in the environment to decrease behaviors. 45338 3. Review of the Quarterly MDS assessment for Resident #1 dated 2/27/24 revealed the resident scored 2 out of 15 on a BIMS exam, which indicated severely impaired cognition. Review of the Health Status Note dated 10/17/23 at 2:05 PM documented, Residents were coming out of the dining room at lunch. Resident [Resident #141] ran her wheelchair into the back of [Resident #1's] wheelchair. Both residents became visibly and verbally upset. Resident [Resident #141] struck the resident on the shoulder with her hand three times. Full body assessment completed, no injuries or abrasions reported. Residents immediately separated. After lunch, CNA responsible for assisting resident to eat will assist resident to her room or recliner to lay down. Review of the Incident Report dated 10/17/23 at 1:13 PM for Resident #1, pertaining to the event above, documented the following per the Resident Description: I didn't do anything to her .she hit me, that's bad manners. Observation on 4/23/24 at 2:43 PM revealed Resident #1 seated in a wheelchair in the television area by the dining room. 4. Review of the MDS assessment for Resident #5 dated 12/26/23 revealed the resident scored 2 out of 15 on a BIMS assessment, which indicated severely impaired cognition. Review of Progress Notes for 1/30/24 and 1/31/24 lacked documentation of a resident to resident incident in Resident #5's electronic health record. The Facility Policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting, dated 10/22, documented, All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.

Based on clinical record review and staff interview, the facility failed to ensure accurate coding of pressure ulcers on the Minimum Data Set (MDS) assessment for one of six residents reviewed for MDS accuracy (Resident #4). The facility reported a census of 36 residents. Findings include: Review of the MDS assessment dated [DATE] revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, Resident # 4 was at risk to develop pressure ulcers/injuries, and did not have one or more unhealed pressure ulcers/injuries. The assessment also revealed the resident did not have venous or arterial ulcers present. Review of Census information for Resident #4 revealed the resident readmitted to the facility on [DATE]. The Nursing Admission Screening/History V2 form for Resident #4 dated 1/15/24 revealed the following per the Skin section: a. The assessment documented a pressure area to the left toes, documented as stage II (two). b. The assessment documented a pressure area to the left lateral foot, documented as stage II. c. The assessment documented a pressure area to the left heel, documented as stage II. Review of the Skin/Wound Evaluation dated 2/2/24 for Resident #4's blister to the left heel documented the area as present on admission, documented as present since 11/18/23. Review of the Skin/Wound Evaluation dated 2/2/24 for Resident #4's pressure area to the left lateral foot documented the area staged as a deep tissue injury, documented as present on admission. The assessment revealed it was unknown how long the wound had been present, however an exact date of 11/18/23 was documented on the form. The Health Status Note dated 2/6/24 at 2:01 AM documented, in part, resident only compliant with wearing heel protector/boot on Lt (left) foot tonight. Resident didn't want to wear either one, but with encouragement, he was compliant with wearing the Lt one for added protection/tx (treatment) of wound on Lt heel. On 4/24/24 at 3:03 PM, the MDS Coordinator explained they pulled the resident's MDS dated [DATE] and explained it was an oversight they did not list the wound. The MDS Coordinator acknowledged she followed the Resident Instrument Assessment (RAI) Manual.

Based on observation, interview, and record review, the facility failed to ensure safety of residents when transporting residents without foot pedals during transport in a wheelchair for three of six residents reviewed for falls (Resident #7, Resident #9, Resident #92). The facility reported a census of 36 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan dated 9/20/22, revised 2/14/24, documented, the resident at risk for falling r/t (related to) muscle weakness and edema. Observation on 4/22/24 at 8:26 AM revealed Staff A, Certified Nursing Assistant (CNA) assisted Resident #9 and pushed the resident in their wheelchair. The resident did not have foot pedals present to the wheelchair pushed in the wheelchair by staff. The resident had shoes present to their feet at the time of observation. Observation on 4/22/24 at 8:30 AM revealed the resident again assisted by staff, and Resident #9 pushed in their wheelchair without foot pedals present. 2. Review of the MDS dated [DATE] revealed Resident #92 scored 6 out of 15 on a BIMS assessment, which indicated severely impaired cognition. Review of the resident's Morse Fall Scale-V2 form dated 4/2/24 for Resident #92 revealed the resident scored 50 on the assessment, which indicated high risk for falling. The Care Plan dated 4/12/24 documented, the resident is at risk for falls r/t poor gait/balance problems and inability to ambulate on admission. Review of the Health Status Note dated 4/11/24 at 5:56 PM for Resident #92 documented the following: Resident observed on floor in hallway. Resident on left side, wheelchair at feet and sock attached to wheelchair. Resident being assisted to shower room by CNA to get weight. Per CNA and resident, his sock got caught on the wheelchair which caused him to fall out of his wheelchair. Resident stated he did not have more pain than he was having previously. Resident and CNA stated the resident did not hit his head. Educated staff on use of wheelchair foot pedals. Review of the Fall Scene Investigation Report dated 4/11/24 at 5:47 PM documented, root cause of fall is believed to be: no use of pedals. Observation on 4/18/24 at 8:28 AM revealed Resident #92 self propelling down the hall in their wheelchair, using their feet. On 4/24/24 at approximately 4:40 PM when queried about use of wheelchair foot pedals when moving residents in a wheelchair, the Director of Nursing acknowledged if the resident pushed anywhere the foot pedals needed to be applied. The Facility Policy titled Fall Checklist, undated, did not address the area of concern. 48888 3. The MDS, dated [DATE], for Resident #7 revealed a BIMS score of 14 out of 15, indicating intact cognition. Diagnoses included: Cerebral Vascular Accident (CVA), polyarthritis, and long term use of anticoagulants. Resident able to transfer, ambulate, and toilet self independently, supervision required for bathing. The Care Plan, revised 01/10/24, revealed Resident #7 at high risk of falls with the goal that resident will transfer and ambulate independently while minimizing the risk for falls. On 04/15/24 at 11:50 AM, observation of staff member push Resident #7 in wheelchair, without foot pedals in place, from the [NAME] hallway to South hallway spa room, feet skimmed across the top of the floor.

Based on staff interviews, provider interview, clinical record review, and hospital record review, the facility failed to identify and notify the provider in a timely manner, of changes in urine and catheter for 1 of 2 residents (Resident #8) reviewed for urinary catheter care. The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Diagnoses included: vesicointestinal fistula, neurogenic bladder, and renal insufficiency, renal failure, or End Stage Renal Disease (ESRD). Resident #8 required an indwelling catheter and dependent on staff assistance with transfers and toileting hygiene. The Care Plan, revised on 04/15/24, revealed a focus area for indwelling urinary catheter due to neurogenic bladder with a goal that Resident #8 will have catheter care managed appropriately by not exhibiting signs of infection or urethral trauma. The Care Plan instructed staff to monitor, document, and report any signs of Urinary Tract Infection (UTI), listed as: acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea, vomiting, foul odor, concentrated urine, blood in urine, fever, chills, altered mental status, and change in behavior (01/08/24). Review of Nursing Progress Notes, revealed the following entries: a.) 11/07/23 at 01:24 PM: Nurse notified of possible liquid stool in Resident #8's catheter tubing and drainage bag. Facility notified Provider and received order to send Resident #8 to emergency room (ER) for further evaluation/treatment. b.) 11/07/23 at 06:56 PM: ER updated facility on Resident #8 condition, confirmed resident had a fistula, received surgical consultation at Hospital. c.) 12/18/23 at 12:38 PM: Orders from a Urology appointment instructed staff to monitor for fecal matter in urine and monitor for signs/symptoms of infection that could lead to sepsis. Notify Urology Office if resident showed fecal matter so referral to Specialist would be made. d.) 02/04/24 at 01:37 PM: Resident #8 stated her catheter felt like it was leaking, staff noted a small amount of urine in brief. Nursing deflated catheter balloon, advanced it, and reinflated with 30 milliliter (mL). e.) 02/05/24 at 05:48: Small amount of urine leakage into resident's brief, adequate amount of clear yellow urine also noted in Foley bag. f.) 02/06/24 at 03:38 AM: Catheter drained slightly cloudy yellow urine, no increased odor. No acute concerns. g.) 02/20/24 at 08:01 PM: Catheter changed due to leaking, new 16 French catheter with 30 mL balloon inserted via sterile technique. h.) 02/27/24 at 05:43 AM: Concentrated urine with intermittent brown sedimentation observed in catheter tubing. An FYI provided on nursing communication sheet for continued monitoring and follow up as needed with urology. i.) 02/27/24 at 09:46 AM: Provider and Urology office notified of brown sedimentation in catheter, referral made to Specialist to schedule an appointment. j.) 03/01/24 at 12:51 PM: Resident #8 reported catheter felt like it was leaking, nursing adjusted catheter. k.) 03/02/24 at 02:23 PM: Resident #8 stated she wet though pants and had to change pants three times the day before due to leakage. l.) 03/03/24 at 11:23 AM: [NAME] sediment present in catheter bag and tubing, Resident #8 stated she felt like she had urinated in pants every time she took a drink. m.) 03/03/24 at 02:27 PM: Provider notified of feces present in drainage bag, Provide stated since resident is stable without complaint to notify Urology the following day. The Progress Notes lacked any documentation of Urology follow up. n.) 03/05/24 at 1:46 AM: Foley patent and continues to drain concentrated urine with presence of dark brown sedimentation. Resident afebrile and denies dysuria. Urology referral appointment continues to be pending per Provider follow up recommendation. At 10:19 AM message left with Urology. At 4:00 PM appointment scheduled for 5/22/24. o.) 03/08/24 at 09:09 AM: Urine light yellow in color with random chunks of brown matter noted in tubing. Nursing reported continued to monitor. p.) 03/11/24 at 09:57 AM: Catheter draining light yellow urine with large chunks of white sediment noted throughout tubing. q.) 04/23/24 at 08:23 AM: Catheter draining light yellow urine with scant amount of opaque sediment noted throughout tubing. The Progress Notes lacked notification to the provider of the delay in the urology appointment. The Hospital History and Physical (H&P) note, dated 11/07/23, revealed the diagnosis of Colovesicular fistula, based on CT scan, plan, and plan to be evaluated by surgery, nothing by mouth intake status. The CT scan report, signed 11/10/23, revealed there appeared to be a fistula between right colon and bladder posterior as well as view of urinary bladder collapsed around a Foley catheter and a small amount of contrast viewed within the bladder lumen, presumed to be related to bowel fistula. On 04/22/24 at 4:00 PM, Nurse Practitioner (NP) unaware of Resident #8 symptoms of stool in urine. NP stated that, in general, residents with indwelling catheter may have intermittent sedimentation and that urine color change may not be required to call immediately to Provider but if accompanied by other systematic changes to call Provider right away. NP revealed the expectation to call right away for the following examples: resident's symptoms worsened or continued, resident had fever, changes in vital signs, or no output. On 04/24/24 at 04:36 PM: Director of Nursing (DON), revealed that the Urology office had instructed nursing to call office for changes in urination, such as brown sedimentation in urine as this would indicate feces in stool.

Based on clinical record review, facility record review, staff interviews and facility procedure review the facility failed to ensure a resident received medications only prescribed to them for one of eight residents reviewed for medication administration (Resident #14), when staff administered Resident #14 medications prescribed to Resident #10. The facility reported a census of 36 residents. Findings include: 1.The Minimum Data Set (MDS) for Resident #14 dated 12/23/23 documented the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of the Medication Error Report dated 1/23/24 at 3:05 PM documented the following description of error: Wrong meds given to resident. The Type of Error section marked wrong resident, and the Reason for Error section documented, Failure to identify resident. The Progress Note dated 1/23/24 at 4:28 PM documented, the resident received Risperdal 0.25 mg (milligram) (an antipsychotic medication), Atrovastatin 40 mg, Calcium plus Vitamin D 600-400 mg, Corlanor 5 mg, Depakote 250 mg, and Midodrine 5 mg. Resident observed sitting upright in W/C (wheelchair) in his room, denies discomfort or feeling anything other than his normal. VS (vital signs) obtained, BP (blood pressure)-145/71,P (pulse) 64 and regular, R (respirations)-18, T (temperature)-97.9, O2 (oxygen) 95% RA (room air). This nurse spoke with [Name Redacted] NP (Nurse Practitioner) regarding above. Received verbal order to obtain VS (vital signs) and monitor for dizziness and double vision every 2h (hours) x 12h (hours). Review of an email dated 1/23/24 from the facility's former Director of Nursing, subject med error, documented, The med tech this afternoon gave [Resident #10's] medications to [Resident #14]. Review of the resident's Medication Administration Record (MAR) dated January 2024 did not include the following medications for Resident #14: Risperdal, Calcium Vitamin D, Corlanor (medication used for heart failure), Depakote (an anticonvulsant medication), and Midodrine (medication used for low blood pressure). 2. Review of Resident #10's MAR dated January 2024 revealed Risperdal, Atrovastatin, Calcium Vitamin-D, Corlanor, Depakote, and Midodrine were all prescribed to Resident #10. On 4/24/24 at 2:10 PM when queried about identification of residents for medications, the Director of Nursing explained there were pictures, and depending on the BIMS could ask the resident their name. The MDS Coordinator explained some of the staff had been at the facility awhile, and further explained could ask someone who knew the resident. Review of the procedure sheet provided by the facility titled Medication Administration Pocket-Guide, undated, revealed, Read MAR (Medication Administration Record) carefully (Right Drug, Dose, Time, Route to the Right Resident).

Based on training records review, staff interview, and facility assessment review, the facility failed to ensure training for communication and behavioral health occurred prior to a staff member working independently with residents for one of five employees reviewed for staff training (Staff D, Registered Nurse). The facility reported a census of 36 residents. Findings include: Review of a Hire and Termination list provided by the facility revealed Staff D, Registered Nurse, rehired to the facility on [DATE]. Review of training records provided for Staff D revealed communication training completed 11/6/20, and behavioral health training completed 9/3/22. On 4/25/24 at 11:31 AM, proof of trainings provided on orientation for Staff D requested via email from the facility's Administrator. On 4/25/24 at 11:44 AM, the Administrator explained via email she did not have them. Review of the Facility assessment dated ,d+[DATE] updated 2/13/24 did not include requirements for behavioral health or communications training for all employees.

Based on clinical record review, policy review and staff interviews, the facility failed to carry out assessments and interventions for a change in condition for 2 of 3 residents reviewed (Resident #1 and #3). The facility reported a census of 38 residents. Findings include: 1. The Admission Minimum Data Set (MDS) assessment, dated 4/7/23, listed diagnosis for Resident #1 which included: seizure disorder; chronic heart failure; and hypertension The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 12 out of 15, which indicated moderate cognitive impairment. A review of the Care Plan revealed a focus on impaired cognition with initiated date of 4/11/23. Interventions for this focus area directed staff to: Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, levels of consciousness, mental status. During an interview on 5/22/23 at 11:50 AM, Staff A, Certified Nursing Assistant (CNA) stated during shift change on 5/12/23 at 2:00 PM the previous staff reported Resident #1 in her room napping. Staff A reported when she checked on the resident she found the resident to be non responsive to verbal and physical stimuli. Staff A stated she reported the residents unresponsiveness to Staff B, Registered Nurse (RN). Staff A reported the nurse stated the resident is not her patient, and she does not know the resident but will check on her. Staff A stated the nurse did check on her and stated maybe the resident had a narcotic. Staff A stated she also informed the Director of Nursing (DON) and Staff C, Certified Medication Assistant (CMA) of her concerns. Staff A reported they informed her the resident likely had a seizure and it takes the resident awhile to return to baseline. Staff A stated Staff D did go to the resident's room and take the resident's vitals. Staff A stated Staff B then put a Bilevel Positive Airway Pressure (BiPap) machine (device to assist with breathing) on the resident. Staff A stated she approached the nurses several more times during her shift to express her concerns regarding the patient's status. Staff A stated she continued to be informed the resident is recovering from a seizure. The Electronic Health Record (EHR) lacked documentation of an assessment or vitals taken prior to 6:00 pm on 5/12/23. During an interview on 5/22/23 at 12:20 PM, Staff C, CMA stated on 5/12/23 Staff A reported Resident #1 had been incontinent, and was not acting herself. Staff C stated the resident had a history of incontinence. Staff C stated she did go to the residents room and took vitals. Staff C stated the resident did not talk, but that happened sometimes. She stated while in the room, the resident pushed against the wall and yanked her nightgown down. Staff C stated the residents' vitals were within normal limits, except for a low oxygen saturation level. Staff C stated she did not feel the level was too low, but did assist the resident with wearing the BiPap. Staff C stated she did not document the vital results because she took them for her own information and nothing was off. Staff C stated she did not think much of the residents status as if there had been seizure activity it takes the resident time to come back to baseline. When queried about seizure activity protocol, Staff C stated a nurse would assess a resident after seizure activity. Staff C stated she did not inform a nurse of her findings. During an interview on 5/22/23 at 1:33 PM, Staff D, CNA stated on 5/12/23 she answered a call light for Resident #1. Staff D stated the resident reported having a headache, and requested Tylenol. Staff D stated she reported this to Staff B, RN. A review of the May 2023 Electronic Medication Administration Record (EMAR) revealed the resident did not receive Tylenol on 5/12/23. During an interview on 5/22/23 at 1:55 PM, Staff B, RN stated on 5/12/23 Staff A, CNA reported her concerns of a change in Resident #1. Staff B stated she had not met Resident #1 prior to 5/12/23, and did not know baseline information. Staff B stated she did not know the resident had complained of having a headache. Staff B stated she went to the residents room, and the resident looked at her, grasped Staff B ' s hand, and then the resident tapped her thumb on Staff B's hand. Staff B stated she then asked Staff C to check on the resident due to her not knowing the residents baseline. Staff B stated it is outside of Staff C's scope of practice to complete an assessment. Staff B stated she talked to the DON, and Staff C about the resident. Staff B stated they thought the resident had a seizure, and informed her sometimes it takes the resident a while to come back to baseline after seizure activity. Staff B denied discussing a seizure protocol or a plan to do neurological assessments. Staff B denied completing an assessment on the resident, or documenting her findings when she did check on the resident. Staff B stated she should have completed and documented an assessment. Staff B explained a new resident arrived at the facility after 2:00 PM and she worked on the admission. Staff B stated at 6:00 PM on 5/12/23, Staff E, RN started his shift. She stated after Staff E checked on Resident #1 he reported to her that the resident needed to be sent out. During an interview on 5/23/23 at 8:05 AM, Staff E RN stated when he arrived to work on 5/12/23, at approximately 6:00 PM Staff A, CNA informed him of her concerns with the changes in Resident #1. Staff E stated he went to the residents room and was unable to get a response to verbal or physical stimuli. Staff E stated he talked very loud, pinched the residents check and performed a sternal rub with no response. Staff E stated he checked the residents code status, and after confirming a full code order called the on-call service for the primary health care provider to report his findings. Staff E stated he received an order to send the resident to the emergency room for an evaluation. A review of the Electronic Health Record (EHR) revealed a Health Status Note dated 5/12/23 at 6:35 PM documented the resident not responding to her name when said loudly, to touch stimuli, and was unable to follow commands and directions. Vitals documented included oxygen saturation of 83%. On 5/12/23 the EHR documented a note at 7:00 PM for an order to send the resident to the emergency room (ER) for an evaluation. A review of the emergency room records, dated 5/12/23, documented the resident examined by the ER physician at 8:04 PM. The ER performed an endotracheal intubation (artificial airway established) due to altered Level of Consciousness (LOC). The resident had a Computed Tomography of the Head (commonly called a head CT, which is an imaging procedure used for diagnosis). Results indicated the resident incurred an acute intraventricular hemorrhage (bleeding in the brain). The records revealed the University of Iowa Hospital and Clinics (UIHC) accepted the resident as a code stroke. The resident transferred to UIHC. During an interview on 5/23/23 at 11:46 AM, the Nurse Practitioner (NP) stated she would expect to be notified if a resident had seizure activity. The NP stated she does not recall being notified Resident #1 had seizure activity on 5/12/23. The NP stated if a resident had seizure activity and did not return to baseline within 30 minutes to an hour, she would expect the facility to call with an update as the resident would need to be seen in the emergency room for an evaluation. The NP stated if the resident had seizure at 2:00 PM and the facility did not call to report a status change until after 6:00 PM this is too long to wait. A review of the EHR revealed a lack of documentation about provider notification of seizure activity. During an interview on 5/23/23 at 12:35 PM, the DON stated on 5/12/23 she heard staff discussing concerns with Resident #1 The DON stated she had been working on a new admission who needed orders for pain medication. The DON stated she asked Staff B, RN if an assessment had been completed. The DON stated she discussed with the staff the need to do vitals and monitoring the resident. The DON stated she continued to work on the new admission. The DON stated she knew Staff B checked on the resident, and Staff C, CMA administered medications to the resident at 4:00 PM. The DON stated she received a call from Staff E, RN informing her Resident #1 had orders to be sent to the emergency room for an evaluation. The DON stated she had not been aware the resident complained of a headache, and requested Tylenol which had not been given. She stated the resident complaining of a headache was common The DON stated the resident had chronic seizures, headaches and a history of noncompliance. The DON stated she had not been aware Staff A, CNA relayed her concerns of the change in Resident #1 multiple times to the nursing staff. The DON stated she wished someone would have stopped her and let her know. She stated there is a communication breakdown if someone did not let her know of a concern. When queried if waiting from 2:00 PM to 6:00 PM to report a change of condition for the resident was too long, the DON stated it is hard to say. The DON stated she did not know Staff B, RN asked Staff C, CMA to check on the resident. The DON stated Staff B should have completed and documented her own assessment. The DON stated her expectations after a resident has a seizure is for nursing staff to monitor the resident and assess for improvement. The DON stated the facility does not have a specific protocol, it is nursing judgment. 2. The Admission MDS assessment, dated 2/1/23, listed diagnosis for Resident #3 as: Spinal enthesopathy (inflammation of tendons and ligaments), diabetes mellitus Type 2, and obstructive and reflux uropathy (obstruction of urine flow). The MDS assessed the resident as totally dependent for bed mobility, transfers, toilet use and personal hygiene. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated no cognitive impairment. The EHR included a Physician Order, dated 1/23/23, for a Foley catheter, with a change every four weeks. A review of the Care Plan revealed a focus area with initiated date of 2/6/23 documented the resident required an indwelling urinary catheter related to obstructive uropathy (block of urine flow). The interventions directed staff as follows: Report Urinary Tract Infection [symptoms listed included acute confusion, low back/flank pain, malaise, and foul odor], measure and record output. The EHR revealed hospital records, dated 3/7/23, documented on 3/6/23 the resident underwent a pelvic exam and biopsy of an endometrial (tissue lining the uterus) mass. This exam also included a D&C (dilation and curettage - procedure to expand the cervix so the uterus can be scraped for tissue sample). During an interview on 5/22/23 at 11:15 AM, Staff F, CNA stated she worked on 3/20/23 and was assigned the center hallway where Resident #3 resided. Staff F reported when she and Staff A, CNA assisted the resident with catheter care they noted a foul odor. Staff F described the odor as a combination of yeast and infection. Staff F stated the resident also had a noticeable amount of bloody yellow discharge in her incontinence brief. Staff F stated she reported the foul odor to the DON. Staff A stated the DON stated the resident had a recent procedure done and the discharge and odor likely related. Staff F stated she went back to the residents room to finish care. Staff F stated Staff G, RN walked by the residents room, and she asked the nurse about the odor. Staff F stated Staff G informed her she smelled something odd, and thought it to be yeast. Staff F stated Staff G reported the concern to the DON. Staff F stated the DON came to the residents room and assessed the resident. Staff F stated the DON stated she also noted a foul odor but contributed it to the recent D&C procedure. Staff F stated when she returned to work on 3/24/23 she found the resident to be very confused and rolling side to side in her bed as in discomfort. A Health Status Progress Note, dated 3/24/2, revealed a physician order to send the resident out to the emergency room due to hallucinations and unresponsiveness. During an interview on 5/22/23 at 11:45 AM, Staff A, CNA stated she recalled assisting Staff F with Resident #3 catheter care on 3/20/23 due to the resident having a foul smell. Staff A stated Staff G came into the room and agreed the resident had a foul odor. Staff A stated the DON assessed the resident, and stated the odor may have been from the procedure the resident had done on 3/6/23. A review of the EHR revealed a lack of a nursing assessment or health status progress note completed on 3/20/23. During an interview on 5/22/23 at 1:30 PM, Staff D, CNA stated on 3/21/23 she had been assigned to the hallway Resident #3 resided on. Staff D stated she noted a foul odor when completing catheter care. Staff D stated she reported the odor to the nurse on duty and was informed the odor had been reported the night before. A review of the EHR revealed a lack of a nursing assessment or health status progress note completed on 3/21/23. During an interview on 5/23/23 at 12:08 PM, Staff G, RN stated she recalled the CNA's concern with a foul odor noted on 3/20/23 when catheter care started on Resident #3. Staff G stated she went to the residents room and also noted an alarming odor. Staff G stated she knew the resident had a recent procedure and often refused showers and did not know if that could be related. Staff G stated she informed the DON of the foul odor, and then resumed her duties. Staff G stated she is unaware of what occurred after she reported the concern. During an interview on 5/23/23 at 12:18 PM, the DON stated she noted Resident #3 to be in the dining room coloring the day before her hospitalization . The DON explained the resident had a D&C procedure for a mass in her abdomen earlier in March 2023. When queried about her assessment of the resident on 3/20/23 after being informed of a foul odor, the DON stated she had never been informed by any staff the resident had a foul odor noted during catheter care. The DON stated she had not done an assessment on the resident on 3/20/23. The March 2023 Facility Schedule for 3/20/23 showed the DON worked 7:30 AM to 6 PM on the floor due to a call in by another nurse. The facility policy, dated 10/10/19, titled Change in Condition, Physician Notification revealed the assessment of the care or treatment required to meet the needs of a resident shall be ongoing throughout the resident's facility stay, with the assessment process individualized to meet the needs of the residents population.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to identify the causal factors of falls to implement appropriate interventions to prevent further falls and evaluate the current fall interventions for effectiveness for 1 (Resident #25) of 3 residents reviewed for falls. Resident #25 sustained 46 falls from 11/02/21 through 11/02/22. This failure resulted in the resident sustaining falls with injuries including a fractured right ankle on 1/10/22, a small hematoma on the back of the head on 1/15/22, and a fractured hip on 1/20/22. Resident #25 was also transported and evaluated in the emergency roiagnom on [DATE] for a possible refracture of the right hip and on 6/09/22 for a CT (computed tomography) scan after a fall which resulted in a hematoma to the forehead. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 1/10/22 when Resident #25 sustained a fall resulting in an ankle fracture. The Administrator and DON were notified of the IJ on 11/06/22 at 12:00 PM and provided the IJ template at 12:06 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 11/08/22 at 10:12 AM. The IJ was removed on 11/09/22 at 11:12 AM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of G that was not immediate jeopardy for F689. The facility identified a census of 42 current residents. Findings included: A copy of the facility's fall prevention policy was requested and on 11/04/22 at 11:45 AM, Nurse Consultant #1 stated they did not have a policy on falls but provided a policy titled, Completion of Incident Report, dated 8/10/18. The policy indicated, An incident report shall be initiated for any unusual incidents involving residents whether they occur at the facility or not, whether injury is apparent or not. Further review of the policy revealed Unusual incidents include but are not limited to: a. Fall: unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). Continued review indicated Instructions and/or demonstrations should be given to the resident or employee to prevent future incident of a like nature, when appropriate. A review of an Admission Record indicated Resident #25 had diagnoses which included late onset Alzheimer's disease, osteoarthritis, repeated falls, and history of falls. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required extensive to total assistance with all activities of daily living (ADLs) except eating. The MDS indicted the resident was frequently incontinent of bowel and bladder and had two or more falls since the previous assessment on 6/14/22. A review of Resident #25's care plan, initiated 10/29/21, revealed the resident was at risk for falling with interventions which directed staff to: - Assist the resident to bed after administering anti-anxiety medications, initiated 8/02/21 - Apply non-skid socks at night, initiated 8/22/21 - Keep items off the floor and within reach, initiated 9/02/21 - Ensure proper arrangement of bedding, initiated 10/11/21 - Ensure the resident was seated when applying footwear, initiated 11/16/21 - Apply slipper socks, initiated 11/17/21 - Apply half rails times two to assist with bed mobility and repositioning, initiated 11/03/21 and revised 12/15/21 - Apply non-skid strips to the bathroom floor, initiated 12/15/21 - Give the resident cookies or snacks when they are sitting, initiated 12/17/21 - Provide a night light outside of the bathroom door, initiated 1/10/22 - Apply non-skid padding in the recliner, initiated 1/18/22 - Resident was non-ambulatory at that time, initiated 10/29/21 and revised 1/19/22 - Apply non-skid padding in the wheelchair, initiated 1/20/22 - Always keep the resident in a supervised area. The resident was only to be in their room for naps and at night, initiated 1/14/22 and revised 2/08/22 - Transfers with assistance of two and the Stand-aid (mechanical lift), initiated 10/29/21 and revised 3/07/22. - Use a fall mat, initiated 3/10/22 - Use a bolster mattress, initiated 4/01/22 - Keep the resident's wheelchair out of sight when they are in the recliner, initiated 8/09/22 - Provide the resident with an activity basket between meals, initiated 8/09/22 - Provide adequate lighting, initiated 8/09/22 - Allow the resident to rest in the recliner after dinner until bedtime, initiated 6/09/22 and revised 8/09/22. A review of a Fall Risk assessment, dated 11/2/21, indicated Resident #25 was at risk for falls, and fall interventions should be initiated. Review of Incident Reports revealed Resident #25 sustained 46 falls from 11/2/21 through 11/2/22. Based on these reports, a review of Progress Notes, and interviews, there was no evidence that the facility thoroughly investigated each fall for causal factors and there was no evidence of what interventions were in place at the time of the fall. The facility did not evaluate the current fall interventions for effectiveness. The facility did not have evidence that new appropriate interventions were put into place and that those interventions were communicated to staff. A review of Resident #25's Incident Reports and Progress Notes between 11/02/21 and 12/28/21 revealed Resident #25 had 10 falls, including four falls related to ambulating in, to, or from the bathroom. A review of the care plan revealed the only interventions put into place for the falls related to the bathroom were to put non-skid strips in the bathroom in front of the toilet after the fall on 12/15/21. The resident had a fall on 12/28/21 that occurred when the resident was ambulating between the bed and the bathroom and the tennis balls on the walker malfunctioned. The facility failed to analyze the data they had from previous falls to determine causal factors in order to implement effective interventions to prevent the resident from falling again and obtaining a serious injury. A review of a Progress Note and Incident Report, dated 1/10/22 at 5:20 AM, revealed Resident #25 had a fall in the bathroom (seen scooting out of the bathroom on their buttocks), and when assessed the resident complained of discomfort to the right ankle. The physician was contacted via fax and an order for an x-ray of the resident's right ankle was received at 6:41 AM. On 1/10/22 at 2:32 PM, the progress note indicated the resident had an x-ray of the right ankle which showed a non-displaced distal right fibular fracture. Later in the day on 1/10/22, the progress notes and incident report indicated the resident sustained a second fall at 2:45 PM and was seen scooting on the floor out of the bathroom. The facility failed to investigate the causative factors of the falls but added an intervention to place a night light outside the bathroom door. A review of Progress Notes and Incident Reports between 1/12/22 and 1/18/22 revealed Resident #25 had four falls, one on 1/12/22, two on 1/15/22, and one on 1/18/22. Review of the care plan revealed the facility developed new care plan interventions for two of the four falls. The facility failed to analyze the data they had from previous falls to determine causal factors in order to implement effective interventions to prevent the resident from falling again and obtaining another serious injury. A review of a Progress Note, dated 1/20/22, indicated Resident #25 slipped off the front of the wheelchair trying to get up, with no complaints of pain and no injuries identified at that time. The care plan was updated to include non-slip padding in the wheelchair. A review of a Progress Note, dated 1/24/22, indicated Resident #25 had increased complaints of pain, x-rays were obtained, and the resident was found to have a right hip fracture and was sent to the hospital for surgical repair of the right hip. The resident's fall care plan was not updated with any new interventions when the resident returned from the hospital. A review of the facility's Self-Report, dated 1/25/22, indicated the facility contributed the right hip fracture to the fall that occurred on 1/20/22. A review of a Progress Note, dated 1/31/22, indicated Resident #25 was found on the floor after falling from a recliner and was sent to the hospital for evaluation of the right hip. The care plan was updated to include the resident was non-ambulatory with no new interventions. A review of Progress Notes and Incident Reports between 2/07/22 and 6/09/22 revealed Resident #25 fell seven times, three times from the bed and four times from the recliner. The facility failed to analyze the data they had from previous falls to determine causal factors in order to implement effective interventions to prevent the resident from falling again and obtaining a serious injury. Review of the care plan revealed it was updated four out of the seven times the resident had fallen during this time with new interventions. A review of a Progress Note, dated 6/09/22, indicated Resident #25 fell , hitting their head, resulting in the resident having a hematoma to the left side of their forehead and a laceration to the left cheek. The resident was sent to the hospital for evaluation. The care plan was updated with an intervention for the resident to be in the recliner after dinner until bedtime. A review of Progress Notes and Incident Reports between 8/25/2022 and 11/02/22 revealed Resident #25 had 19 falls, including 14 falls from the bed. Interviews with staff (see below) revealed the resident was going over the bolsters on the bed onto the fall mat and used the half rails to assist with doing this. The facility failed to track and trend the resident's falls and identify the pattern of falls from the bed and the facility failed to identify the cause of the resident's repeated falls from the bed. A review of the care plan indicated it was updated on 8/09/22 with new interventions, but there was no documentation in the resident's record to imply new interventions had been initiated or care planned for any of the 19 falls after 8/09/22. A review of physician progress notes indicated the physician recommended one-to-one support as much as possible when the resident was seen on 1/31/22 (after the resident had fallen 17 times since November 2021). The physician repeated this again on 2/18/22, after the resident had another fall, and again on 4/19/22, after the resident had fallen four more times. There was no documented evidence the one-to-one support occurred. During an interview on 11/04/22 at 1:36 PM, Staff F, a Certified Nurse Aide (CNA), stated she had been at the facility for almost [AGE] years and was a CNA mentor. She stated if a resident fell , she would notify the nurse to come and check them. Once the nurse said the resident was okay, then they would use the mechanical lift to get the resident up into the bed or chair. She stated she worked with the nurses to implement new interventions. Staff F stated fall interventions in place for Resident #25 included checking on the resident frequently, a bolster bed, pool noodles, and if the resident was up in the living room, they put a non-slip pad in the chair first. She stated the resident did have a fall mat, but they removed it and put down non-skid strips because the mat was not preventing anything. Staff F stated Resident #25 was able to crawl out of the bed and go over the bolsters, but was sliding out of the bed, not falling. During an interview on 11/04/22 at 1:47 PM, Staff E, a Certified Medication Aide (CMA), stated that when a resident fell , she would make sure the resident was safe and get the nurse. She stated she had no part of implementing interventions after a fall. Staff E stated fall interventions for Resident #25 included frequent checks, a bolster mattress, low bed, fall mat, toilet use and positioning schedule, and using common knowledge, such as if the resident was tired, then lay them down or put them in a recliner. She stated they would also reposition the resident from lying to sitting, provide hydration and nourishment, and one-to-one support. Staff E stated Resident #25 would go over the bolsters on the bed, and Staff E had seen the resident slide over the bolsters with their head on the bed and their bottom over the bolster. Staff E stated the resident was able to do it when they were determined. During an interview on 11/04/22 at 2:15 PM, Nurse Consultant #1 and the Director of Nursing (DON) stated if an intervention was a one-time intervention, then it would not be care planned. Nurse Consultant #1 stated interventions were documented on the fall summary done during the Falls Committee Meeting as part of their Quality Assurance (QA) process and would not necessarily be documented on the care plan or the resident's record. Nurse Consultant #1 stated staff were notified of new or changed interventions verbally during report, by the charge nurse, or by each other, and stated if they did not know they would ask. Nurse Consultant #1 stated they could not expect the staff to remember all of Resident #25's multiple interventions. The DON stated Resident #25 did not go over the bolster but kicked them out of the way. She stated no staff had reported the resident going over the bolsters. A review of Resident #25's Fall Summary revealed the facility identified Resident #25 had fallen 45 times since 11/02/21. The summary did not identify causal factors of the falls, as the Potential Contributing Factors section was left blank. The resident's response to interventions was only documented twice out of 45 falls listed on the summary. During an interview on 11/05/22 at 1:01 PM, Staff R, a CNA, stated if a resident fell , she would make them comfortable and get the nurse and then get vital signs. She stated the staff had a huddle every day at 2:00 PM to go over any changes made after a fall. She stated fall interventions for Resident #25 included bolsters on the bed, a floor mat, to check on them often, and they had a new mattress coming. Staff R stated the bed rails were supposed to help keep the resident in the bed, but the resident used the rails to help them get over the bolsters. Staff R stated she was not aware of the pool noodle being used. She stated the bolsters on the bed clipped on the sides, but they were ordering a concave mattress to try and help keep the resident in the bed. During an interview on 11/05/22 at 2:39 PM, Staff A, a Registered Nurse (RN), stated Resident #25 had a pool noodle to help keep them in bed with the bolster, fall mat with non-skid strips under it, and the staff were to check on the resident whenever they walked by. During an interview on 11/05/22 at 2:52 PM, Staff D, a RN, stated Resident #24's fall interventions included a fall mat, low bed, activities, redirection, toilet use, skid socks, mattress bolsters, repositioning, snacks/drinks, and music. She stated the resident would put themselves on the fall mat or scoot in the bed until they fell . She stated the resident had put themselves on the floor to take a nap. Staff D stated the bolsters were to keep the resident from rolling out of bed, but the resident would go over them, so they had ordered the resident a special bed on which the bolsters were attached. She stated the resident did not use a pool noodle. Staff D stated the nurse should implement the new interventions, put it on the incident report, and include it on a progress note. She stated she did not update the care plan but did a fall risk assessment after each fall. She stated she would verbally tell the staff what the new interventions were and pass it along to the next shift. During an interview on 11/09/22 at 4:44 PM, the Administrative Assistant stated her expectation was for interventions to be implemented immediately after a fall after determining the root cause. She stated new interventions were to be placed in the communication book and then the nurse managers would review the fall in the morning meeting and add to the care plan if needed. Removal Plan: 1. On 11/06/22, the Director of Nursing and MDS Nurse with input from direct staff reviewed Resident #25's fall interventions. Potential contributing factors for previous falls were discussed. The care plan was updated on 11/06/22 with current fall interventions. New interventions were communicated to staff via a fall intervention communication form. A new fall risk assessment will be completed on every resident by a licensed nurse on 11/07/22. An audit of all resident fall interventions will be conducted by the restorative nurse and MDS nurse. The MDS Nurse in collaboration with the restorative nurse will review fall interventions for effectiveness and update resident care plans as needed. Audit will be completed 11/07/22. 2. On 11/06/22, all staff present on this date received education from the Director of Nursing on Fall Scene Investigation Report process. All other staff will receive education on the Fall Scene Investigation Report process before or during their next scheduled shift. All staff not scheduled will be educated via phone by the end of business day on 11/07/22 by the Director of Nursing. 3. The Fall Scene Investigation Report is a data collection tool used to investigate and determine the root cause of a fall. The tool guides staff to review potential contributing factors such as: alarm use, amount of assistance in effect, assistive devices, environmental factors, environmental noise, footwear, medication, medical or physical condition change, acute changes to mood or mental status, toilet use needs, and sensory impairment. The report will be completed by a licensed nurse immediately after the resident is stabilized after a fall. To do this, the charge nurse asks all the staff working in the area of the fall to meet briefly together to determine the root cause analysis (RCA) of the fall. 4. An immediate fall intervention will be implemented by the attending nurse based on the results of the Fall Scene Investigation and will be documented by the nurse on the fall intervention communication form and the resident's care plan. Restorative nurse or designee will review the communication form for completeness and accuracy and updated this form as needed after every Fall Committee Meeting. The fall intervention communication form is a communication tool for the nursing staff and will be available in a binder at the nursing station. This form includes sections for the date, resident name, and new fall intervention. This form will remain in the binder for a minimum of one month. Director of nursing or designee will remove the communication tool from the binder. The forms will be submitted to the QAPI [Quality Assurance Performance Improvement] team for review quarterly. 5. The Fall Team, consisting of the Administrator, Director of Nursing, MDS Nurse, and Restorative Nurse, will meet daily during business days to review each Fall Scene Investigation Report to monitor and review for completeness, accuracy, and appropriateness of the fall intervention/s put into place. If it is determined, after this review, that an alternative intervention needs to be implemented, the MDS or restorative nurse will update the resident's care plan and communicate the change on the fall intervention communication form. The outcome of each review will be documented on the last page of the fall scene investigation form. 6. Fall scene investigations will be submitted and reviewed quarterly by the QAPI team. This process will be reviewed for the next 4 quarters. 7. All corrections were completed on 11/07/22. 8. The immediacy of the IJ was removed on 11/07/22. Onsite Verification of Removal Plan: The IJ was removed on 11/09/22 at 11:12 AM after the survey team performed onsite verification that the Removal Plan had been implemented. The survey team verified Resident #25's care plan was updated on 11/06/22 with appropriate person-centered fall interventions and the new interventions were placed on the fall intervention communication form. A fall risk assessment for Resident #25 was completed 11/07/22. Fall risk assessments for all residents were completed on 11/07/22 which was verified by reviewing a random sample of residents. The audit of all resident fall interventions was reviewed and revealed seven residents' plans of care were updated during the audit. A review of the education related to the fall investigation process and sign-in sheets revealed all staff had been in-serviced either in person or via phone by 11/07/22. This was verified with the staff list provided by the facility compared to the education sign-in sheet. Interviews on 11/09/22 with five CNAs, one CMA, two floor nurses, the Restorative Nurse, the MDS nurse, the DON and the Administrative Assistant confirmed they received the training. Review of the Fall Scene Investigation Report process revealed it included all information identified in the Removal Plan. Review of the Fall Intervention Communication Form revealed no concerns, and the location of the binder was verified to be at the nurse's station. Interviews on 11/09/2022 with five CNAs, one CMA, two floor nurses, the Restorative Nurse, the MDS nurse, the DON and the Administrative Assistant confirmed the initiation of the new forms and the new process.

Based on facility policy review, clinical record review, interviews, and review of facility documents, the facility failed to protect the residents' right to be free from physical abuse by other residents for 5 residents (#3, #8, #14, #34, and #42) of 6 residents reviewed for abuse. The facility identified a census of 42 current residents. Findings included: The facility's policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/22 specified, All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy further indicated, Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 1. The Admission Record documented Resident #42 entered the facility on 4/21/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment, dated 4/28/22, recorded Resident #42 had daily behavioral symptoms that were not directed toward others. The MDS further revealed the resident's Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score as 99, indicating the resident could not complete the interview. The MDS indicated Resident #42's cognitive skills for daily decision-making were moderately impaired. The quarterly MDS, dated [DATE], recorded that Resident #42 was unable to complete the BIMS evaluation. The quarterly MDS further revealed Resident #42 had physical behavioral symptoms directed toward others on one to three days of the assessment period and had verbal symptoms directed toward others on four to six days of the assessment period. The MDS further indicated the resident displayed wandering behavior daily. Resident #42's Care Plan contained focus areas of physical behavioral symptoms (hitting, kicking, pushing, scratching) directed toward others and verbal behavioral symptoms (threatening others, screaming at others, and cursing at others) directed toward others that were initiated on 5/11/22. The interventions included to assess whether the behavior endangered the resident and/or others and intervene if necessary. a. A review of the Admission Record Resident #3 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The MDS assessment of 9/06/22 documented Resident #3 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated that Resident #3 had physical and verbal behavioral symptoms that were directed toward others that occurred on one to three days during the assessment period. A review of Resident #3's Care Plan revealed focus areas of physical behavioral symptoms (hitting, kicking pushing, scratching) toward others and verbal behavioral symptoms (threatening others, screaming at others, cursing at others) toward others initiated on 2/28/22. The interventions included to assess whether the behavior endangered the resident and/or others and intervene if necessary. The Self Report dated 7/01/22 at 9:10 AM documented Resident #42 was seen repeatedly striking Resident #3 in the upper arm in the West Hallway. The incident report indicated the residents were immediately separated and no injury was noted. The report indicated that the corrective action taken was to immediately separate the residents and educated staff to distance the residents from each other when they were spotted too close. An additional Self Report recorded Resident #42 and Resident #3 were involved in another incident on 7/03/22 at 8:00 AM. Staff H, a Certified Nursing Assistant (CNA), witnessed Resident #42 and Resident #3 near each other. Staff H started toward the residents to separate them, but before she could reach them, Resident #42 began hitting Resident #3 with Resident #42's wheelchair and Resident #42 was holding/grabbing Resident #3. Resident #3 tried to shove the wheelchair away from Resident #42 and Resident #42 then started hitting Resident #3 and hit the resident several times on the arms and shoulders. The self report further indicated that Resident #3 then hit Resident #42 twice on the left arm. The residents were then separated. The report documented an intervention for staff to continue to monitor the residents and for Resident #42 to wheel along with nursing staff during medication administration to ensure extra supervision. The Self Report dated 8/18/22 at 3:45 PM documented a third altercation between Resident #42 and #3. The residents were found by a Licensed Practical Nurse (LPN) and CNA in a physical altercation in the South Hallway. Resident #3 was grabbing Resident #42's shirt, which resulted in scratches to Resident #42's chest and neck; the residents were separated. The report further indicated that Resident #3 was going to visit another resident of the facility that lived on the South Hall. The description of the corrective action taken included scheduled visiting times for Resident #3 to visit another resident of the facility. Staff Q, Occupational Therapist, stated in an interview on 11/08/22 at 11:58 AM that on 7/01/22 at approximately 9:20 AM, there was a noise outside the therapy room and after opening the door, he observed Resident #42 grabbing Resident #3's arm, getting out of the wheelchair, standing over Resident #3, and hitting the resident's other arm with force. Staff Q called for help and was able to separate the residents. Staff H, CNA, stated in an interview on 11/08/2022 at 4:25 PM that on 7/03/22, she came out of a resident's room and observed Resident #42 go to a table where Resident #3 sat and started ramming the wheelchair into Resident #3, who was also in a wheelchair. Staff H stated Resident #42 would continue ramming the wheelchair into anything in their path. Staff H separated the residents and wheeled Resident #42 to the nurses station and completed an incident report. Staff H stated the incident was discussed with the nurse on duty and the DON because this had happened before with these residents. During an interview on 11/08/22 at 4:25 PM, Staff L, CNA, stated that on 8/18/22, she heard yelling and saw Resident #3 and Resident #42 in an altercation. Resident #3 had Resident #42's hand and Resident #42 yelled, No, stop. Staff L stated she ran down the hall to calm and separate the residents. Resident #3's glasses were on the floor, and there were scratches on the resident's chest. During an interview on 11/09/2022 at 2:46 PM, Staff B, LPN stated that on 8/18/22, Resident #3 and Resident #42 were too close to each other in their wheelchairs, and they started pushing each other away. b. The Admission Record documented Resident #34 entered the facility on 5/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS assessment of 8/16/22 documented Resident #34 had a BIMS score of 2, which indicated severe cognitive impairment. The MDS revealed she had issues with inattention and disorganized thinking. A review of Resident #34's Care Plan revealed a focus area of physical behavioral symptoms toward others initiated on 5/31/22 and included hitting, kicking, pushing, and scratching. The interventions included to keep distance between the resident and others (staff, other residents, and visitors) when a resident became physically abusive. The Self-Report dated 7/5/22 at 5:00 PM, documented that Staff M, Dietary Aide, witnessed Resident #42 slapping Resident #34. The report indicated that Resident #34 sat in a wheelchair at the dining table when Resident #42 self-propelled her wheelchair, approached Resident #34 and then slapped her. The report indicated the immediate intervention was to place Resident #42 on 1 on 1 supervision while the facility continued to seek another placement for the resident. During an interview on 11/8/22 at 1:16 PM, Staff M stated she observed Resident #34 and Resident #42 in the dining area hitting each other on 7/5/22. Staff M told Staff D, Registered Nurse (RN), who was nearby. Staff M stated the DON was also close by when the incident occurred. Staff D, RN, was interviewed on 11/08/22 at 2:44 PM and stated she did not observe the incident, but had been told that Resident #42 hit Resident #34. The residents were separated, and vitals done on each. Staff D indicated the residents were kept apart after the incident. c. The Admission Record documented the facility admitted Resident #14 on 10/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment of 9/20/22 recorded Resident #14 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. The MDS noted that there were no behaviors for Resident #14. A review of Resident #14's Care Plan revealed the resident occasionally had physical behaviors toward others that was initiated on 11/30/21. The interventions included to keep distance between Resident #14 and others when he became physically abusive. A review of a document titled Self Report revealed on 8/24/22 Staff A, RN observed Resident #42 run into Resident #14's legs with Resident #42's wheelchair while wheeling down the hallway. Resident #14 turned around and yelled at Resident #42 and attempted to push Resident #42 away and Resident #14 then swatted Resident #42. Resident #42 swatted back at Resident #14 and both residents appeared to be smacking each other simultaneously. The report further indicated that a nearby CNA separated the residents, and no injury was noted to either resident. Corrective action instructed to place Resident #42 in a stationary chair in the afternoon hours with a walker nearby for safety with ambulation. During an interview on 11/9/22 at 11:16 AM, Staff A stated that on 8/24/22 at 4:30 PM, Resident #14 came out of the room using a walker, and Resident #42 was going down the hall in a wheelchair. Resident #14 became angry, and they may have swatted at each other. An evaluation was completed on both with no problems noted and each resident went on their way. 2. The Admission Record indicated Resident #3 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] recorded Resident #3 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated that Resident #3 had physical and verbal behavioral symptoms that were directed toward others that occurred on one to three days during the assessment period. Resident #3's Care Plan documented focus areas of physical behavioral symptoms (hitting, kicking pushing, scratching) toward others and verbal behavioral symptoms (threatening others, screaming at others, cursing at others) toward others initiated on 2/28/22. The interventions included to assess whether the behavior endangered the resident and/or others and intervene if necessary. The Admission Record documented Resident #8 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS assessment dated [DATE] recorded Resident #8 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS further indicated the resident had verbal behavioral symptoms directed toward others on one to three days during the assessment period. A review of Resident #8's Care Plan revealed a focus area for physical behavioral symptoms toward others and verbal behavioral symptoms toward others that was initiated on 11/15/21. The interventions included to assess whether the behavior endangered the resident and/or others and to intervene if necessary. The care plan indicated when the resident became physically abusive to keep distance between the resident and others (staff, other residents, and visitors). The Self Report dated 7/01/22 at 5:45 PM documented that as residents were gathering in the main dining room for supper, Staff K, CNA, found Resident #3 to be hitting Resident #8 in the left arm/armpit area. Staff K immediately separated the residents and both residents were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/9/22 at 11:50 AM, Staff K stated that on 7/1/22 she heard yelling and the two residents had ahold of each other. Staff K separated the residents, told the nurse, and wrote a statement. Staff K did not remember who the nurse was that worked that day. An interview with the Administrator on 11/07/22 at 4:06 PM revealed she expected anything that might be considered abuse to be reported to her or the Director of Nursing (DON) and they would do an investigation from there. The Administrator stated they interviewed staff and residents as appropriate and tried to get information about what happened. An interview with the DON on 11/09/22 at 4:21 PM revealed the facility did investigations that included talking to the people involved to find out what happened and to get statements as required. The DON stated they tried to find interventions to prevent reoccurrence. When the incident involved another resident, the DON stated they separated everyone and reached out to notify the family. The DON stated the residents involved did not have high BIMS scores, indicating the residents were cognitively impaired, and therefore the facility could not say the residents' actions were malicious.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to properly clean and store the BiPAP (Bilevel Positive Airway Pressure) machine for 1 (Resident #46) of 1 resident reviewed for respiratory care. The facility identified a census of 42 current residents. Findings included: A review of a facility policy titled, C-PAP (Continuous Positive Airway Pressure)/Bi-PAP Cleaning Protocol, dated 09/18/2018, specified, Nursing staff shall follow all appropriate infection prevention and control measures for the disinfection of reusable respiratory equipment. The policy further specified, Daily Procedure: Wash mask daily with warm, soapy water. Rinse with warm water and allow to air dry on a towel. Allow inside of tubing to air dry. If humidifier is used - fill with clean distilled water before use. Wash daily with mild, soapy water. Rinse and air dry on a towel. Supplies should be stored when dry, in a plastic bag or plastic, lidded container or equipment storage/carrying case until next use. Weekly Procedure: Wash mask and tubing with warm, soapy water or follow manufacturer's recommendations. Rinse well and allow to air dry on a towel. Wash humidifier (as needed) with warm, soapy water or follow manufacture's recommendations. Rinse well and allow to air dry on a towel. Recommend increasing frequency of humidifier cleaning if resident is experiencing repeat sinus or respiratory infections. Wash headgear with warm, soapy water. Rinse and allow to air dry on a towel. Wipe exterior of machine with a damp cloth. Monthly and as needed: Wash reusable foam filter with warm, soapy water. Rinse and dry with a towel. Disposable felt filter may be replaced as needed. Do not clean. A review of Resident #46's Admission Record indicated the facility admitted the resident with diagnoses that included acute respiratory failure with hypoxia (low blood oxygen) and obstructive sleep apnea (a sleep-related breathing disorder). A review of Resident #46's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was severely cognitively impaired. During observations on 11/01/2022 at 9:25 AM, 11/02/2022 at 2:16 PM, 11/03/2022 at 10:45 AM, 11/04/2022 11:18 AM, and 11/08/2022 at 2:45 PM, Resident #46's BiPAP machine was observed lying on top of the nightstand in the resident's room with the mask and tubing still connected in front of the machine. There was no date on the machine, tubing, or mask and the humidifier chamber was half full of liquid. During an interview on 11/08/2022 at 2:47 PM, Staff D, a Registered Nurse (RN), stated the BiPAP mask should be cleaned daily, air dried, then placed in a plastic bag. According to Staff D, Resident #46 would refuse to wear the BiPAP; however, the equipment should be cleaned and stored when not in use. During an interview on 11/09/2022 at 10:19 AM, the MDS Nurse stated the facility had a protocol that indicated the BiPAP mask should be rinsed and stored in a bag when not in use. During an interview on 11/09/2022 at 11:04 AM, Staff A, an RN, stated BiPAP equipment should be cleansed every night when used. Per Staff A, the mask was cleaned daily and stored in its case or a plastic bag at night. During an interview on 11/09/2022 at 3:08 PM, the Restorative Nurse stated the BiPAP mask and tubing should be cleaned weekly. During an interview on 11/09/2022 at 4:01 PM, the Director of Nursing (DON) stated the BiPAP machine was cleaned monthly, the mask was rinsed daily, and the tubing was rinsed weekly then air dried and put into a bag. During an interview on 11/09/2022 at 4:44 PM, the Administrative Director stated she expected equipment to be cleansed according to the facility's policy and standards of practice.

Based on clinical record review and interviews, the facility failed to notify the responsible party (RP) of a room change for 1 (Resident #16) of 1 resident reviewed for notification of change. Specifically, in May 2022, the facility moved Resident #16 to another room in the facility without notifying the resident's responsible party. The facility identified a census of 42 current residents. Findings included: A review of the Admission Record revealed Resident #16 had diagnoses that included atrial flutter, bradycardia, and atherosclerosis. Further review revealed Resident #16 had a responsible party who was also the resident's durable power of attorney (POA) for health care and finances. A review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had a Brief Interview for Mental Status (BIMS, a structured evaluation for cognition) score of 8, which indicated the resident had moderate cognitive impairment. A review of Resident #16's Care Plan, updated on 10/19/22, revealed she needed 24-hour care and would remain in long-term care. On 11/02/22 at 12:19 PM, an interview with Resident #16's responsible party/POA (Power of Attorney) revealed they were not informed about a room change. The family member stated she came to visit one day and was informed that Resident #16 was in another room. The family member stated she received no notice of the room change prior to visiting. During an interview on 11/03/22 at 3:34 PM, the MDS Nurse stated Resident #16 admitted to a room in the COVID-19 quarantine area, where the resident stayed until 2/14/22 when the resident was released from quarantine and moved toward the upper end of the hall. In May 2020, due to another COVID-19 outbreak, the MDS Nurse stated Resident #16 was moved to the end of the hall to a non-quarantine area. During a follow up interview with the MDS Nurse on 11/04/22 at 12:15 PM, the MDS Nurse reviewed the administrative screen of Resident #16's electronic health record (EHR), which indicated no notes entered regarding notification to the family of the May, 2022 room change. During an interview on 11/07/22 at 3:28 PM, the Director of Nursing (DON) stated the Administrator usually documented room changes. The DON stated she was unsure why Resident #16's room change was not documented but knew the resident's family frequently visited. The DON stated she understood staff usually discussed a room change with the resident (if cognition allowed) or family prior to the room change. The DON stated she did not know why there was no documentation of Resident #16's room change. An interview with the Administrator on 11/07/22 at 3:54 PM revealed resident room changes were usually discussed with family, consent obtained, and the room change then documented in the administration portion of the resident's EHR. The Administrator stated that due to an outbreak of COVID-19, Resident #16 was moved from the area where COVID-19 positive residents were living.

Based on observations, record review, and staff interviews the facility failed to exhaust all efforts to mitigate the spread of COVID-19. The facility cohorted COVID positive and negative residents in the same room, allowed COVID positive staff to care for COVID negative residents, and failed to implement an effective screening process in accordance with Centers for Disease Control and Prevention (CDC) and CMS recommended guidance. The facility had a cumulative total of 21 out of 28 residents positive for COVID. Findings include: During an interview on 11/3/20 at 1:12 p.m., the Administrator stated prior to the COVID outbreak at the facility, screening protocols included the standard questioning of staff regarding signs and symptoms of COVID, exposure to COVID and taking a temperature. All staff were expected to be screened and having symptoms, an elevated temperature or recent exposure to someone with COVID was enough to restrict the employee from entering the facility. Sometime around October 15 to17, 2020, they began having multiple aides (4) testing positive for COVID as well as an outbreak of positive COVID among residents (10). The Administrator stated they were having difficulty covering shifts and she initiated Centers for Disease and Prevention (CDC) staffing mitigation protocols. The Administrator stated she contacted staffing agencies and requested assistance through I-serve, but had no response. The Administrator, who was responsible for the scheduling during that time, decided to allow asymptomatic positive staff to continue to work with positive COVID residents. The Administrator stated she conveyed this guidance to her staff through face to face contact, notes at the nurse's station and through texts. During this time other staff began complaining of having signs and symptoms of COVID on their screening form. For those whom symptoms seemed legitimate, they did a rapid test and if negative the staff were allowed to work. The Administrator stated on October 22, 2020, three nurses tested positive for COVID, including the scheduled day shift and overnight shift nurses. By this time there were 21 residents and 9 aides or nurses positive for COVID. The Administrator stated she was most concerned with covering the overnight shift and texted Staff G and Staff J, who both refused to cover the overnight shift. The Administrator stated she did not ask Staff G or Staff J to help cover the day shift and instead allowed Staff F, who had just tested positive for COVID that morning to remain and work her shift. 1. The Centers for Disease Control and Prevention https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html guidance on updated April 30, 2020 and recommended the following: Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Upon entering the facility on 10/22/20 at 2:30 p.m., the Administrator provided a Resident Room Roster with resident names highlighted who have tested positive for COVID. The Room Roster indicates Resident #1, who is currently negative for COVID, is sharing a room with Resident #2 who is positive, Resident #3 who is currently negative for COVID is sharing a room with Resident # 5 who is positive and Resident #4 who is currently negative for COVID is sharing a room with Resident #6 who is positive. The room roster also indicated multiple vacant rooms including South Hall rooms 3, 4, 5, 10 and 11 and North Hall all rooms 4, 7 and 11. During an interview on 10/22/20 at 2:30 p.m., the Administrator was asked why residents positive for COVID remain in rooms with residents who are negative. The Administrator stated her corporate office indicated it was not necessary to separate the residents since the negative residents have already been exposed. The Administrator stated on Thursday, 10/8/20, during routine testing of staff, a staff member tested positive for COVID, prompting testing of all residents. The first positive residents occurred by testing done on Monday, 10/12/20. The Administrator stated they first started moving positive residents to the North hall which was planned as their isolation/COVID Hall, but after several more residents became positive they decided to just keep everyone where they were. According to the State Hygienic Laboratory Analytical Report Resident #2 had a positive COVID test result on 10/18/20. Resident #1 continued to share a room with Resident #2, until Resident #1 moved to a private room on South Hall on 10/22/20. According to the Progress Notes dated 10/25/20 at 9:23 a.m., the staff performed a rapid COVID test and Resident #1 had a positive test result. The State Hygienic Laboratory Analytical Report revealed Resident #1 had negative COVID test results on 10/18/20 and 10/21/20. According to the State Hygienic Laboratory Analytical Report Resident #5 had a positive COVID test result on 10/18/20. Resident # 5 continued to share a room with Resident #3. According to the State Hygienic Laboratory Analytical Report Resident #3 had a positive COVID test result on 10/21/20 after being previously negative on 10/18/20. According to the State Hygienic Laboratory Analytical Report Resident #6 had a positive COVID test result on 10/18/20. Resident #6 continued to share a room with Resident #4, until Resident #4 moved to a private room on South hall on 10/23/20. According to the State Hygienic Laboratory Analytical Report Resident #4 had a COVID negative test results on 10/18/20 and 10/21/20. The Routine Testing-Symptoms Screening Sheet dated 10/27/20 revealed Resident #4 had a negative COVID test result. According to Routine Testing-Symptoms Screening Sheet Resident #7 had a positive COVID test result on 10/14/20. Resident #8 continued to share a room with Resident #7. According to the State Hygienic Laboratory Analytical Report Resident #8 had a positive COVID test result on 10/18/20 after being previously negative on 10/15/20. 2. The Centers for Disease Control and Prevention @ www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html updated guidance on July 17, 2020 and recommended the following: Strategies to Mitigate Healthcare Personnel Staffing Shortages, utilizing positive COVID health care professionals to provide direct care to residents without suspected or confirmed COVID should only be done as a last resort. According to the Facility Screening Tool: If you answer yes to any symptoms or have a fever, you will not be allowed to remain in the facility. During an interview on 10/27/20 at 12:00 p.m., the Director of Nursing stated staff are to be screened upon entering the facility, noting someone other than the person being screened will review the staff's answers and check their temperature. The DON was uncertain what staff were to do if they were having signs and symptoms of COVID or an elevated temperature or whether they would be allowed to work, go home or call someone. Record review of Staff Screening Forms for October 2020, of which few were dated, found several instances in which staff members indicated they were having symptoms. On 10/20/20 at 1:50 p.m., Staff A (Nurse Aide) indicated she was having a sore throat, new or worsening cough, chills, headache, congestion, runny nose, muscle or body aches. Under the signature of individual column, there are initials and then written out, COVID negative. During an interview on 10/27/20 at 3:47 p.m., Staff A (Nurse Aide) stated she has been having signs and symptoms of COVID for about two weeks. Staff A stated when she came into work with signs or symptoms, they would test her and she was always negative. Staff A stated she was never sent home despite her reported symptoms and there were no restrictions placed on her working with negative residents. Staff A stated on Tuesday, 10/20/20 she came to work and was coughing really hard and on Friday 10/23/20 she came to work feeling really bad. Each time she was tested and negative. On Saturday 10/24/20 she tested positive for COVID. According to Staff A's Timecard Report during the times she indicated she was having signs and symptoms of COVID, she worked shifts on 10/13, 10/14, 10/15, 10/16, 10/17, 10/19, 10/20, 10/22, and 10/23. Record review of Staff Screening Forms for October 2020, of which few were dated, found several instances in which staff members indicated they were having symptoms. One such instance, date unknown, involved Staff B, maintenance who indicated arrival at 7:56 a.m. and symptoms which included a new or worsening cough, new or worsening of shortness of breath, chills, congestion, runny nose, muscle or body aches, loss of smell or taste and new or worsening fatigue. Under signature of individual column completing screen, there are initials and then written out, COVID negative. During an interview on 10/27/20 at 4:00 p.m., Staff B (Maintenance) stated he has been having signs and symptoms of COVID for about a week to 10 days. His symptoms have been on-going and mild to moderate. Staff B stated he was noticeably having symptoms on Monday 10/19/20 and lost his sense of smell on Tuesday 10/20/20. Staff B stated each time he reported feeling bad he tested negative and was allowed to work. Staff B stated he had developed shortness of breath, fatigue and a dry cough through the weekend and had a temperature ranging from 99.2 to 101 F. Staff B stated he came in today and tested positive for COVID. According to Staff B's Timecard Report during the times he indicated he was having signs and symptoms of COVID he worked shifts on 10/13, 10/14, 10/15, 10/16, 10/17, 10/19, 10/20, 10/21, 10/22 and 10/23. During an interview on 10/27/20 at 11:03 a.m., Staff C (Registered Nurse) stated on the morning of 10/21/20 she came to work with all the signs and symptoms of COVID. She was feeling like crap. Staff C stated she spoke with the Administrator, who suggested a rapid test. Staff C took the test and it was negative. Staff C stated she remained at work that day. The next day (10/22) she tested again and this time was positive for COVID. Staff A stated she has not worked since. During an interview on 10/27/20 at 11:47 a.m., Staff D (Licensed Practical Nurse) stated she first started feeling ill while working her 6:00 p.m. to 6:00 a.m. shift on Wednesday, 10/21/20. Staff D stated she had a bad headache and was tired. Following her shift on the morning of 10/22/20 she tested positive for COVID. During an interview on 10/27/20 at 11:12 a.m., Staff E (Nurse Aide) stated on 10/17/20 she worked a 10:00 a.m. to 10:00 p.m. shift. During that day she thought she had a mild sinus infection, which included a headache and body aches. Staff E stated she completed her shift and wanted tested to reassure she wasn't taking home COVID. Staff E stated she tested positive. During an interview on 10/27/20 at 10:15 a.m., Staff F (Licensed Practical Nurse) stated on 10/22/20 she was involved with testing staff for COVID using the rapid test. Staff F stated she completed a test on herself within 30 minutes of her arrival (6:30 a.m.) and it was positive for COVID. Staff F stated she did not notify anyone at the time and continued to work, but did not have contact with any resident that was negative. Staff F stated there was a Medication Aide working and she passed the medications to the negative residents. Staff F stated when the Administrator arrived, she informed her she was positive. The Administrator was on the phone and had a meeting and Staff F continued to work her shift and only had contact with residents who were positive. Staff F stated she didn't recall what came of the meeting, but was approved to continue to work. Staff F stated she may have passed insulin and may have done some assessments, but was now not sure about passing routine medications to negative residents. Review of the Medication Administration Records for Residents #1, #3 and #4 (all negative on 10/22/20) revealed Staff F passed medications and completed assessments. During an interview on 10/27/20 at 10:22 a.m., Staff G (Registered Nurse) stated she came in on the morning of 10/22/20 around 9:00 a.m. to 10:00 a.m. to get her routine test. Staff G stated she was never called that morning to see if she could work. During an interview on 10/29/20 at 7:50 a.m., Staff J (Registered Nurse) stated she tested positive for COVID this morning and wondered if it is acceptable for her to work. Staff J asked if on 10/22/20, when Staff F tested positive for COVID, was she ever contacted and asked to cover Staff F's shift. Staff J stated she was never contacted. During an interview on 10/26/20 at 4:20 p.m., the Director of Nursing (DON), stated staff who test positive for COVID are only to provide cares for residents who are positive for COVID. The DON stated they have attempted to call agencies to help with staffing and have put in a request to I-Serve. Thus far no one has responded. When asked what efforts were made to replace a nurse (Staff F) who tested positive on 10/22/20, the DON stated she was uncertain whether any of the two unscheduled nurses were contacted. The DON stated she came in around 10:00 a.m. to 11:00 a.m. that day and did not work the floor. The DON stated Staff F would have worked her 6:00 a.m. to 6:00 p.m. shift and would have passed medications to negative residents. On 10/23/20 at 12:45 p.m., the State Agency notified the facility of the Immediate Jeopardy. On 10/23/20, the facility abated the Immediate Jeopardy. The facility made room changes on 10/23/20 to provide private rooms for all negative residents, implemented CDC crisis staffing mitigation which included, as a last resort, allowing positive staff to care for negative residents and will continue to allow asymptomatic positive staff to work with negative residents. After corrective actions the scope lowered from a K to F.

Based on record review and interviews, the facility failed to provide adequate supervision to protect one of five residents from hazards during transfers. The facility failed to use a mechanical lift when transferring Resident #1. On 7/15/15, Resident #1 fell when one staff transferred him/her without a mechanical lift. Interviews revealed three staff then lifted the resident from the floor to the bed without an assessment or according to his/her care plan. Record review and hospital records revealed Resident #1 sustained a femur fracture after the fall on 7/15/15. The resident ' s care plan directed two staff perform transfers using a mechanical Stand Eze lift. The facility identified a census of 37 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified [DIAGNOSES REDACTED]. The MDS documented the resident had impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 (8-12 indicates moderate impairment). The resident required one staff assistance for bed mobility (tuning side to side or body positions while in bed) and two staff assistance when transferring (moving between surfaces to and from bed or wheelchair). The test for balance revealed the resident had been unsteady when transferring with staff from seated to standing position or when moving on/off the toilet; and during surface to surface transfers (transfers between bed and wheelchair). The MDS noted the resident did not have any falls since the prior MDS assessment period. The functional status section for the resident revealed the resident had impairment of function of both upper extremities. Pain assessment revealed the resident took a scheduled and PRN (as needed) pain medications and the resident reported he/she had frequent severe pain. The care plan prior to 7/15/15 identified the resident at risk for self-care deficit due to general weakness. Staff was directed to transfer the resident with a mechanical Stand-Eze lift and two staff members. The resident's fall assessment completed on 4/24/15 revealed the resident at risk for falls with a score of 13 (with a score of 10 or above indicating a high risk of falls). Review of Progress Notes (narrative nurse's notes) for Resident #1 revealed the following entries: On 7/15/15 (late entry entered on unknown date) at 3:03 p.m. by Staff A, Licensed Practical Nurse (LPN): approached by certified nurse aide (CNA) and told resident had been lowered to the floor. The CNA reported the resident was not hurt. The nurse documented at 8:00 p.m. the resident appeared to be sleeping, the nurse administered medications to the resident at that time and the resident had no complaints of pain. On 7/17/15 at 1:47 p.m. by Staff K, LPN: Resident yelling out during movement of left hip. No warmth or increased swelling to left lower extremity. Slightly edematous left knee. No decrease in range of motion (ROM) of left knee. Resident complained of increased discomfort to hip during flexion/extension but not with rotation. No lengthening or shortening of leg. ROM to left hip normal. Resident utilized PRN pain medicine at lunch time. Resident continued to propel self in wheelchair throughout facility using hands and feet. The next entry in Progress notes dated 7/22/15, revealed no complaints of pain noted for Resident #1. Progress Note entries on 7/24/15 revealed the resident complained of pain to upper left leg for last several days. The facility notified the physician who ordered a mobile x-ray and urine analysis (UA). The mobile x-ray had been delayed with arrangements for the X-ray to occur on 7/27/15. The facility notified the resident ' s family. The note revealed a positive UA for urinary infection and the resident started antibiotic treatment. The facility staff were now instructed to use a Hoyer lift for transfers until the x-ray results were taken and evaluated. There were no entries on 7/25/15 or 7/26/15 and the narrative documentation continued on 7/27/15 and revealed the mobile x-ray of left upper leg was completed and a fracture was present. The physician and family were notified and the resident had been sent to the emergency room for evaluation. The Progress Notes revealed the resident ' s family member stated she was aware of the incident when the resident had been lowered to the floor and also stated she had not noticed anything out of the ordinary about her parent other than increased confusion since 7/15/15. Review of a Radiology Report dated 7/27/15 noted the resident had a distal femoral fracture with mild lateral and posterior displacement at the distal fracture fragment. The History and Physician dated 7/29/15 documented Resident #1 sustained an injury to his/her left leg resulting in a comminuted left distal femur fracture. The resident had a left total hip (replacement) above this which made it difficult to perform the fixation during surgery; however there was a notable anterior distal femur comminuted fracture. Review of a Radiology Report dated 8/9/15 noted the resident had surgery to stabilize the fracture and the bone was in alignment. The radiologist noted the resident had osteopenia. The Administrator noted a timeline for the incident on 7/15/15 which included the following information: Resident #1 had been put to bed by Staff B, when the resident started to fall so Staff B lowered the resident to the floor. Staff B had used a gait belt but did not use the Stand-Eze (according to the resident ' s care plan). Staff B told Staff H the bed rolled and she lowered Resident #1 to the floor, and did not know Resident #1 require a transfer with a lift. The nurse did not complete an assessment and helped Staff B and Staff H lift Resident #1 off the floor and into bed. On 7/17/15, Staff K informed other nurses of Resident #1 being lowered to the floor and she completed a head to toe assessment. Due to the resident ' s increased pain and inability to hang onto handles of Stand-Eze, the facility started using a Hoyer lift. During an interview on 8/11/15 at 8:30 a.m. with the Administrator he stated he was not aware of the resident's incident when lowered onto the floor on 7/15/15 until 7/17/15 when a nurse became aware of the fall. He stated lowering the resident to the ground is considered a fall and fall protocol had not been followed by the nursing staff on 7/15/15. He stated nursing staff should have done a head to toe assessment with vital signs, transferred the resident from the floor to the bed by Hoyer lift, notified the family and physician, and completed an incident report which would have initiated a three day follow-up. He stated the CNA who transferred the resident did not use the Stand-Eze as care planned. During an interview on 8/11/15 at 11:00 a.m. with Staff B, Certified Nurse's Aide (CNA) she stated she started work at the facility around the beginning of June 2015. She stated she oriented on the night shift and had been hired for the night shift. She requested to receive orientation for an evening shift in case she was ever called in early or filled in for evening shift. Staff B stated 7/15/15 was her initial evening shift and she was orienting with Staff H, CNA. She stated Staff H asked her to go to Resident #1's room and assist the resident with bedtime cares (washing face, teeth, and putting bedtime clothes). Staff B assisted the resident to complete cares while seated in the wheelchair and removed the resident's top and placed the nightgown over the resident's head. Staff B stated she asked the resident if he/she could stand with help and the resident sated yes . The CNA placed the gait belt around the resident and asked Resident #1 to stand. The CNA stated she held the gait belt and was going to pivot turn the resident around onto the bed, when she stated the bed moved and she lowered the resident to the ground to avoid a fall. The CNA went to the nurse's station where she found Staff H, CNA, Staff L, CNA, and Staff A, LPN, and told them about lowering the resident to the floor. She stated Staff A asked her if the resident dropped or had been lowered to the ground, and she responded the resident had been lowered down. The (3) three CNAs (Staff B, H, and L) returned to the resident's room, helped the resident up to a standing position, and placed the resident in bed. The resident stated his/her legs hurts and indicated the pain had been in his/her left hip area. Staff B resumed un-dressing the resident and removed his/her slacks. The CNA stated the resident did not indicate pain when removing the pants or while the CNA situated the resident in bed. Staff B reported the 3 staff left the room and did not see the resident again that night. The CNA stated she had been oriented on night shift and had observed and assisted with ambulation and transfers involving gait belts and pivot turns. She stated the CNA who oriented her told her to check the cheat sheet or the care plan to find out specifics about residents. He also told her she could ask another staff member to help if unsure. She stated night staff does not use the mechanical lifts and she had not been oriented in the use of the Hoyer lift or the Stand-Eze lift. She stated since the resident told her he/she was able to stand with her help the CNA did not check the care plan or ask Staff H how the resident transferred. She stated she was trying to be helpful and that is why she did not ask Staff H to assist with transferring the resident from wheelchair to bed. Staff B stated she later found out, Resident #1 should have been transferred with the Stand-Eze lift. Record review of Staff B's undated Orientation Flow sheet for CNAs revealed the following tasks were initialed by the CNA who oriented her for night shift duties- safely using gait belts (task 6), lifting and moving a resident in bed (7), and lifting and moving a resident from bed to chair (8). Several tasks on the flow sheet were not initialed including safely using mechanical lifts (5) and Safety and emergency procedures- falls (52). Staff B received an employee warning for not properly transferring a resident on 7/15/15. The explanation revealed the incident may have been the cause of left femur fracture (for the resident) and she should have followed the resident ' s care plan. During an interview on 8/11/15 at 11:00 a.m. with Staff H, Certified Nurse's Aide (CNA) she stated she worked evening shift on 7/15/15 and had been assigned to orient Staff B, CNA, to the evening shift routine. Staff H stated she asked Staff B to go to Resident #1's room and assist the resident with bedtime cares. She stated she told Staff B she would be in shortly to assist with transferring the resident to bed. Staff H went into another resident's room to complete cares and when she went into the hall she stated Staff B told her she had to lower Resident #1 onto the floor. Staff H stated Staff B told her the resident was adamant about going directly to bed when the cares were done so she placed the gait belt and assisted the resident to stand and pivot turn. Staff B stated to Staff H the bed slid away from the resident. Staff H stated the bed wheels should have been locked. Staff H went into the room and saw the resident on the floor and he/she had been screaming. She asked Resident #1 if she had any pain and the resident stated, God yes . She asked the resident if the pain was worse than usual and the resident replied, no . Staff H told Staff A, LPN, what had occurred and stated they went back to the room to assist the resident up off the floor and to bed. She stated during the transfer the resident acted nervous but did not act as if in pain or verbalize pain. She stated she frequently cared for Resident #1 prior to 7/15/15 and between 7/15/15 -7/27/15. She stated the resident had frequent complaints of discomfort prior to the incident and Staff H did not notice an increase of pain complaints between 7/15-7/27/15. During an interview on 8/11/15 at 2:00 p.m. with Staff A, LPN, she stated she had been passing medications in the dining room when three CNAs (Staff B, H, and L) came to her and told her they lowered Resident #1 down to the floor during a transfer. The staff reported the resident did not fall, was not hurt, had been placed back in bed, and was fine. The LPN stated she went into the resident's room 15 minutes later and the resident appeared to be sleeping. The LPN woke the resident and stated the resident did not complain of pain. The LPN stated she did not consider lowering a resident to the floor to be a fall so she did not do a full head to toe assessment, incident report or notify the physician/family. She stated she has been educated since this incident and knows lowering a resident to the floor is a (considered) a fall and fall protocols must be followed. During an interview on 8/11/15 at 11:25 a.m. with Staff I, LPN and interim DON, LPN, she stated Staff B had finished orientation on night shift and had her own work load of residents on night shift. Staff I acknowledged that Staff B had not trained in the use of mechanical lifts since they are not used on night shift. She stated Staff B should have checked the resident's care plan for transfer status prior to transferring him/her on 7/15/15. During an interview on 8/14/15 at 10:45 a.m. with Staff K, LPN, she stated she had been told before lunch on 7/17/15 by a CNA Resident #1 had complained of generalized leg pain. She did a complete assessment of the resident's lower extremities. During report to the evening shift she mentioned to Staff C, Registered Nurse (RN), of the resident ' s generalized complaint of leg pain earlier in the shift. Staff C told Staff K that she thought the resident had been lowered to the floor on 7/15/15. Staff K stated she checked the Progress Notes for information on the incident and when she could not find any notes she informed Staff I, Interim DON. She stated prior to this incident staff did not consider lowering a resident to the floor a fall unless an injury occurred and then an incident report would be completed and three day follow-up would be documented. She stated the staff had been re-educated and all incidents of residents on the floor with or without injury were considered falls with incident reports completed. Staff K stated facility nurses chart by exception and they chart only abnormal and unusual assessments. Since the following entries through 7/24/15 did not include complaints of pain and/or difficulty with transfer and self-propelling the wheelchair the resident must not have expressed or demonstrated any difficulties. During an interview on 8/11/15 at 8:30 a.m. with the Administrator he stated corrective actions taken after identification of the incident which most likely resulted in the resident's fracture include the following: Disciplinary action on the CNA (for not following the care plan) and Nurse (for not completing full assessment) involved on the night of 7/15/15.