Every finding on record at Oakland Manor

Based on observation, record review, and interview, the facility failed to ensure staff monitored door alarms, maintained door latches, and performed visual checks to prevent elopement (unsupervised exit) for 1 of 3 residents reviewed (Resident #3) for wandering and elopement. The facility reported a census of 34 residents.The facility corrected the deficient practice prior to the survey on 6/12/26 through the following actions:All staff re-education on the facility's elopement policyFacility wide audit of all facility doors to include exit doorsAll staff educated on covering door keypad with hand so residents cannot see the codeAll staff educated to check that no residents are exiting the facility when leaving the buildingAll staff educated to ensure that the door has firmly shut before leaving that areaSigns were placed on outside doors alerting all staff to enter and exit through the front doors only.Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severely cognitively impaired. The MDS documented Resident #3 wandered the facility daily, walked independently throughout the facility, and wore a wander guard (electronic safety bracelet). The MDS listed diagnoses for Resident #3 including hypertensive heart disease (high blood pressure heart condition), Alzheimer's disease (progressive memory loss disorder), insomnia (sleep disorder), and tremors (involuntary shaking). The Care Plan Focus revised 8/3/26 identified Resident #3 had risk for injury due to wandering or attempting elopement and required a wander guard bracelet. Documentation showed Resident #3 exited the building on 6/9/26 and exited into the courtyard on 7/19/26 while staff remained present following facility policy. A Progress Note dated 6/9/26 at 10:15 PM documented a Certified Nursing Assistant (CNA) reporting at 9:00 PM finding Resident #3 at the front door attempting to re-enter the building from outside. Staff didn't visually witness Resident #3 leave the building, and Resident #3 couldn't explain the exit due to a BIMS score of 0. Staff last observed Resident #3 inside the building at 8:45 PM in the day room watching television. Resident #3 returned inside without difficulty, resting comfortably watching television. Documentation noted Resident #3 had a history of exit seeking, door testing, and wandering, requiring frequent staff redirection. The facility completed an incident report per facility protocol. On 8/5/26 at 10:30 AM an observation showed Resident #3 walking around the facility wearing a wander guard bracelet on the left wrist. On 8/6/26 at 1:20 PM observed the kitchen staff exit the kitchen through the door leading to the dining room and shutting the door. At 1:26 PM staff asked Resident #3 to play trivia in the dining room with peers, and Resident #3 remained in the dining room. An observation showed a panel behind the nurse's station near the medication room with a list of alarmed doors. The panel displayed a red light when an alarm sounded until staff deactivated the alarm. At 1:59 PM Resident #3 attempted opening the door leading to the basement until maintenance staff redirected Resident #3 away from the door. Resident #3 then followed a staff member toward a utility room and attempted entry, but the staff member informed Resident #3 entry wasn't permitted. Staff asked Resident #3 to go outside, and Resident #3 followed other residents and staff to the courtyard. On 8/11/26 at 9:50 AM witnessed a keypad on the door leading from the dining room into the kitchen. Past the stove and steam table, a doorway led to the dishwashing room, where a door led back to the facility. To the right of the kitchen, 3 doors led to the pantry accessible via keypad, the basement, and an exterior emergency exit door leading to the west side of the building. Opening the exterior door sounded an alarm shutting off when staff closed the door. A CNA and the Assistant Director of Nursing (ADON) investigated the door alarm activation. On 8/6/26 at 1:40 PM Staff F, Registered Nurse (RN), stated they sat at the nurse's station the evening Resident #3 exited the building (6/9/26), she watched him walk past the station during typical wandering. Minutes later, staff heard the main entrance doorbell ring. A CNA observed Resident #3 standing outside the door, brought him inside, and questioned him, who made a circular finger motion symbolizing walking outside. Staff checked all doors to identify the exit point. They observed the dining room door to the kitchen and the exterior door unlatched. Both doors required keycodes for access. Opening the exterior door sounded an alarm, while the re-entry required a keycode. Resident #3 wandered frequently prior to the incident without attempting exit. The staff didn't recognize kitchen door issues prior to that evening. Staff F estimated Resident #3 remained outside under five minutes, noting a head-to-toe assessment showed normal results. On 8/6/26 at 3:38 PM the Director of Nursing (DON) stated the facility staff identified Resident #3 as an elopement risk upon admission and applied a wander guard bracelet. On the day Resident #3 exited, at approximately 9:10 PM, Staff C, CNA, walked up the 300 hall, observed Resident #3 knocking in the foyer, and assisted Resident #3 inside. Prior to the exit, Staff D, Licensed Practical Nurse (LPN), exited through the ambulance door for a break. Staff E, CNA, questioned Staff D regarding Resident #3 following Staff D outside, and Staff D denied Resident #3 followed them, stating the door closed. Staff checked all exit doors to verify alarm function, observing the kitchen door standing ajar, assuming Resident #3 went out the kitchen door and the exterior kitchen door. The DON stated the exterior kitchen door lacked the interior keycode requirements, lacked a wander guard receiver, and required keycodes only for re-entry. Staff E acknowledged the kitchen door alarm sounded, and Staff E silenced the alarm out of habit without physically checking the door. Facility management couldn't determine who last used the kitchen door, assuming the kitchen staff left the door unlatched. During a follow-up interview on 8/6/26 at 4:16 PM, the DON stated facility management educated staff regarding the elopement policy, instituted daily audits checking doors and alarms, and instructed staff to utilize only the main entrance for entry and exit. On 8/7/26 at 2:48 PM Staff D stated they stepped outside for a brief break, under five minutes within the parking lot, after notifying the unit nursing assistants. Walking back toward the building, a nursing assistant questioned whether Staff D observed Resident #3 outside, she denied seeing Resident #3. When she questioned, the staff reported he Resident #3 stood at the front door. After checking the facility doors, staff concluded Resident #3 accessed the kitchen door and exited outside. The dining room door to the kitchen lacked an alarm, and Resident #3 tested doors frequently to find open access. Staff D noted Staff E should've checked the door alarm, stating door alarm activations require staff to proceed to the door to visually verify exiting individuals. Staff D stated Resident #3 maintained baseline behavior the remainder of the night, remaining easily redirectable without aggression while continuing to test the doors. On 8/7/26 at 3:14 PM Staff E stated attempting to locate Staff D around 9:00 PM for a different resident about a medication question. While conversing with Staff F, the kitchen door alarm sounded. Staff E silenced the alarm without verifying who activated the door, assuming Staff D re-entered the facility through that door. Staff E estimated Resident #3 remained outside 30 seconds to one minute between alarm activation and Staff C observing Resident #3 ringing the front doorbell. After assisting Resident #3 inside, the staff inspected the doors and discovered the dining room door to the kitchen unlatched due to a mechanical malfunction. It required the staff to pull down on the door to ensure complete closure. Staff E acknowledged they failed to visually check the alarming door prior to silencing the alarm. Staff E stated they received post-incident facility education, to ensure complete door closure, and physically inspect the alarming doors prior to silencing alarms. Staff E stated Resident #3 didn't seek exits prior to the incident, retiring to bed after re-entry, and gesturing in a circle when asked about destination. On 8/7/26 at 3:33 PM Staff C stated they conducted hall rounds during Resident #3's exit. Staff C observed Resident #3 ringing the front doorbell, notified the nurse's station staff, and assisted Resident #3 inside without hearing an alarm. When questioned about the exit route, Resident #3 pointed toward the kitchen and emergency exit door. Staff recognized a nurse used the emergency exit door simultaneously, sounding the alarm that staff silenced. Staff discovered the dining room door to the kitchen unlatched, concluding Resident #3 went out the kitchen to exit. Staff C reported Resident #3 displayed baseline behavior prior to the incident, wandering and watching television, but appeared confused and nervous when questioned post-incident. The facility management provided post-incident education regarding elopement protocols, reporting procedures, and door alarm verification, mandating staff visually inspect alarming doors rather than silencing alarms out of habit. On 8/11/26 at 9:50 AM Staff B, Cook, stated facility maintenance repaired the kitchen door post-incident to ensure automatic closure. Entering the kitchen required a keycode, while exiting didn't require a code. Staff B noted the incident occurred after kitchen staff left, without verifying who left the door unlatched. Post-incident, the kitchen staff close the door between the kitchen and dish room and a pocket door closing off the pantry, basement, and exit doors upon their evening departure. An exterior west-facing door posted signage instructing individuals to use the main entrance. Management provided post-incident staff education regarding door closure, alarm verification, and main entrance usage. On 8/11/26 at 12:18 PM the ADON stated the helped the DON investigate Resident #3's exit. The investigation revealed the kitchen serving door failed to close automatically due to swelling. The ADON noted Resident #3 seeks exits, tested doors, and lacked comprehension, wandering to search for a spouse or vehicle. Resident #3 opened the unlatched kitchen door, walked out the kitchen, and exited the emergency door before staff assisted Resident #3 inside at the front entrance. Interviews revealed Staff E silenced the alarm without verifying the alarming door location. Following the completion of the investigation, the facility management educated staff regarding the elopement policy, and collected signed education acknowledgments. The Elopement/Missing Resident policy revised 2/6/23 instructed staff to secure and maintain resident safety. The policy defined elopement as an incident where a resident with impaired decision-making ability leaves the facility without staff knowledge or supervision, or a resident with decision-making capacity leaves without facility awareness. The policy directed all exit doors feature audible alerts, instructing staff:In the case of a door alarm sounding, staff will immediately go to the door indicated on the enunciator system and check both inside and outside the door to determine who/why the door alarm sounded,If no person is in the vicinity of the alarming door, staff will go outside the door and search for the person activating the alarm and will alert staff inside that the alarm is sounding,Under no circumstance will a door alarm be de-activated until the source of the activation has been determined.

Based on record review, staff interviews and facility policy review the facility failed to ensure staff completed physician-ordered referrals for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 34 residents.Findings include:Resident #1's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #1's MDS documented receiving medications during the 7-day review period including an antipsychotic (mood and behavior stabilizing medication) on a routine basis only, an antianxiety (anxiety reducing medication), and an antidepressant (depression medication). Resident #1's MDS listed active diagnoses including Huntington's disease (inherited brain disorder), anemia (low red blood cells), Crohn's disease (inflammatory bowel disease), malnutrition (lack of proper nutrition), anxiety (excessive worry), depression (mood disorder), repeated falls, alcohol abuse with alcohol-induced mood disorder, nicotine dependence (tobacco addiction), and bipolar disorder (brain disorder causing extreme mood swings). Resident #1's Care Plan Focus Area revised 4/6/26 documented Resident #1 held risk for extreme mood swings, agitation, restlessness, poor concentration, increased energy, paranoia (unrealistic mistrust), and rapid speech related to bipolar disorder. The Care Plan directed staff to complete psychological consults and treatments as ordered. Resident #1's Care Plan Focus Area revised 4/6/26 documented Resident #1 experienced mood alterations evidenced by negative statements, repetitive questions, repetitive vocalizations, persistent anger with staff or others, self-depreciation, expressions of unrealistic fears, recurrent statements, repetitive complaints, medication or bowel obsessions, crying, repetitive movements, and reduced social interactions related to depression. The Care Plan directed staff to complete behavioral and psychological consults as ordered. The Progress Note dated 4/9/26 at 5:15 PM documented the Medical Director completing a visit and writing orders for psychological and neurological referrals, noting order processing at the time. A Physician Visit Form dated 4/9/26 documented medical problems requiring attention including new admission, Huntington's disease behaviors, multiple falls, impulsive behaviors, and wandering into other resident rooms. The Medical Director wrote orders for psychology and neurology referrals, and the Assistant Director of Nursing (ADON) noted the form on 4/9/26. A phone order record for a psychology evaluation documented Staff A, Agency Licensed Practical Nurse (LPN), confirming the order on 4/24/26 at 5:02 PM, and the Medical Director signed the order on 4/28/26. An Encounter Note dated 4/30/26 documented Resident #1 failing to start outpatient psychology, and the Advanced Registered Nurse Practitioner (ARNP) referred Resident #1 to psychology for further management. The Progress Note dated 5/2/26 at 10:54 AM documented staff calling the Medical Director, who ordered Resident #1 seen by a psychology provider. The Progress Note dated 5/4/26 at 11:16 AM documented the Social Worker (SW) calling to schedule a neurology appointment, with an operator placing a high-priority note to return the call to schedule the appointment. The Progress Note dated 5/4/26 at 11:22 AM documented the Social Worker calling Resident #1 Representative (Power of Attorney - POA) regarding psychology provider visits for medication management, and Resident #1 Representative provided verbal agreement. Resident #1's Care Plan Focus Area revised 5/8/26 documented Resident #1 experienced mood alterations evidenced by repetitive vocalizations, single-subject obsessions, restlessness, fatigue, irritability, headaches, stomachaches, excessive worry, and sleep disturbances related to anxiety. The Care Plan directed staff to complete behavioral and psychological consults as ordered. A review of Resident #1's clinical record showed staff failed to complete a psychology referral as ordered. On 8/6/26 at 2:43 PM the Director of Nursing (DON) acknowledged receiving information regarding orders for Resident #1's psychology referral on 4/9/26, 4/30/26, and 5/2/26 without completion evidence. The DON stated the Social Worker schedules appointments following order entry, expressing belief staff attempted placing Resident #1 on the schedule for the next in-person visit for medication review, noting the psychology provider visits the facility monthly. On 8/11/26 at 12:15 PM the Social Worker stated holding responsibility to schedule Resident #1's psychology and neurology evaluations, expressing belief staff scheduled Resident #1 for monthly on-site visits and a May 2026 neurology consult. On 8/11/26 at 12:50 PM during a follow-up interview, the Social Worker confirmed scheduling appointments based on Progress Notes entered on 5/4/26. The Social Worker reported recalling no notes or documentation received between 4/9/26 and 5/4/26 regarding referrals made on 4/9/26, 4/30/26, and 5/2/26, stating staff don't review progress notes to identify appointments, as nurses typically deliver written orders directly to schedule appointments. On 8/11/26 at 12:18 PM the ADON stated processing orders upon referral receipt by printing and delivering documentation to the Social Worker for scheduling, following notification of no order placed after the 4/9/26 referral until 4/24/26. Questioned regarding a follow-up system to ensure order execution, the ADON stated they worked as a floor nurse at the time not the ADON. The ADON reported a psychology provider visited the facility monthly to round on assigned residents, while neurology referrals required an off-site facility transport. The Provision of Physician Ordered Services policy revised 2025 instructed staff to provide a reliable process for proper and consistent provision of physician-ordered services according to professional standards of quality. The policy directed qualified nursing personnel to submit timely requests for physician-ordered services, including consultations, to appropriate entities. The policy instructed staff to store documentation of consultations, diagnostic tests, results, and date and time of physician notification in a resident's clinical record.

Based on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the State Agency no later than 2 hours after the allegation of abuse was suspected. The facility reported a census of 33 residents.Findings include: 1. According to Resident #1's quarterly Minimum Data Set (MDS) assessment tool with a reference date of 2/3/2026, she had a Brief Interview of Mental Status (BIMS) score of 8. A BIMS score of 8 suggested mild cognitive impairment. The MDS documented Resident #1 received a scheduled pain medication regimen, received an as needed (PRN) pain medications or was offered and declined. Resident #1 reported no pain during the MDS assessment. The MDS listed the following diagnoses: Parkinson's disease, renal failure, stroke, depression, atrial fibrillation, fusion of cervical and lumbar spine. A Care Plan Focus Area with a revision date of 12/4/2025 documented Resident #1 had chronic pain and increased risk for injury from decreased function related to a diagnosis of spinal fusion and spondylosis. The Focus Area documented she was had routine pain management. The care plan directed staff to administer scheduled and PRN pain medications as ordered, evaluate the effectiveness of pain interventions/medications.Review of October 2025 Medication Administration Record (MAR) revealed the following order: oxycodone (scheduled II narcotic for severe pain) tablet, 5 milligrams (mg) by mouth every six hours as needed (PRN) related to left femur fracture. This order had a start date of 7/3/2024 and discontinued date of 10/24/2025.On 4/20/2026 9:30 AM resident lying in bed. Denied having uncontrolled pain in the last month or two. Felt her pain has been managed, have discontinued some of her medications without further pain.On 4/22/2026 at 9:08 AM completed a check of narcotic count sheet and medication card. Resident #1 did not have a count sheet or medication card for oxycodone in the medication cart.2. According to Resident #2's quarterly MDS assessment tool with a reference date of 3/3/2026, he had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented he received an opioid during the review period. The MDS listed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), heart failure, renal failure, non-Alzheimer's disease, depression, low back pain, and chronic pain. The Care Plan Focus Area with a revision date of 1/14/2026 documented Resident #2 had chronic pain and was on a scheduled pain regimen. The Care Plan directed staff to administer scheduled/PRN pain medications as ordered and to monitor for effectiveness and side effects. Review of a document titled Order Summary Report, dated 3/11/2026 documented Resident #2 had an order for oxycodone tablet, 5 mg by mouth every 24 hours PRN for breakthrough pain. The order had a start date of 1/22/2026.On 4/22/2026 at 9:11 AM resident lying in bed watching TV. Stated he felt his pain was well controlled, he has medications he can ask for if he needs it but tries to tolerate it without taking anything too invasive.On 4/22/2026 at 9:57 AM with facility staff present, observed Resident #2 had two medication cards of his oxycodone 5mg tablet, present in the medication cart. The medication cards did not appear to have been tampered with.3. According to a Significant Change MDS assessment tool with a reference date of 2/10/2026, Resident #3 had a BIMS score of 11. A BIMS score of 11 suggested mild cognitive impairment. The MDS documented he received an opioid during the review period and was on hospice. The MDS documented Resident #3 did not receive scheduled pain medications, but did receive a PRN pain medication or was offered and declined. The following diagnoses were listed for Resident #3: emphysema, atrial fibrillation, heart failure, renal failure, neurogenic bladder, non-Alzheimer's dementia, schizophrenia, post-traumatic stress disorder, palliative care, adult thrive to thrive, and spondylosis. The Care Plan Focus Area with revision date of 2/12/2026 documented Resident #3 had chronic pain. The Care Plan directed staff to administer scheduled and PRN pain medications as ordered. Staff were to evaluate the effectiveness of the pain medications.Review of a document titled Order Summary Report, dated 3/7/2026 documented Resident #3 had an order for oxycodone tablet, 5 mg by mouth every 4 hours PRN for pain. The order had a start date of 2/02/2026.On 4/22/2026 at 9:08 AM with facility staff present, observed Resident #3 had one packet of his oxycodone 5mg tablets, present in the medication cart. The medication card did not appear to have been tampered with.On 4/22/2026 at 9:38 AM Resident #3 stated he did have increased pain at his groin a couple of months ago. When asked how much pain, he stated he knew it was there. Resident #3 stated today his pain is good, denied having any pain.4. According to the Quarterly MDS assessment tool with a reference date of 4/7/2026, Resident #4 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she received a scheduled pain medication, received a PRN medication or was offered and declined during the review period. The MDS indicated she received an opioid during the review period. The following diagnoses were listed for Resident #4: stroke, depression, emphysema, pressure ulcer to left heel, and pain.The Care Plan Focus Area with a revision date of 1/13/2026 documented Resident #4 had chronic pain and received scheduled pain medications. The Care Plan directed staff to administer scheduled/PRN pain medications as ordered and monitor for effectiveness.Review of a document titled Order Summary Report, dated 3/11/2026 documented Resident #4 had an order for oxycodone tablet, 5 mg by mouth every 12 hours PRN for breakthrough pain. The order had a start date of 1/08/2026. The Order Summary Report also documented he had an order for oxycodone 5mg, 1 tablet, twice a day (BID) for pain. This order had start date of 1/8/2026.On 4/22/2026 at 9:15 AM Resident #4 denied having any increased pain in the last 2-3 months. She indicated her pain is under control and voiced no concerns.On 4/22/2026 at 9:30 AM with facility staff present, observed Resident #4 had three packets of her oxycodone 5mg tablets for PRN and scheduled orders, present in the medication cart. The medication cards did not appear to have been tampered with.5. According to a Quarterly MDS assessment tool with a reference date of 3/10/2026, Resident #5 had a BIMS score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS documented he received an opioid and received a PRN pain medication or was offered and declined during this review period. The MDS listed the following diagnoses for Resident #5: paraplegia, renal failure, neurogenic bladder, anxiety, depression, bipolar, and chronic pain syndrome.The Care Plan Focus Area with a revision date of 12/18/2025 documented Resident #5 had chronic pain related to a diagnoses of chronic pain syndrome. The Care Plan directed staff to administer scheduled and PRN medications as ordered and to monitor for effectiveness.Review of a document titled Order Summary Report, dated 3/11/2026 documented Resident #5 had an order for oxycodone tablet, 10 mg by mouth every six hours PRN for severe pain. The order had a start date of 8/26/2024.On 4/22/2026 at 9:08 AM with facility staff present, observed Resident #5 had 2 packets of his oxycodone 10mg tablets, present in the medication cart. The medication cards did not appear to have been tampered with. The pill present was pink in color and scored down the center.On 4/22/2026 at 1:00 PM Resident #5 denied having concerns about how his pain is being managed.The facility provided a document titled 5-Day Investigation Summary:Timeline-Incident was reported to the Director of Nursing (DON) by Staff A Registered Nurse (RN) on 3/4/2026 at 6:21 AM. The Administrator was contacted on 3/4/2026 at 6:27 AM.On March 4, 2026 at 6:21 AM Staff A contacted the DON to report a suspected narcotic discrepancy identified during the shift change narcotic count. Staff A stated Staff B Agency RN questioned the appearance of Resident #1's oxycodone 5mg medications while completing the controlled substance count on the [NAME] (300) medication cart with the night nurse.During the count, Staff B observed that the #59 tablet with the blister card appeared to be secured with regular medical tape, which prompted further examination. Upon closer inspection of the medication card, both nurses noted that the back of blister pack appeared to have been tampered with. The tablet located in position in #59 appeared consistent with oxycodone 5mg, however the remaining tablets in the card displayed different physical characteristics and appearance than the expected medication.Further examination revealed that each blister cavity on the back of the card had been covered with a small piece of paper tape. Upon removal and inspection, it appeared that all tablets except #59 had been replaced with a different medication. Staff A immediately took photographs of the front and back of the medication card, ensuring that no resident identifying information included. At the same time, the nurses reviewed available drug identification resources and determined that the tablets in the remaining cavities appeared consistent with loratadine (antihistamine).Following this discovery, the nursing staff initiated a review and recount of all narcotic cards located on the medication cart to determine whether additional discrepancies were present. During this review, staff identified additional oxycodone 5mg and 10mg medication cards that appeared to have been tampered with in a similar manner, with the prescribed medication replace by what appeared to be loratadine tablets.At the time five oxycodone 5mg medication cards were identified as potentially tampered with. All affected medication cards and corresponding narcotic documentation were immediately removed from the medication cart and secured by nursing leadership pending further investigation. The DON was notified and an internal investigation was initiated.The DON contacted Staff C previous Administrator at 6:27 AM to report this medication diversion.At 7:30 AM the DON and Staff C arrived at the facility. The DON went to each cart and reexamined/counted cards with Staff A on the East (100) medication cart and Staff B on the [NAME] (300) medication cart. Upon counting with Staff A it was found that Resident #5's oxycodone 10 mg card with tablets that are pink in color was found to be tampered with as well, there appeared to be no oxycodone 10mg present in the card at this time. This medication was replaced with over the counter (OTC) pink Vitamin B-12 round tablets and the card was tampered with exactly like the others; with paper tape precisely placed over each bubble in the pack. The DON removed the card and narcotic sheet-gathered the others and went to fully examine all of them with Staff C.Additional residents assigned to the [NAME] (300) medication cart whose medications were identified as tampered with include Resident #1 and Resident #3, both of whom had oxycodone 5mg tablets replaced with loratadine within their medication blister packs.Review of narcotic blister cards for Resident #2 and Resident #4 revealed similar signs of tampering, including paper tape applied to the back of the blister cavities, with the prescribed oxycodone tablets replaced with loratadine. Both residents receive scheduled oxycodone multiple times per day, and the physical condition of the blister cards suggests that the medication replacement may have occurred during this timeframe.The following information was documented in a medication diversion matrix:a) Resident #1 had 1 medication card of oxycodone 5mg, with 59 missing/replaced with another drug;b) Resident #2 had 2 medication cards of oxycodone 5mg, with 70 missing/replaced with another drug;c) Resident #3 had 1 medication card of oxycodone 5mg, with 11 missing/replaced with another drug;d) Resident #4 had 1 medication card of oxycodone 5mg, with 55 missing/replaced with another drug;e) Resident #5 had 2 medication cards of oxycodone 10mg, with 84 missing/replaced with another drug;f) A total of 7 cards affected and a total of 279 narcotic tablets missing. On 4/22/2026 at 2:10 PM a State Agency Complaint Intake Specialist provided a print screen of the intake the facility reported. The print screen documented the reporting party was Staff C and was aware of the allegation of missing medication occurred on 3/4/2026 at 6:10 AM. The print screen documented a submission date of 3/5/2026 at 11:21 AM. On 4/22/2026 at 2:10 PM Staff C stated he was made aware of the incident by the DON and filed the report with the State Agency. He stated he reported it on 3/4/2026 but not top notch in the technology world and did not get the information completely submitted. He went in the next morning to make sure he submitted it and learned he hadn't saved it. It was user error on his part that it was not submitted correctly. The facility provided a policy titled Abuse, Neglect and Exploitation with an implemented date of 1/9/2025. It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. IV. Reporting/ResponseThe facility will have written procedures that include:Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orNot later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, record review, facility investigative file review, resident and staff interviews and facility policy review the facility failed to ensure 5 of 5 residents (Resident #1, #2, #3, #4, and #5) were free from misappropriation of their medication. The facility reported a census of 33 residents. Findings include: 1. According to Resident #1's quarterly Minimum Data Set (MDS) assessment tool with a reference date of 2/3/2026, she had a Brief Interview of Mental Status (BIMS) score of 8. A BIMS score of 8 suggested mild cognitive impairment. The MDS documented Resident #1 received a scheduled pain medication regimen, received an as needed (PRN) pain medications or was offered and declined. Resident #1 reported no pain during the MDS assessment. The MDS listed the following diagnoses: Parkinson's disease, renal failure, stroke, depression, atrial fibrillation, fusion of cervical and lumbar spine.A Care Plan Focus Area with a revision date of 12/4/2025 documented Resident #1 had chronic pain and increased risk for injury from decreased function related to a diagnosis of spinal fusion and spondylosis. The Focus Area documented she had routine pain management. The care plan directed staff to administer scheduled and PRN pain medications as ordered, evaluate the effectiveness of pain interventions/medications.Review of October 2025 Medication Administration Record (MAR) revealed the following order: oxycodone (scheduled II narcotic for severe pain) tablet, 5 milligrams (mg) by mouth every six hours as needed (PRN) related to left femur fracture. This order had a start date of 7/3/2024 and discontinued date of 10/24/2025.A Progress Note dated 3/4/2026 at 7:59 PM documented facility wide pain assessment, range of motion (ROM), and activities of daily living (ADLs) check in. When asked, resident denied all pain/discomfort at this time. Stated I feel good right now. She appeared to be ready to take a nap. She was alert and oriented x 2 (baseline). Resident continues to be within normal limits (WNL) for ROM and activities of daily living. Resident voiced no concerns at this time.On 4/20/2026 9:30 AM resident lying in bed. Denied having uncontrolled pain in the last month or two. Felt her pain has been managed, have discontinued some of her medications without further pain.On 4/22/2026 at 9:08 AM completed a check of narcotic count sheet and medication card. Resident #1 did not have a count sheet or medication card for oxycodone in the medication cart.2. According to Resident #2's quarterly MDS assessment tool with a reference date of 3/3/2026, he had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented he received an opioid during the review period. The MDS listed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), heart failure, renal failure, non-Alzheimer's disease, depression, low back pain, and chronic pain.The Care Plan Focus Area with a revision date of 1/14/2026 documented Resident #2 had chronic pain and was on a scheduled pain regimen. The Care Plan directed staff to administer scheduled/PRN pain medications as ordered and to monitor for effectiveness and side effects.Review of a document titled Order Summary Report, dated 3/11/2026 documented Resident #2 had an order for oxycodone tablet, 5 mg by mouth every 24 hours PRN for breakthrough pain. The order had a start date of 1/22/2026.A Progress Note dated 3/4/2026 at 7:59 PM documented facility wide pain assessment, ROM and ADLs check in. Resident stated, my pain feels normal, it's there. No increase in it and my pain medications help. My pain is chronic and all over my body. Resident rated current pain 7 out of 10. Residents ROM at baseline, transfers/ADLs completed as care planned. No decline or uncontrollable pain observed/reported. Resident stated he was currently comfortable in bed and was ready to take a nap, he voiced no concerns.On 4/22/2026 at 9:11 AM resident lying in bed watching TV. Stated he felt his pain was well controlled, he has medications he can ask for if he needs it but tries to tolerate it without taking anything too invasive.On 4/22/2026 at 9:57 AM with facility staff present, observed Resident #2 had two medication cards of his oxycodone 5mg tablet, present in the medication cart. The medication cards did not appear to have been tampered with.3. According to a Significant Change MDS assessment tool with a reference date of 2/10/2026, Resident #3 had a BIMS score of 11. A BIMS score of 11 suggested mild cognitive impairment. The MDS documented he received an opioid during the review period and was on hospice. The MDS documented Resident #3 did not receive scheduled pain medications, but did receive a PRN pain medication or was offered and declined. The following diagnoses were listed for Resident #3: emphysema, atrial fibrillation, heart failure, renal failure, neurogenic bladder, non-Alzheimer's dementia, schizophrenia, post-traumatic stress disorder, palliative care, adult thrive to thrive, and spondylosis.The Care Plan Focus Area with revision date of 2/12/2026 documented Resident #3 had chronic pain. The Care Plan directed staff to administer scheduled and PRN pain medications as ordered. Staff were to evaluate the effectiveness of the pain medications.Review of a document titled Order Summary Report, dated 3/7/2026 documented Resident #3 had an order for oxycodone tablet, 5 mg by mouth every 4 hours PRN for pain. The order had a start date of 2/02/2026.A Progress Note dated 3/4/2026 at 7:30 PM documented facility wide pain assessment, ROM and ADLs check in. Resident denied any pain. He came out for each meal this shift. No sudden decline when transferring. However, resident is on hospice for overall decline. Resident voiced no concerns at this time.On 4/22/2026 at 9:08 AM with facility staff present, observed Resident #3 had one packet of his oxycodone 5mg tablets, present in the medication cart. The medication card did not appear to have been tampered with.On 4/22/2026 at 9:38 AM Resident #3 stated he did have increased pain at his groin a couple of months ago. When asked how much pain, he stated he knew it was there. Resident #3 stated today his pain is good, denied having any pain.4. According to the Quarterly MDS assessment tool with a reference date of 4/7/2026, Resident #4 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she received a scheduled pain medication, received a PRN medication or was offered and declined during the review period. The MDS indicated she received an opioid during the review period. The following diagnoses were listed for Resident #4: stroke, depression, emphysema, pressure ulcer to left heel, and pain.The Care Plan Focus Area with a revision date of 1/13/2026 documented Resident #4 had chronic pain and received scheduled pain medications. The Care Plan directed staff to administer scheduled/PRN pain medications as ordered and monitor for effectiveness.Review of a document titled Order Summary Report, dated 3/11/2026 documented Resident #4 had an order for oxycodone tablet, 5 mg by mouth every 12 hours PRN for breakthrough pain. The order had a start date of 1/08/2026. The Order Summary Report also documented he had an order for oxycodone 5mg, 1 tablet, twice a day (BID) for pain. This order had start date of 1/8/2026.A Progress Note dated 3/4/2026 at 7:14 PM documented facility wide pain assessment, ROM and ADLs check in. In regards to pain resident stated, she aways felt the same, her pain is from nerve damage. It's chronic and affects the left side of her body from a stroke. She rated her pain 7 out of 10; stating it's always that, I haven't had a huge increase in pain recently. Resident is alert/oriented x4. ADL at baseline, ROM WNL for this resident. No decline observed. Resident appears stable. Resident stated she has no concerns at this time.On 4/22/2026 at 9:15 AM Resident #4 denied having any increased pain in the last 2-3 months. She indicated her pain is under control and voiced no concerns.On 4/22/2026 at 9:30 AM with facility staff present, observed Resident #4 had three packets of her oxycodone 5mg tablets for PRN and scheduled orders, present in the medication cart. The medication cards did not appear to have been tampered with.5. According to a Quarterly MDS assessment tool with a reference date of 3/10/2026, Resident #5 had a BIMS score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS documented he received an opioid and received a PRN pain medication or was offered and declined during this review period. The MDS listed the following diagnoses for Resident #5: paraplegia, renal failure, neurogenic bladder, anxiety, depression, bipolar, and chronic pain syndrome.The Care Plan Focus Area with a revision date of 12/18/2025 documented Resident #5 had chronic pain related to a diagnoses of chronic pain syndrome. The Care Plan directed staff to administer scheduled and PRN medications as ordered and to monitor for effectiveness.Review of a document titled Order Summary Report, dated 3/11/2026 documented Resident #5 had an order for oxycodone tablet, 10 mg by mouth every six hours PRN for severe pain. The order had a start date of 8/26/2024.A Progress Note dated 3/4/2026 at 7:51 PM documented facility wide pain assessment, ROM and ADLs check in. Resident denied pain at this time, rating it 0 out of 10. He stated it's better controlled now, a couple weeks ago his shoulder hurt but it felt better now. Resident had no issues performing cares on himself, transferring in and out of bed or self-propelling wheelchair in the facility. His ROM was WNL and his ADLs were at baseline. No recent decline noted. Resident denied concerns at this time.On 4/22/2026 at 9:08 AM with facility staff present, observed Resident #5 had 2 packets of his oxycodone 10mg tablets, present in the medication cart. The medication cards did not appear to have been tampered with. The pill present was pink in color and scored down the center.On 4/22/2026 at 1:00 PM Resident #5 denied having concerns about how his pain is being managed.The facility provided a document titled 5-Day Investigation Summary:Timeline-Incident was reported to the Director of Nursing (DON) by Staff A Registered Nurse (RN) on 3/4/2026 at 6:21 AM. The Administrator was contacted on 3/4/2026 at 6:27 AM.On March 4, 2026 at 6:21 AM Staff A contacted the DON to report a suspected narcotic discrepancy identified during the shift change narcotic count. Staff A stated Staff B Agency RN questioned the appearance of Resident #1's oxycodone 5mg medications while completing the controlled substance count on the [NAME] (300) medication cart with the night nurse.During the count, Staff B observed that the #59 tablet with the blister card appeared to be secured with regular medical tape, which prompted further examination. Upon closer inspection of the medication card, both nurses noted that the back of blister pack appeared to have been tampered with. The tablet located in position in #59 appeared consistent with oxycodone 5mg, however the remaining tablets in the card displayed different physical characteristics and appearance than the expected medication.Further examination revealed that each blister cavity on the back of the card had been covered with a small piece of paper tape. Upon removal and inspection, it appeared that all tablets except #59 had been replaced with a different medication. Staff A immediately took photographs of the front and back of the medication card, ensuring that no resident identifying information included. At the same time, the nurses reviewed available drug identification resources and determined that the tablets in the remaining cavities appeared consistent with loratadine (antihistamine).Following this discovery, the nursing staff initiated a review and recount of all narcotic cards located on the medication cart to determine whether additional discrepancies were present. During this review, staff identified additional oxycodone 5mg and 10mg medication cards that appeared to have been tampered with in a similar manner, with the prescribed medication replaced by what appeared to be loratadine tablets.At the time five oxycodone 5mg medication cards were identified as potentially tampered with. All affected medication cards and corresponding narcotic documentation were immediately removed from the medication cart and secured by nursing leadership pending further investigation. The DON was notified and an internal investigation was initiated.The DON contacted Staff C previous Administrator to report this medication diversion.At 7:30 AM the DON and Staff C arrived at the facility. The DON went to each cart and reexamined/counted cards with Staff A on the East (100) medication cart and Staff B on the [NAME] (300) medication cart. Upon counting with Staff A it was found that Resident #5's oxycodone 10 mg card with tablets that are pink in color was found to be tampered with as well, there appeared to be no oxycodone 10mg present in the card at this time. This medication was replaced with over the counter (OTC) pink Vitamin B-12 round tablets and the card was tampered with exactly like the others; with paper tape precisely placed over each [NAME] in the pack. The DON removed the card and narcotic sheet-gathered the others and went to fully examine all of them with Staff C.Following verification of the narcotic discrepancies by the DON, Staff C and the DON initiated a detailed investigation to determine the timeframe of the diversion and identify staff members who had access to the medication carts during the relevant period.As part of the investigation, nursing leadership reviewed staff schedules, pharmacy delivery records, MAR, narcotic control sheets, and the physical narcotic blister cards associated with the affected residents. This review was conducted to establish a timeline and determine when the controlled substances may have been removed.Record review indicated that Staff D RN began working independently on the [NAME] (300) medication cart on 2/16/2026, after completing three days of orientation with facility nursing staff. Based on pharmacy delivery records and comparison with the MAR, narcotic control sheets, and the condition of the blister cards, findings suggest that the narcotic diversion may have begun shortly after the nurse began working independently on that medication cart.Physical examination of the affected blistered cards revealed that the narcotic tablets had been removed and replaced with an OTC medication, later identified as loratadine. The blister cavities appeared to have been resealed with paper tape placed on the back of the card, making the blister packs appear intact during routine counts.For example, Resident #5's oxycodone 10mg prescription was delivered to the facility during the night shift on 2/16/2026. Documentation shows that Staff D was assigned to the [NAME] (300) medication cart (where Resident #5's medications were located) independently on 2/17/2026. Upon review of the physical blister card for this medication, tape was observed covering each cavity on the back of the card, consistent with the tampering identified in other affected medication cards. Based on these findings, the timeframe for the suspected diversion is believed to have begun on or around 2/17/2026.Additional residents assigned to the [NAME] (300) medication cart whose medications were identified as tampered with include Resident #1 and Resident #3, both of whom had oxycodone 5mg tablets replaced with loratadine within their medication blister packs.On 3/2/2026 due to a temporary reduction in facility census, Staff C and the DON adjusted nursing staffing assignment, resulting in one nurse covering both medication carts after 10:00 AM. On that date Staff D began her shift at 6:00 AM on the [NAME] (300) medication cart, while Staff A began the morning medication pass on the East (100) medication cart from 6:00 AM until approximately 10:00 AM. At approximately 10:00 AM both nurses completed and verified narcotic counts on both medication carts. Following this count, Staff D was assigned responsibility for both medication carts and was provided both sets of medication cart keys from approximately 10:00 AM until 6:00 PM.Review of narcotic blister cards for Resident #2 and Resident #4 revealed similar signs of tampering, including paper tape applied to the back of the blister cavities, with the prescribed oxycodone tablets replaced with loratadine. Both residents receive scheduled oxycodone multiple times per day, and the physical condition of the blister cards suggests that the medication replacement may have occurred during this timeframe.The following information was documented in a medication diversion matrix:Resident #1 had 1 medication card of oxycodone 5mg, with 59 missing/replaced with another drug;Resident #2 had 2 medication cards of oxycodone 5mg, with 70 missing/replaced with another drug;Resident #3 had 1 medication card of oxycodone 5mg, with 11 missing/replaced with another drug;Resident #4 had 1 medication card of oxycodone 5mg, with 55 missing/replaced with another drug;Resident #5 had 2 medication cards of oxycodone 10mg, with 84 missing/replaced with another drug;A total of 7 cards affected and a total of 279 narcotic tablets missing.Investigation Conclusion:Following the facility's review of pharmacy delivery records, MARS, narcotic control sheets, staffing schedules, and the physical condition of the affected narcotic blister cards, the investigation identified Staff D as the staff member with consistent access to the medication carts during the timeframe in which the narcotic discrepancies occurred. Based on the timeline of pharmacy deliveries and staff assignments, Staff D was determined to have had access to the affected narcotic supplies during the period when the medications were believed to have been removed.The facility worked in coordination with the county sheriff's department during the course of the investigation. On 3/6/2026 at approximately 2:59 PM, law enforcement personnel met with facility leadership in person and reported that Staff D admitted to removing oxycodone medications from the facility and from the affected residents' narcotic supplies.The facility provided the following staff statements:Staff A documented she arrived to the facility to start her shift on 3/4/2026 at 6:00 AM. She received report on the 100/200 cart on residents. It was reported that Resident #2 was complaining more about unmanaged pain, this nurse took note. Narcotics were counted at this time. The numbers in the narcotic book matched the number of pills in each card and each card was accounted for. The overnight nurse then gave report to Staff B on the 200/300 cart. As they counted narcotics, Staff A went to the kitchen to fill her water pitcher and heard Staff B calling her name. She came out of the kitchen and Staff B told her a pill was taped back in to the card and is different from the rest of the pills in the card. Staff A took a photo of the front and back of the card to notify the DON. Upon further investigation of the medication, the pill taped back into the card was an oxycodone and the rest of the pill were loratadine based off the number and letter combo on the pill. It was then noticed by a nurse that the back of the card had a small piece of white paper tape on each pill pouch. The DON was called and notified at 6:21 AM that oxycodone 5mg tablets were missing. The DON directed Staff A to recheck all narcotic cards on both carts. Upon rechecking the backs of all narcotic cards, it was noticed that all cards with full pills of oxycodone were replaced with loratadine and taped in. The DON was notified of this as well at 6:32 AM. All of these cards were removed from cards with count sheets and taken to the DON office. Count reverified with DON at 8:15 AM. Staff A additionally documented it had been noticed over the last couple of days that Staff D had not been seen for roughly 20 minutes but then would come out of the medication room. She did not inquire what she was doing. Staff A also indicated she would go to the nurse's station commonly and Staff D would not be there. Staff A signed and dated her statement on 3/4/2026 at 10:00 AM and 12:50 PM.Staff B documented on the morning of 3/4/2026 as she was counting narcotics during shift change per norm, she notified a pill had been taped back into a slot. She then analyzed it to make sure it was the same one as all the other ones in the card but discovered it was different. She then showed it to the overnight nurse who she was counting with. She then called Staff A over to verify. Staff A took a picture of the card then proceeded to look up the pill that had been taped back into the slot. It was oxycodone 5mg at which was confusing. They then proceeded to look up the other pills on the card which came up as loratadine 10mg. The overnight nurse then pointed out that the card looked as though it had been taped up. When the card was turned around, to our surprise, every slot had been meticulously opened and taped back together. Staff A then proceeded to call the DON to make her aware of the situation at which point Staff B started to check all the narcotic cards and noticed another card with the same pattern of behavior. Staff B gave the cards to Staff A as she was on the phone with the DON. Once off the phone, Staff A then proceeded to check her medication cart and also found some cards with the same pattern. All cards had pictures taken by Staff A and were pulled from the medication carts. When the DON arrived to the facility, they proceeded to count check the carts and two more cards were found that had been tampered with. The DON proceeded to remove the cards from the cart along with their count sheets. Staff B signed her statement.The County Sheriff's Office provided a case report that included the investigator's narrative: on 3/4/2026 at about 3:00 PM we arrived at Staff D's apartment and made contact with her at the front door. The Sergeant told her that he had taken a theft report at the facility regarding the pills that had been taken off of the pill cart. He told her a large amount of oxycodone pills were taken recently and since she just got off two long shifts at the nursing home we wanted to speak with her. We told her that she was the first person we had made contact with so far other than the reporting staff. Staff D stated that she had absolutely no idea as to what could have happened to the pills. She was asked if she could think of anyone that would do this and she stated not anyone that works for the facility but perhaps one of the temporary agency employees could have done it. Staff D said that she did just work the last two shift of 6:00 AM to 10:00 PM and didn't notice anything suspicious or anyone acting suspicious. The Sergeant asked her if she was responsible for taking the medication, Staff D said absolutely not and that she would never do that. We continued to talk to her about who else could have had access to the pills and how the signing out of medication works and she continued to deny involvement with taking or tampering with the pill carts. Staff D advised that what they do to count medications is that the outgoing nurse and the oncoming nurse both go through the medication cart, count medications and document it on a handwritten log. Staff D said that the pills are counted in the blister packs and not taken out or off the medication cart when doing this. She said they just basically just peel back the stack and count the packs on the bottom as full and just visually look at what ones are missing on the top. Essentially this would keep anyone from looking at the back of the packages or really inspecting the packages. She claimed that there are probably around 10 people that would have access to the key for the medication cart while they are working. She stated that only one person at a time would have the key though. We were unable to locate Staff D at her apartment until 3/6/2026. Before we could get together to talk with her the Sergeant saw Staff D driving was able to make a traffic stop. The investigator arrived on location and met with the Sergeant. He was talking with Staff D in front of his cruiser and told me that his stop was done and she was just waiting for a ride to come pick her up. I walked up to Staff D and told her that she was free to go and I would like to speak with her a little bit more about the pill thing. If she didn't want to talk to me she didn't have to if she didn't want to. I asked if she wanted to speak with me in her car or mine or stand outside; asked her how she wanted to do it. She said I don't care so I asked if she wanted to sit in my car. She said she did have a ride coming and walked with me back to my car where she sat in the front seat. I told Staff D that when we came to her house the other day we talked to her early on and didn't really know much about this incident yet. I told her that that information was new and since then it's been pretty clear that she was with the pills alone. Other people at the nursing home have given statements, time lines and what people have seen, and everything kept coming back to her as the one responsible for taking the pills. I told her that it wasn't really a matter of whether she took the pills as it was clear that she did take them as this behavior has been happening for a couple years. I told her that I was assuming she was consuming the pills and had a bit of an addiction to them. Staff D then said I did. I told her I think this is being carried on or she is selling them which either way is not great but I was more concerned she has a serious issue and that is why these pills keep coming up missing. I told her that we already know she did this and wanted to know where the pills are and what her thought process was during this. Staff D then said they are disposed of; she said her family already did that. I asked her when the pills were taken and if it was over the course of several days or all at once. Staff D said that it was over the course of a period of time. I told her that they were recently noticed and asked if pills were taken before this or recently. She said that the pills were swapped out prior to that. I asked Staff D if she brought the replacement pills with her or if they were already there. She said that they were already on site. I asked her if she knew how many pills were taken out of the blister packets and she stated a hundred or more. I asked if she still had them and she said that she flushed them all down the toilet. I asked her if she has ever done this before and she nodded her head no. She said she broke her foot recently and was in a lot of pain. She said her prescriptions were the same as what pills were taken from the nursing home; oxycodone. Staff D stated that she brought home the pills over the course of like two months but never sold any of them. I asked her how the packets were opened. She said that the blister was punctured, and I asked her if it was sliced with a knife and she said yeah. I then asked if she put little pieces of tape over them and she nodded yes.On 4/21/2026 at 11:10 AM the responding Sergeant with the County Sheriff's office stated once he got the call about diversion, he went to the facility and got the gest of what had taken place. The DON showed him the medication cards, sign out sheets, and a possible suspect but did not have supporting evidence. He reached out to the investigator and spoke to him a bit and went to Staff D's apartment to see what they could get from her. During their initial interview they did not get anything out of her but they also did not have evidence to suspect her. Fast forward a couple days, they did a follow up with the DON. She had received statements from nursing staff that gave them a little bit more leverage against Staff D. The Sergeant later performed a traffic stop with Staff D. Once the Sergeant completed his traffic stop, the Investigator then questioned Staff D. He stated long story short, he asked her about taking the pills and if she was addicted to them or selling them. Staff D told him she was addicted to them and started tampering with the packets and taking the medications a couple of months ago. She admitted to having an addiction problem because of an ankle injury.On 4/21/2026 at 12:49 PM Staff B stated she trained Staff D when she started at the facility and did not notice anything odd during that time. On the day she noticed the discrepancies, she was doing her narcotic counts with the over night nurse and noticed the back of the medication packet was opened a little bit. She could see it through the front of the card. She looked at the entire card to make sure all were the same but the numbers were different from the pill that was located in the opened blister. She called Staff A over to have her verify with her. Staff A noticed the pill was different from the others too. The other pills in the medication card were loratadine. When they turned the card over, each blister had been taped on the far-right side. Once they noticed this, they went through the entire medication cart and the second medication cart. They noticed other medication cards were the same way. She could not recall how many medication cards were tampered with. The other medication cards they found to be tampered with were also replaced with medications that looked similar to the prescribed medication. The DON was notified of their initial findings and again they learned there were more medications cards that had been tampered with. They pulled all of those cards out of the medication carts so Staff A could take pictures of them. Staff B believed Staff D had worked the day prior to discovering this issue. On 4/22/2026 at 9:08 AM Staff B obtained a bottle of Vitamin B-12 1000 micrograms (mcg) and removed a pill from the bottle. The pill was circular shaped, a lighter color of pink than Resident #5's oxycodone pills that were present in his medication card. The Vitamin B-12 pill did not have a score down the middle.On 4/22/2026 at 10:48 Staff A stated she was on the 100 hall cart and Staff B was on the 300 hall cart. While Staff B received report from the overnight nurse, Staff B called her name. She reported that the pills were different in Resident #5's oxycodone pill packet. The pill was taped in the packet and looked different from the other pills. They got online and looked up the numbers that were on the pills; it was oxycodone and that's what the medication card label read as well. But they noticed the other pills looked different from this one. They turned the card over and noticed the back had white paper tape on each individual blister. They turned the card back over and looked up the numbers on the other pills and found they all were Vitamin B-12. They found another medication card that had tape on the back of it on each individual blister. Those oxycodone pills had been replaced with loratadine. Staff A removed the cards and went to the medication room and called the DON. She let her know all of Resident #5's oxycodone from his medication cards were gone. The DON asked her to go to the other cart to inspect those medications cards as well. When they did this, they noticed every medication card that was to have oxycodone in it, did not have oxycodone in them. The pills had been replaced with loratadine. It looked like the person took their fingernail to the curve at the back of the blister and removed the medication. She called the DON again to let her know what they found. She told Staff A to lock up all the medication cards with narcotic sheets until she arrives at the facility. Staff A stated Staff D always wanted to be on the 300 cart never on the 100 cart. The 300 cart had more narcotics on it.On 4/22/2026 at 1:04 PM the DON stated on 3/4/2026 around 5:45-5:50 AM she received a call from Staff A and found a huge narcotic discrepancy. During narcotic count Staff B noticed Resident #1's oxycodone had one of the blisters taped shut and the pill looked different than the others. They looked up the pill number and it was loratadine same as the other pills in the medication cards. Staff A took pictures of the cards front and back and sent them to her. The DON called Staff A and told her to redo their narcotic count and look for other discrepancies. When they went to the other medication cart they pulled those cards and called her back to tell her that the oxycodone had been taken from the medicati

Based on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to store narcotics to minimize loss when 1 of 3 residents (Resident #1) discontinued narcotic pain medication remained in the medication cart for almost 6 months. This resulted the in pills being misappropriated by a facility staff member. The facility reported a census of 33 residents. Findings include: According to Resident #1's quarterly Minimum Data Set (MDS) assessment tool with a reference date of 2/3/2026, she had a Brief Interview of Mental Status (BIMS) score of 8. A BIMS score of 8 suggested mild cognitive impairment. The MDS documented Resident #1 received a scheduled pain medication regimen, received an as needed (PRN) pain medications or was offered and declined. Resident #1 reported no pain during the MDS assessment. The MDS listed the following diagnoses: Parkinson's disease, renal failure, stroke, depression, atrial fibrillation, fusion of cervical and lumbar spine.A Care Plan Focus Area with a revision date of 12/4/2025 documented Resident #1 had chronic pain and increased risk for injury from decreased function related to a diagnosis of spinal fusion and spondylosis. The Focus Area documented she was had routine pain management. The care plan directed staff to administer scheduled and PRN pain medications as ordered, evaluate the effectiveness of pain interventions/medications.Review of October 2025 Medication Administration Record (MAR) revealed the following order: oxycodone (scheduled II narcotic for severe pain) tablet, 5 milligrams (mg) by mouth every six hours as needed (PRN) related to left femur fracture. This order had a start date of 7/3/2024 and discontinued date of 10/24/2025.Record review revealed the a renew orders form that listed Resident #1's oxycodone 5mg tablet to be discontinued on 10/24/2025. The form documented this was completed.On 4/22/2026 at 1:04 PM the Director of Nursing (DON) was asked how Resident #1's discontinued oxycodone medication card was missed and not pulled out of the medication cart. She believed it got missed due to inconsistency in staffing. The medication should have been destroyed by two licensed nurses. If the medication card was full and not touched it could have been returned to pharmacy.The facility provided a policy titled Controlled Substance Administration & Accountability with a copyright date of 2025. It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure.Policy Explanation and Compliance Guidelines:4. Obtaining/Removing/Destroying Medications:d) Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system.6. Returning Medications:a) Non-stock drugs are returned to the pharmacy when no longer needed for the patient in whose name they were issued as per state or pharmacy regulations. (See also Unused Medication Return Policy.)b) Controlled substances returned to the pharmacy are delivered by a licensed nurse, consultant pharmacist, or pharmacy technician.c) Unused controlled substances may be returned to stock if they are still in the original unopened tamper proof packaging. (See also Unused Medication Return Policy.)d) Two licensed staff must witness return of controlled substances.e) If the package has been opened or the tamper seal removed, it must be destroyed. (See also Destruction of Unused Drugs Policy.)Two licensed staff must witness the disposal of controlled substances.

Based on observations, clinical record review, staff interviews and facility policy review the facility failed to accurately document a skin assessment for 1 of 3 residents (Resident #1) reviewed with a pressure ulcer. The facility also failed to complete proper hand hygiene while completing a treatment to Resident #1's pressure ulcer. The facility reported a census of 35 residents. Findings include:According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 12/11/2025 documented Resident #1 had a Brief of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented he did not reject evaluation or care during the 5-day review period. Resident #1 had impairments to bilateral lower extremities and utilized a wheelchair. Resident #1 was dependent on staff for toilet hygiene, lower body dressing, and chair/bed to chair transfer. He required partial/moderate assistance of staff for rolling left to right. The MDS documented he had a urostomy and was always incontinent of bowel. The MDS documented he did not have a pressure ulcer/injury, was at risk for developing pressure ulcers/injuries and did not have one or more unhealed pressure ulcers/injuries. The following diagnoses was listed for Resident #1: neuromuscular dysfunction for bladder, renal failure, paraplegia, neurogenic bowel, and chronic pain.The Care Plan Focus Area with an initiated date of 12/17/2025 documented Resident #1 had impaired skin integrity and is at risk for edema, skin/tissue color changes, swelling, pain and pressure ulcers related to a diagnosis of paraplegia. Resident #1 had a recurrent stage 4 pressure wound to his left gluteal crease. Staff were instructed to administer treatments as ordered, encourage Resident #1 to shift weight every 2 hours to assist with skin integrity, monitor/document location, size and treatment of skin injury. The Care Plan documented Resident #1 was noncompliant with recommended time frames of being in his wheelchair and removal of the mechanical lift sling while in bed. Resident #1 had an alternating pressure reduction mattress to his bed and a cushion on his wheelchair.A Weekly Nursing Skin assessment dated [DATE] documented Resident #1 did not have any alterations in skin integrity. A small blister was charted yesterday, no new skin issues noted.A Weekly Non-Pressure Wound assessment dated [DATE] at 2:09 PM documented a ruptured blister on his inner aspect of his upper right hip. The assessment documented only 1 of this type was present. The document did not have additional wounds listed. The documented was completed by Staff A previous Assistant Director of Nursing (ADON)/Wound Nurse.Record review revealed the following Progress Note was documented on 1/9/2026 at 11:21 PM: this nurse went in to completed a neurogenic bowel treatment and observed a skin impairment to his right gluteal fold. Resident #1 had an open area with predominantly granulated tissue, borders defined, periwound skin with peeling/excoriation, small amount serosanguineous drainage with purulent drainage noted. There was no foul odor. Wound measured as 4.5 (centimeters) cm x 5.0 cm x 0.2 cm to inner right gluteal fold. This nurse cleansed wound, packed wound with moistened collagen pad, applied mepilex dressing, reinforced with medipore tape and signed and dated dressing.On 2/12/2026 at 10:35 AM Staff A RN and Staff C Agency RN completed Resident #1's neurogenic bowel treatment and dressing change to his left gluteal fold. They both washed their hands. Staff A came out of the bathroom, put her hair in low ponytail then donned a gown and pair of gloves. Staff A scratched her scalp, picked up a packet of adult wipes that fell on the floor. She then picked up the trash can that was by his dresser and moved it closer to his bed. Staff A and Staff C completed his neurogenic bowel treatment with stool present. They both doffed their gloves and donned a new pair of gloves. Staff failed to complete hand hygiene prior to donning a new pair of gloves. Staff A removed the old dressing to his left gluteal fold, doffed her gloves and donned a new pair without completing hand hygiene. She cleansed the area with saline with her right hand, making his skin taunt with her left hand, doffed her gloves and donned a new pair without completing hand hygiene. Staff A applied no skin barrier around the area, doffed her gloves and donned a new pair without completing hand hygiene. Staff A completed the treatment, doffed her gloves and donned a new pair without completing hand hygiene. She placed a gauze and Tegaderm dated and initialed. After she repositioned Resident #1 in bed, she doffed her gown and gloves then washed her hands. On 2/11/2026 at 11:20 AM Staff A stated the weekly nursing skin assessments are to have any new wounds documented on it, as well as existing wounds and treatments. These were to be done by the nurses working on the floor that day. When asked how the weekly non-pressure wound assessments are completed, she stated with the new company that took over they had not trained them on what was to be done. They were just expected to know things. There was no training or communication about these assessments. When asked how skin assessments are to be completed, she stated their previous policies said a head-to-toe assessment had to be completed. At least that's how she was trained. When asked about the weekly non-pressure assessment that she completed on 1/9/2026 at 2:09 PM she stated she actually completed that on the 7th but did not change the date. She just saw the blister on his hip. He had an old wound on his fold and was healed. When residents have healed wounds, they are to be followed for 2-3 weeks. When she did her assessments, she would only look at the areas of concern. If a new skin area were to develop the nurse would communicate that after they complete their assessment. She would focus on wounds that are known about and present.On 2/11/2026 at 11:27 AM Staff D Registered Nurse (RN)/Wound Nurse) stated the weekly nursing skin assessments are completed weekly by the nurse working on the floor. They are to look and document all old skin issues and anything new. A weekly non-pressure wound assessment is to be completed by the wound nurse. They are to look at the current and new wounds. Essentially, they are to look at all the wounds that is on the resident as that is part of their wound tracking. When asked how these assessments are to be completed, she stated it's a head-to-toe assessment, they should be removing their clothes. She saw the resident's wound on 1/10/2026 prior to his family taking him to the emergency room (ER). She stated with his condition, you had to move his skin around because he had a lot of loose skin. There was scarred tissue surrounding the wound and the center was opened with beefy red tissue exposed. She added there was some drainage noted.On 2/12/2026 at 10:06 AM the Director of Nursing (DON) stated the weekly nursing skin assessments should be done after looking at everything. With the new company taking over they have changed things but have done education on those changes. She stated with Resident #1 that spot on his left gluteal fold should have been noticed on the weekly skin assessment. These assessments are usually done on their bath days so every area is assessed. The pressure and non-pressure assessments are to be completed by the wound nurse, since the new company took over in November. They are to round on residents once a week, look at the wound(s) and obtain measurements. When Staff A completed the assessment that was documented on 1/9/2026 she should have looked at the healed areas as well. Her personally opinion any resident that is a quadriplegic or paraplegic we should be looking at their bottom. She added she could see how that spot got missed because you have to move the skin up to visualize it. During a follow up assessment on 11:36 AM she was asked when hand hygiene should be completed during pressure ulcer/wound treatments she stated prior to entering the room, after getting the resident set up and ready for the treatment, after setting up the treatment supplies, after removing the old dressing, once the treatment is completed, after applying a new adult brief and once she was all done, she would wash her hands, basically between glove changes. The DON stated she cares hand sanitizer in her pocket so she probably over does it with hand hygiene.The facility provided a document titled Skin Assessment with an implemented date of 12/5/2025. The documented indicated it is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.Policy Explanation and Compliance Guidelines:1.A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days and weekly thereafter.7.Documentation of skin assessment:b) document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.)c) document type of woundd) describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain).f) document other information as indicated or appropriate.The facility provided a document titled Hand Hygiene with an implemented date of 12/5/2025. The document indicated all staff will perform proper hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.

Based on Electronic Health Record (EHR) review, observation, resident interviews, and staff interviews the facility failed to provide adequate response from nursing staff to assure residents safety by not responding to call lights in a timely manner for 2 of 12 residents reviewed (Resident #6 and #16). The facility reported a census of 32 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #16 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented Resident #16 was always incontinent of urine and bowels. On 1/5/26 at 3:05 PM Resident #16 stated it frequently takes longer than 15 minutes to answer the call light. Resident #16 stated staff not answering call lights within 15 minutes happened frequently on both shifts equally. 2. During continuous observation on 1/5/26 at 12:46 PM until 1:02 PM (16 minutes) a call light was observed to be unanswered in the East hallway. Review of Resident #6's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnoses of renal insufficiency, neurogenic bladder (a condition where nerve damage from issues in the brain, spinal cord, or peripheral nerves disrupts normal bladder control, causing problems like incontinence, retention, or incomplete emptying due to the bladder and sphincter muscles not working together properly), and paraplegia (paralysis affecting the lower half of the body). Interview on 1/5/26 at 2:04 PM with Resident #6 revealed he had been waiting to lay down, and had his call light on. Resident #6 further revealed that it had been around 20 minutes at this time, and he was watching his watch. Resident #6 then revealed that this happens from time to time. Interview 1/7/26 at 8:21 AM with the Director of Nursing (DON) revealed her expectation is for call lights to be answered within a timely manner of 15 minutes or less. 3. During a resident council meeting held 1/8/26 at 10:46 AM with residents #12, #13, #16, #28, and #37 revealed call lights can take longer than 15 minutes at most shift changes. Review of a facility provided policy titled, Call Lights: Accessibility and Timely Response with an implementation date of 11/9/25 revealed: a. All staff members who see or hear an activated call light are responsible for responding.

Based on clinical record review, resident interview, staff interviews, and policy review the facility failed to provide range of motion (ROM) services to a resident with limited ROM to prevent further decrease in range of motion or development of contractures for 1 of 14 residents reviewed (Resident #8). The facility reported a census of 32.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented diagnoses of quadriplegia, generalized muscle weakness and need for assistance with personal care. On 1/5/26 at 1:00 PM Resident #8 stated he does not have a restorative program or see therapy but would like to participate in therapy. Review of Resident #8's EHR documented no restorative, occupational, or physical therapy plans.On 1/7/26 at 2:16 PM Staff I, Assistant Director of Nursing (ADO) stated there is no restorative program at the facility. On 1/7/26 at 2:19 PM Staff L, Director of Rehab stated the facility had a restorative program for a little bit. Staff L explained restorative programs were developed for some residents but then restorative was stopped. Staff L acknowledged the restorative program was around during 7/25. Staff L stated there were residents currently at the facility that would benefit from being on a restorative program. Staff L stated Resident #8 could benefit from a restorative program. Staff L stated Resident #19 could use some more cuing to come down to use the gym while at the facility. Staff L stated Resident #21 would benefit from a restorative program. Staff L explained Resident #20 could use a restorative program because he really wants to do more but he only gets 12 visits at a time when is on therapy. Staff L stated anyone who was currently at the facility that was on a restorative program earlier in the year could benefit from a restorative program currently. Staff L revealed previous restorative programs for Residents #6, #7, #8, #9, #19, #20, #21, #25 #27, #34, #36, #37, #38 and #40 who currently reside at the facility. Staff L stated all of those residents would benefit from a restorative program. Staff L explained she could not think of any resident that had decreased function without a restorative program. Staff L stated if there was decreased function it would be noticed on her quarterly evaluation and that resident would then be picked up by therapy.On 1/7/26 at 4:30 PM the DON stated she felt there were some residents that would benefit from a restorative program at the facility. The DON stated there was not a direct Registered Nurse (RN) to cover the restorative program with the previous owners of the facility. The DON stated she would like to implement a restorative program at the facility. The DON stated there was restorative in July but there was no training with the restorative aide that was providing the restorative to the residents. The DON explained within the last 8 weeks there had been so many changes there had not been the right time to discuss the restorative department. The DON stated there was not enough staff to assign a staff as the restorative aide at that current time. Review of Policy implemented 11/8/25 titled, Restorative Nursing Programs documented It was the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to maintaining proper positioning and body alignment, encouraging and assisting residents, as needed, in turning and position changes, encouraging residents to remain active and assisting with any exercises according to the plan of care, Promoting independence in ADLs, assisting residents with range of motion exercises, performing passive range of motion for residents who lack active range of motion ability, promoting continence with various toileting and/or bowel and bladder training activities. All residents will receive maintenance nursing services as described above, as needed, by certified nursing assistants. The Restorative Nurse and restorative aides receive additional training on restorative nursing program activities upon hire and as needed. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include passive or active range of motion, splint or brace assistance, bed mobility training, training and skill practice in transfers or walking, training and skill practice in dressing and/or grooming. Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy.

Based on electronic health record (EHR) review, resident interviews, observations, policy review, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of a resident and/or resident representative to allow developing the care plan and making decisions about his or her care and follow existing care plan interventions to 5 of 12 residents reviewed (Resident #2, #6, #24, #31 and #38). The facility reported a census of 32 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. On 1/5/26 at 2:05 PM Resident #2 stated the facility does not invite him to participate in care conferences and he would if he was asked. On 1/6/26 at 12:22 PM Staff E, Social Services Supervisor stated Resident #2's POA is on vacation and will schedule the care conference for January 21st. Staff E stated care conferences are supposed to be completed quarterly. Staff E stated she had a care conference book and Resident #2 might have got missed. Staff E acknowledged Resident #2's care conference was missed in November. Staff E acknowledged care conferences were expected to be completed quarterly and Resident #2's last care conference was completed 7/17/25. Staff E explained Resident #2 had a care conference prior to that on 4/4/25. On 1/6/26 at 12:37 PM the DON stated the facility's expectation was care conferences would be completed quarterly. The DON acknowledged Resident #2's care conference was last completed on 7/17/25. 2. The MDS dated [DATE] documented Resident #24 had a BIMS of 14 indicating no cognitive impairment. On 1/5/26 at 12:51 PM Resident #24 stated he had not been invited to any care conferences during his time at the facility. On 1/6/26 at 12:22 PM Staff E stated Resident #24's last care conference was completed 9/3/25. Staff E acknowledged Resident #24's care conference was missed in November. Staff E stated she can complete a make up care conference as she does not currently have him scheduled this month. Staff E stated she was not sure why the care conference was missed. Staff E stated she would complete an audit to ensure all residents were in compliance. 3. The MDS dated [DATE] documented Resident #38 had a BIMS of 6 indicating severe cognitive impairment. Observation on 1/6/26 at 2:10 PM revealed Staff D, Activities Director walking with residents outside to smoke. Staff D assisted all residents to apply smoking aprons. Staff D lit the residents cigarettes with a lighter. Resident #38 was not present at the time. Staff D spoke to another staff member and asked them to ask Resident #38 if he wanted to come outside to smoke. Resident #38 walked outside to smoke at 2:11 PM past the DON who was holding the door open for him. Resident #38 sat down outside with a smoking apron on and smoked. Resident #38 got up to walk back inside. Staff D noticed Resident #38 was not walking with a walker. Staff D put her right elbow out for Resident #38 to take and assisted Resident #38 to the entrance to the facility. Resident #38 walked from the entrance to his room by himself without a 4 wheeled walker. Review of Resident #38's EHR titled, Care Plan documented an intervention for ambulation for use of a four-wheeled walker initiated 1/5/26. On 1/8/26 at 12:42 PM Resident #38 stated sometimes he forgets his walker and the staff remind him to use his walker. Resident #38 explained when he forgot his walker staff brought the walker to him. Resident #38 stated he was used to walking without a walker and forgets at times. Resident #38 stated he does not mind using the walker but forgets to use it because has not had the walker long. On 1/6/26 at 2:37 PM Staff D stated she does not get the opportunity to take the residents outside to smoke very often. Staff D stated it is required that all residents wear a smoking apron outside while smoking. Staff D acknowledged she had access to the residents' care plans. Staff D stated normally Resident #38 should be using a walker. Staff D stated she did not notice till Resident #38 stood up to go back inside. Staff D stated Resident #38 had used the walker for a couple weeks now. Staff D stated normally Resident #38 has the walker all the time. Staff D acknowledged that she walked with Resident #38 back up to the facility entrance. Staff D explained she should have asked Resident #38 to remain seated and brought the walker to him. Staff D acknowledged the care plan documented Resident #38 required a 4 wheeled walker when ambulating. On 1/6/26 at 3:07 PM the DON stated after she thought about the ambulation of Resident #38 she noticed he was not using a walker when he went outside to smoke. The DON stated her expectation was that the staff would have gone inside and brought the walker back out to Resident #38 to ambulate back to the room. The DON stated her expectation was staff would offer Resident #38 the use of a walker when he forgot. 4. Review of Resident #6's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed Resident #6 utilized a urostomy (a surgical diversion that creates an opening (stoma) in the abdomen to allow urine to exit the body into an external pouch). The MDS then revealed diagnoses of renal insufficiency, neurogenic bladder (a condition where nerve damage from issues in the brain, spinal cord, or peripheral nerves disrupts normal bladder control, causing problems like incontinence, retention, or incomplete emptying due to the bladder and sphincter muscles not working together properly), and paraplegia (paralysis affecting the lower half of the body). Interview on 1/5/26 at 2:07 PM with Resident #6 revealed he has had a catheter for a while now. Resident #6 then revealed that it is a urostomy that the catheter drainage bag is attached too. Review of Resident #6's Care Plan with a revision date of 12/17/25 revealed nursing staff are to observe/record/report to the Medical Doctor for signs and symptoms of a urinary tract infection including no output of urine. Review of Resident #6's EHR revealed no documentation of urinary outputs to review. 5. Review of Resident #31's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed that Resident #31 utilized a nephrostomy tube (a small tube inserted through the skin in the lower back directly into the kidney to drain urine when there's a blockage or injury, diverting it to an external bag to relieve pain, prevent infection, and protect kidney function) as well as a urostomy. The MDS then revealed diagnoses of non-traumatic spinal cord dysfunction, renal insufficiency, neurogenic bladder, and paraplegia. Interview on 1/5/26 at 1:38 PM with Resident #31 revealed that he had nephrostomy tubes, and that the tubes were just changed by the physician. Review of Resident #31's Care Plan with a revision date of 12/18/25 revealed nursing staff are to observe/record/report to the Medical Doctor for signs and symptoms of a urinary tract infection including no output of urine. Review of Resident #6's EHR revealed no documentation of urinary outputs to review. Interview on 1/7/26 at 2:55 PM with Staff A Licensed Practical Nurse (LPN) revealed that staff do not record urine outputs in the computer system, and she tries to make sure staff at least tell her what the urine outputs are. Staff further revealed that she would need to know if she needs to notify the physician for low outputs or changes in urination. Staff A then restated that staff do not chart this in the computer system. Interview 1/07/2026 at 3:17 PM with the Assistant Director of Nursing (ADON) revealed that catheters should be being monitored for output. Interview at 1/7/26 at 3:26 PM with the Director of Nursing (DON) revealed that catheters/urostomies should be monitored, and drainage should be reported to the nurses from the Certified Nursing Assistants (CNAS). The DON then revealed that her expectation would be for outputs to be recorded. Review of a facility provided policy titled, Comprehensive Care Plans with an implementation date of 11/3/25 revealed: a. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress.

Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean, comfortable and homelike environment free of possible hazards. The facility reported a census of 32 residents. Findings include: On 1/05/2026 at 10:50 am to 11:00 AM observation of the facilities main dining room, activities area, hallways surrounding the nurses station revealed several mismatching paint patterns on the walls after drywall repairs. Door frames between 3 main residential hallways and most of the residential rooms displayed chipped paint revealing varies color patterns and sharp edges from the excessive dents, scuffs, and scratches. Many doors with kickplates attached to the lower half corners revealed corners were no longer adhering to the doors, revealing broken and sharp edges. Near the nurses desk, a hallway leading to the dining room revealed on the right side of the entrance a wall edge molding pulled away from the corner, hanging loosely and had a small black nail attached to it. During an interview with the Maintenance Director on 1/06/2026 at 3:00 pm he stated he has been in the position for over a year and had completed some drywall repairs and was aware of the mismatching paint patches throughout the facility. He stated that he was waiting for the new color schemes that were in the process of being decided by the new management company that took over a few months ago. He further stated that some of those drywall repairs were completed last summer and he had enough supplies/budget to match the paint to the current pattern but he didn't want to paint twice. When asked about the wall edge molding by the dining room, he stated it's been there for about a month and a resident picked at it and pulled it. He stated that over half of the facility's surfaces need some type of superficial repairs and that it didn't look dignifying to residents. On 1/7/26 at 10:50 am an interview with the Administrator revealed a new company acquired the facility a few months ago and they inherited the current conditions of the facility but he stated his expectations were things should be fixed in a reasonable amount of time. On 1/7/2026 at 4:37 pm in an interview Staff C, CNA, stated the facility's environment was in need of some paint and had spots on walls where colors didn't match. She stated other staff and residents made comments about it too. Several black round chairs in the dining room that staff set on while providing feeding assistance to residents showed extensive signs of wear with peeling leather and needed to be replaced. A review of the facility provided policy titled Safe and Homelike Environment undated, documented the following:In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment.Orderly is defined as an uncluttered physical environment that is neat and well-kept.

Based on observation, record review, staff interview, Electronic Health Record (EHR) review, resident interviews and policy review the facility failed to provide quality nursing care by not completing assessments related to symptomatic positive influenza A diagnosis and symptomatic respiratory illness or having interventions in place related to the illness for 4 of 4 resident reviewed (Resident #8, #9, #28 and #38). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented diagnoses of quadriplegia, generalized muscle weakness and need for assistance with personal care. On 1/5/26 at 1:00 PM Resident #8 stated he had a cough for the last couple days but was getting over it and also some loose stools. Resident #8 stated the facility had not asked him to isolate in his room or wear a mask. Resident #8 stated the illness had been going around to all the residents at the facility. Review of Resident #8's (Medication Administration Records - Treatment Administration Records) MAR-TAR documented a physician's order that started 1/4/26 for guaifenesin oral liquid 100mg/5mL to give 10mL by mouth every 8 hours as needed for cough and an order that started 1/5/26 for Mucinex oral tablet extended release 12 hour 600mg to give 1 tablet by mouth every 12 hours as needed for congestion for 10 days. Review of Resident #8's EHR titled, Progress Notes documented no respiratory assessment and no lung sounds. Review of Resident #8's EHR titled, Assessments documented no respiratory assessment or infection screen evaluation. 2. The MDS dated [DATE] for Resident #28 documented a BIMS score of 13 indicating no cognitive impairment. On 1/5/26 at 3:57 PM Resident #28 stated she had started coughing on 1/1/26. Resident #28 stated the facility did not test her but just assumed she had the flu like everyone else. Resident #28 explained she remained in her room till this morning. Resident #28 stated the facility staff did not ask her to wear a mask but she wanted to because she was still coughing. Review of Resident #28's EHR titled, MAR-TAR documented a physician's order that started 1/5/26 for benzonatate oral capsule 100mg to give one capsule by mouth 3 times a day for cough for 10 days. On 1/5/26 at 4:09 PM an observation of Resident #28's room revealed no Transmission Based Precautions (TBP), Enhanced Barrier Precautions (EBP) signs or Personal Protective Equipment (PPE) present outside of room or inside of room. No PPE present or TBP sign present inside of the room. On 1/5/26 at 3:57 PM an observation of Resident #28 wearing a mask at the dining table with a cough present during the interview. On 1/6/26 at 12:20 PM an observation of Resident #28 during the lunch meal without a mask with cough present throughout the lunch meal. Review of Resident #28's EHR titled, Progress Notes documented no respiratory assessment and no lung sounds. Review of Resident #28's EHR titled, Assessments documented no respiratory assessment or infection screen evaluation. 3. The Minimum Data Set (MDS) dated [DATE] documented Resident #38 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. On 1/5/26 at 2:33 PM Resident #38 observed coughing in his bedroom during the interview. Resident #38 stated he had been sick recently but was getting better. Resident #38 stated staff to not wear masks or gowns in his room when working with him. Review of document dated 1/2/26 titled, Emergency Department Patient Summary documented Resident #38 had a respiratory panel flu-RSV-Covid collected with discharge instructions influenza is an infection that affects your respiratory tract. Influenza is contagious and spreads easily from person to person. Review of Resident #38's EHR titled, MAR-TAR documented a physician's order that started 1/2/26 for benzonatate oral capsule 100mg to give one capsule by mouth 3 times a day for influenza for 10 days. Review of Resident #38's EHR revealed Resident #38 resided in room [ROOM NUMBER]-A. On 1/5/26 at 4:09 PM an observation of Resident #38's room revealed no TBP signs present outside of room or inside of room. Observation continued to reveal EBP signs outside of the door with PPE available on the back of the door. Signage determined to be for roommate with supra-pubic catheter present. Review of Resident #28's EHR titled, Progress Notes documented no respiratory assessment and no lung sounds. Review of Resident #28's EHR titled, Assessments documented no respiratory assessment or infection screen evaluation. On 1/6/26 at 2:37 PM an observation of Resident #38 smoking revealed Resident #38 had frequent coughing episodes during that activity. Resident #38 sat at the end of the table around other residents who were smoking. Review of document with date printed 1/5/26 titled, CMS 802 Resident Matrix documented no residents in Transmission Based Precautions (TBP). On 1/5/26 at 11:40 AM the Director of Nursing (DON) stated she would double check but currently no resident at the facility was in TBP. On 1/6/26 at 11:30 AM Staff F, Registered Nurse (RN) stated 4 residents went to the hospital this last weekend. Staff F reported the 4 residents were sent out for the same concerns. Hypotension, tachycardia hypoxia, general complaints of weakness. Staff F stated Resident #9 had influenza A, pneumonia, acute kidney injury and septic shock. Staff F said Resident #30 was sent to the hospital for acute hypoxic, respiratory failure, influenza A and bilateral bronchitis. Staff F stated Resident #1 was admitted for influenza A and bilateral bronchitis. Staff F explained the facility does not test for influenza basically but provided symptomatic care. Staff F stated Resident #38 was discovered to have a positive influenza A diagnosis because he was sent out for weakness and tested positive at the hospital. Staff F explained Resident #9 was the first resident that tested positive for influenza A at the facility. Staff F explained Resident #9 asked to be sent to the hospital on an overnight shift. Staff F explained she did not know why, maybe because he did not feel good. Staff F said the hospital did a 4 plex test and Resident #9 tested positive for influenza A. Staff F stated she had been encouraging masks to the staff when going into the residents rooms with any respiratory illness symptoms. Staff F stated Resident #28 was sick and the facility did not test her but obviously she had the flu. Staff F stated she was hoping and praying if the residents were symptomatic there would be assessments being completed. Staff F stated the on call physician was aware influenza was in the building. Staff F stated she would do a focused respiratory assessment every 6 hours to ensure they are not declining more with lung sounds and vitals. Staff F stated with this bout of the influenza the symptoms are mainly weakness and respiratory issues. Staff F stated when Resident #8 tested positive she put EBP signage and PPE outside of the door. Staff F stated she was never told to do so. Staff F stated staff were instructed to put the EBP and PPE away but did not remember who instructed them to do so. On 1/6/26 at 12:11 PM Staff G, RN stated standard precautions required with all resident care. Staff G stated if the resident was coughing he would request the resident to stay in their room. Staff G explained he did not know if there are any residents who currently have influenza. Staff G explained he did not think any residents were tested but were treated as a preventative measure. Staff G said he had cared for Resident #9 and #38 but he was not assessing the two. Staff G stated Resident #28 told him she was not coughing but was just wearing a mask in the hallway. Staff G explained there was no assessment required unless the resident had shortness of breath. Staff G stated he did not see any signs or symptoms of the residents that he cared for that would prompt him to assess lung sounds. On 1/8/26 at 1:03 PM Staff H, Certified Nurse Assistant (CNA) explained Resident #38 had returned from the hospital after a fall positive for influenza A. Staff H explained when Resident #38 returned from the hospital the staff were not required to wear masks or gowns when care was completed. Staff H stated she wore a mask because she had a cough herself. Staff H stated the staff were not required to wear gowns when they worked with Resident #38. Staff H explained staff were not required to wear gowns or a mask in Resident #8, #9, #28, or #38 rooms until after the survey team arrived at the facility. Staff H acknowledged all of these residents had respiratory symptoms prior to the weekend. On 1/7/26 at 1:11 PM the DON stated outbreak status was described as 2 or more confirmed cases of influenza. The DON acknowledged they did not follow the policy for outbreak status. The DON stated there was confusion because of the recent change in ownership and a policy change. The DON explained her expectation was a respiratory assessment with lung sounds and vitals would be completed every shift if the resident had a positive influenza test or any respiratory symptoms. The DON acknowledged the assessments were not completed appropriately for Residents #8, #9, #28, and #38. On 1/7/26 at 1:24 PM Staff I, Licensed Practical Nurse (LPN) / Infection Preventionist (IP) / Assistant Director of Nursing (ADON) stated what should have happened after the one resident tested positive she would recommend isolation and test with PCR and would continue the isolation based on the policy. Staff I explained Resident #9 tested positive for influenza A on the 12/31/25, Resident #38 tested positive for influenza A in the hospital and returned to the facility, Resident #36 was put on Tamiflu through hospice because of symptoms but did not get tested, Resident #8 had symptoms but was not tested, then Resident #1 and #30 tested positive at the hospital, Resident #6 had symptoms 1/5/26 with negative chest x-ray, Resident #36 had symptoms on 1/6/26 but were waiting on the lab results and PCR currently. Staff I stated isolation precautions for droplets were in place now for Residents #8, #9, #28, #30, #34, #36 and #38. Staff I acknowledged droplet precautions with TBP signs were not in place on these residents before 1/7/26. Staff I stated if the facility followed the policy the residents all should have been tested for influenza. Staff I explained vitals and respiratory assessments should have been completed every shift. Staff I stated masking was not mandated to the staff but could encourage the masking. Staff I explained there were signs that would be put up for public knowledge. Staff I explained there should have been 7 days of charting. Staff I stated there should have been charting every shift with vitals and lung sounds. Staff I acknowledged assessments and interventions were not in place and completed appropriately. Staff I acknowledged the local or state public health department should have been notified as well. Staff I explained per the facility's policy 1 positive influenza diagnosis with any other respiratory illnesses among other residents would be considered outbreak status. On 1/7/26 at 1:42 PM Staff J, Medical Director explained any total number of residents greater than 10% would be considered outbreak status. Staff J stated the residents should have orders for Tamiflu or should have been offered. Staff J explained signage would be good outside of the building for public awareness. Staff J stated nursing staff should talk to the physician or the provider to determine if testing is needed. Staff J stated if there was an outbreak determined at the facility he would think everyone should be tested that was symptomatic. On 1/7/26 at 5:06 PM the DON stated she had concerns with differences in policies during the transition of ownership. The DON explained previously when residents displayed symptoms of respiratory symptoms the residents would not be required to wear a mask or stay in their room. The DON stated she was aware of the situation with the influenza A outbreak at the building. The DON acknowledged the outbreak was not handled the appropriate way. The DON explained when Staff I returned from vacation symptoms were tracked and signs were hung. The DON stated she would have expected assessment would have been completed on the residents that were symptomatic. The DON stated the facility's expectation was vitals and assessments every shift for 7 days. The DON explained the assessment would contain a full vitals and listen to the lungs and then a final assessment 24 hours status post. The DON stated the assessment would be found in progress notes. The DON explained the residents who were symptomatic or tested positive for influenza A should have had PPE available in their rooms with TBP signs posted for droplet precautions. 4. The MDS dated [DATE] for Resident #9 documented a BIMS score of 08 indicating moderate cognitive impairment. The MDS listed the following active diagnoses: non-Alzheimer's dementia, seizure disorder/epilepsy, and asthma/COPD. The Electronic Health Record (EHR) Progress notes documented Nurse Note for Resident #9 on 12/5/2025 at 5:51am resident was at the nurses station stating he is not feeling well he has a head cold. Nurse assessed the resident and took vitals and noted they were within normal limits but had audible wheezing and nasal congestion. Resident #9 asked for his inhaler and was given the treatment. The facility did not have documented nursing assessments or interventions between 12/5/25 and 12/12/25. On 12/12/2025 at 9:42 am General Progress Note documented a physician visit and new orders for Guaifenesin 600mg tablets by mouth for 14 days for congestion and upper respiratory infection. The facility did not have documented nursing assessments or interventions between 12/12/25 and 1/1/26. On 1/1/2026 at 1:13 am Progress notes documented a transfer to hospital summary note. Around 2000 the resident called and stated that he was coughing and he was not feeling well. He also requested to go to the hospital because he thought he was having pneumonia. He even called his Power of Attorney (POA) and the POA called the facility. On assessment, he mentioned he was coughing and was not feeling well. There was not signs of shortness of breath (SOB) and wheezing. He was alert and oriented. His blood pressure was very high 217/98, but the rest of the vitals was within the normal limits. About an hour later the Emergency Medical Services (EMS) arrived to transport Resident #9 to the ER. The hospital called the facility and informed them Resident #9 tested positive for Influenza A and will be returning shortly. Progress note on 1/1/2026 at 6:32 am documented Resident #9 returned from the hospital and isolation precautions were initiated, new medications were prescribed for the flu, Tamiflu Oral Capsule 75 MG for Influenza A for 5 Days, and Albuterol Nebulizer 4 times a day for 10 days. Progress note on 1/1/2026 at 5:42 pm documented Resident #9 complained of weakness and general pain all over, pain rate 5/10 on 0-10 pain scale. His Tamiflu medication has not arrived from the pharmacy and the facility staff documented it was unlikely to arrive that evening from the pharmacy. The facility did not have documented nursing assessments or interventions between 1/1/26 and 1/5/26. Progress note on 1/5/2026 at 10:56 am documented Resident #9 was doing well overall post flu diagnosis and his blood pressure was stable. The facility did not have documented nursing assessments or interventions between 1/5/26 and 1/8/26. Progress note on 1/8/2026 at 2:50 pm documented a nursing intervention implemented to complete respiratory assessment and vital signs every shift until the end that day for due to Influenza A, encourage isolation for 7 days and additional 24 hours, and to use droplet precautions (gown, gloves, mask and face shield).

Based on observations, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide appropriate infection prevention practices when providing care to a resident with an indwelling catheter and a nephrostomy tube that was on Enhanced Barrier Precautions (EBP), failed to appropriately wear Personal Protective Equipment (PPE) during the sorting of laundry and failed to provide appropriated infection control standards for an outbreak of influenza A at the facility for 5 of 5 resident reviewed (Resident #8, #9, #28, #31 and #38). The facility reported a census of 32 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented diagnoses of quadriplegia, generalized muscle weakness, presence of urogenital implant and need for assistance with personal care. On 1/5/26 at 1:00 PM Resident #8 stated he had a cough for the last couple days but was getting over it and also some loose stools. Resident #8 stated the facility had not asked him to isolate in his room or wear a mask. Resident #8 stated the illness had been going around to all the residents at the facility. Resident #8 stated staff do not always wear gowns when they emptied his supra-pubic catheter or when care was provided by staff. Review of Resident #8's Medication Administration Records - Treatment Administration Records (MAR-TAR), documented a physician's order that started 1/4/26 for guaifenesin oral liquid 100mg/5mL to give 10mL by mouth every 8 hours as needed for cough and an order that started 1/5/26 for Mucinex oral tablet extended release 12 hour 600mg to give 1 tablet by mouth every 12 hours as needed for congestion for 10 days. An order for a catheter size 24 Fr with 10cc normal saline instilled in the balloon to be changed once a month on the 19th. Review of Resident #8's EHR titled, Care Plan documented Enhanced Barrier Precautions in place initiated on 5/29/25 when bathing, dressing and transferring. Review of Resident #8's EHR titled, Progress Notes documented no respiratory assessment and no lung sounds. Review of Resident #8's EHR titled, Assessments documented no respiratory assessment or infection screen evaluation. On 1/6/26 at 3:45 PM observation of Staff H, Certified Nurse Assistant (CNA) and Staff K, CNA complete a full body lift transfer on Resident #8 for shower revealed Resident #8 was lying in his bed in only a brief, Resident #8 was covered with a blanket from the waist down, Staff K knocked on the door, Staff K read the Enhanced Barrier Precautions (EBP) sign on Resident #8's door, Staff K walked into the room, Staff K removed a gown from the back of the hanger on the back of the door, Staff K said I will need this gown for the shower, Staff K said I am going to take this gown to the shower room, Staff K left Resident #8's room, Staff [NAME] returned to Resident #8's room, Staff H completed hand hygiene, applied gloves, picked up catheter bag, hooked catheter bag to the full body lift, Staff K utilized the control to start lifting Resident #8, Resident #8 said his foot was stuck in the sling, Staff K stopped the lift, Staff H reached under the blanket and moved left leg / foot that was stuck under the right leg, Staff K resumed the lift process, Staff K pushed the lift over to the shower bed, Staff H guided Resident #8 with lift cloth to the appropriate space on the shower bed, Staff K lowered Resident #8 in the lift cloth to rest on the shower bed, Staff H removed left cloth from lift sling, Staff H leaned over Resident #8's abdomen, Staff H said she could not reach the upper lift cloth loop, Staff H stated I can not reach the hook, Staff H attempted several more times, Resident #8 lifted arm and picked lift cloth hook up at the wrist, Staff H was then able to unhook the lift cloth hook from the full body mechanical lift, Staff H removed gloves, completed hand hygiene, both Staff K and H assisted in transporting Resident #8 down the hall to the shower room. 2. The MDS dated [DATE] for Resident #28 documented a BIMS score of 13 indicating no cognitive impairment. On 1/5/26 at 3:57 PM Resident #28 stated she had started coughing on 1/1/26. Resident #28 stated the facility did not test her but just assumed she had the flu like everyone else. Resident #28 explained she remained in her room till this morning. Resident #28 stated the facility staff did not ask her to wear a mask but she wanted to because she was still coughing. Review of Resident #28's EHR titled, MAR-TAR documented a physician's order that started 1/5/26 for benzonatate oral capsule 100mg to give one capsule by mouth 3 times a day for cough for 10 days. On 1/5/26 at 4:09 PM an observation of Resident #28's room revealed no Transmission Based Precautions (TBP), Enhanced Barrier Precautions (EBP) signs or Personal Protective Equipment (PPE) present outside of room or inside of room. No PPE present or TBP sign present inside of the room. On 1/5/26 at 3:57 PM an observation of Resident #28 wearing a mask at the dining table with a cough present during the interview. On 1/6/26 at 12:20 PM an observation of Resident #28 during the lunch meal without a mask with cough present throughout the lunch meal. Review of Resident #28's EHR titled, Progress Notes documented no respiratory assessment and no lung sounds. Review of Resident #28's EHR titled, Assessments documented no respiratory assessment or infection screen evaluation. 3. The Minimum Data Set (MDS) dated [DATE] documented Resident #38 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. On 1/5/26 at 2:33 PM Resident #38 observed coughing in his bedroom during the interview. Resident #38 stated he had been sick recently but was getting better. Resident #38 stated staff to not wear masks or gowns in his room when working with him. Review of document dated 1/2/26 titled, Emergency Department Patient Summary documented Resident #38 had a respiratory panel flu-RSV-Covid collected with discharge instructions influenza is an infection that affects your respiratory tract. Influenza is contagious and spreads easily from person to person. Review of Resident #38's EHR titled, MAR-TAR documented a physician's order that started 1/2/26 for benzonatate oral capsule 100mg to give one capsule by mouth 3 times a day for influenza for 10 days. On 1/5/26 at 4:09 PM an observation of Resident #38's room revealed no TBP signs present outside of room or inside of room. Observation continued to reveal EBP signs outside of the door with PPE available on the back of the door. Signage determined to be for roommate with supra-pubic catheter present. Review of Resident #28's EHR titled, Progress Notes documented no respiratory assessment and no lung sounds. Review of Resident #28's EHR titled, Assessments documented no respiratory assessment or infection screen evaluation. On 1/6/26 at 2:37 PM an observation of Resident #38 smoking revealed Resident #38 had frequent coughing episodes during that activity. Resident #38 sat at the end of the table around other residents who were smoking. Review of document with date printed 1/5/26 titled, CMS 802 Resident Matrix documented no residents in Transmission Based Precautions (TBP). On 1/5/26 at 11:40 AM the Director of Nursing (DON) stated she would double check but currently no resident at the facility was in TBP. On 1/6/26 at 11:30 AM Staff F, Registered Nurse (RN) stated 4 residents went to the hospital this last weekend. Staff F reported the 4 residents were sent out for the same concerns. Hypotension, tachycardia hypoxia, general complaints of weakness. Staff F stated Resident #9 had influenza A, pneumonia, acute kidney injury and septic shock. Staff F said Resident #30 was sent to the hospital for acute hypoxic, respiratory failure, influenza A and bilateral bronchitis. Staff F stated Resident #1 was admitted for influenza A and bilateral bronchitis. Staff F explained the facility does not test for influenza basically but provided symptomatic care. Staff F stated Resident #38 was discovered to have a positive influenza A diagnosis because he was sent out for weakness and tested positive at the hospital. Staff F explained Resident #9 was the first resident that tested positive for influenza A at the facility. Staff F explained Resident #9 asked to be sent to the hospital on an overnight shift. Staff F explained she did not know why, maybe because he did not feel good. Staff F said the hospital did a 4 plex test and Resident #9 tested positive for influenza A. Staff F stated she had been encouraging masks to the staff when going into the residents rooms with any respiratory illness symptoms. Staff F stated Resident #28 was sick and the facility did not test her but obviously she had the flu. Staff F stated she was hoping and praying if the residents were symptomatic there would be assessments being completed. Staff F stated the on call physician was aware influenza was in the building. Staff F stated she would do a focused respiratory assessment every 6 hours to ensure they are not declining more with lung sounds and vitals. Staff F stated with this bout of the influenza the symptoms are mainly weakness and respiratory issues. Staff F stated when Resident #8 tested positive she put EBP signage and PPE outside of the door. Staff F stated she was never told to do so. Staff F stated staff were instructed to put the EBP and PPE away but did not remember who instructed them to do so. On 1/6/26 at 12:11 PM Staff G, RN stated standard precautions required with all resident care. Staff G stated if the resident was coughing he would request the resident to stay in their room. Staff G explained he did not know if there are any residents who currently have influenza. Staff G explained he did not think any residents were tested but were treated as a preventative measure. Staff G said he had cared for Resident #9 and #38 but he was not assessing the two. Staff G stated Resident #28 told him she was not coughing but was just wearing a mask in the hallway. Staff G explained there was no assessment required unless the resident had shortness of breath. Staff G stated he did not see any signs or symptoms of the residents that he cared for that would prompt him to assess lung sounds. On 1/8/26 at 1:03 PM Staff H, Certified Nurse Assistant (CNA) explained Resident #38 had returned from the hospital after a fall positive for influenza A. Staff H explained when Resident #38 returned from the hospital the staff were not required to wear masks or gowns when care was completed. Staff H stated she wore a mask because she had a cough herself. Staff H stated the staff were not required to wear gowns when they worked with Resident #38. Staff H explained staff were not required to wear gowns or a mask in Resident #8, #9, #28, or #38 rooms until after the survey team arrived at the facility. Staff H acknowledged all of these residents had respiratory symptoms prior to the weekend. On 1/7/26 at 1:11 PM the DON stated outbreak status was described as 2 or more confirmed cases of influenza. DON acknowledged they did not follow the policy for outbreak status. The DON stated there was confusion because of the recent change in ownership and a policy change. The DON explained her expectation was a respiratory assessment with lung sounds and vitals would be completed every shift if the resident had a positive influenza test or any respiratory symptoms. The DON acknowledged the assessments were not completed appropriately for Residents #8, #9, #28, and #38. On 1/7/26 at 4:58 PM the DON stated the facility's expectation was the EBP policy would have been followed when providing care to Resident #8. The DON stated the facility's expectation was appropriate PPE would be donned prior to transfer of Resident #8. On 1/7/26 at 1:24 PM Staff I, Licensed Practical Nurse (LPN) / Infection Preventionist (IP) / Assistant Director of Nursing (ADON) stated what should have happened after the one resident tested positive she would recommend isolation and test with PCR and would continue the isolation based on the policy. Staff I explained Resident #9 tested positive for influenza A on the 12/31/25, Resident #38 tested positive for influenza A in the hospital and returned to the facility, Resident #36 was put on Tamiflu through hospice because of symptoms but did not get tested, Resident #8 had symptoms but was not tested, then Resident #1 and #30 tested positive at the hospital, Resident #6 had symptoms 1/5/26 with negative chest x-ray, Resident #36 had symptoms on 1/6/26 but were waiting on the lab results and PCR currently. Staff I stated isolation precautions for droplets were in place now for Residents #8, #9, #28, #30, #34, #36 and #38. Staff I acknowledged droplet precautions with TBP signs were not in place on these residents before 1/7/26. Staff I stated if the facility followed the policy the residents all should have been tested for influenza. Staff I explained vitals and respiratory assessments should have been completed every shift. Staff I stated masking was not mandated to the staff but could encourage the masking. Staff I explained there were signs that would be put up for public knowledge. Staff I explained there should have been 7 days of charting. Staff I stated there should have been charting every shift with vitals and lung sounds. Staff I acknowledged assessments and interventions were not in place and completed appropriately. Staff I acknowledged the local or state public health department should have been notified as well. Staff I explained per the facility's policy 1 positive influenza diagnosis with any other respiratory illnesses among other residents would be considered outbreak status. On 1/7/26 at 1:42 PM Staff J, Medical Director explained any total number of residents greater than 10% would be considered outbreak status. Staff J stated the residents should have orders for Tamiflu or should have been offered. Staff J explained signage would be good outside of the building for public awareness. Staff J stated nursing staff should talk to the physician or the provider to determine if testing is needed. Staff J stated if there was an outbreak determined at the facility he would think everyone should be tested that was symptomatic. On 1/7/26 at 5:06 PM the DON stated she had concerns with differences in policies during the transition of ownership. The DON explained previously when residents displayed symptoms of respiratory symptoms the residents would not be required to wear a mask or stay in their room. The DON stated she was aware of the situation with the influenza A outbreak at the building. The DON acknowledged the outbreak was not handled the appropriate way. The DON explained when Staff I returned from vacation symptoms were tracked and signs were hung. The DON stated she would have expected assessment would have been completed on the residents that were symptomatic. The DON stated the facility's expectation was vitals and assessments every shift for 7 days. The DON explained the assessment would contain a full vitals and listen to the lungs and then a final assessment 24 hours status post. The DON stated the assessment would be found in progress notes. The DON explained the residents who were symptomatic or tested positive for influenza A should have had PPE available in their rooms with TBP signs posted for droplet precautions. 4. The Electronic Health Record (EHR) Progress notes documented a Nurse Note for Resident #9 on 12/5/2025 at 5:51am resident reported to staff symptoms of a head cold. Staff noted on assessment audible wheezing and nasal congestion. Staff did not initiate testing for flu-like symptoms and did not put isolation precautions in place. On 12/12/2025 at 9:42 am General Progress Note documented a physician visit and new orders for Guaifenesin 600mg tablets by mouth for 14 days for congestion and upper respiratory infection. Staff did not initiate testing to determine if Resident #9 had a flu and did not put isolation precautions in place after a diagnosis of Upper Respiratory Illness. On 1/1/2026 at 1:13 am Progress notes documented Resident #9 went to the ER and will be returning shortly after with a diagnosis of Influenza A. Progress note on 1/1/2026 at 6:32 am documented Resident #9 returned from the hospital and isolation precautions were initiated, new medications were prescribed for the flu, Tamiflu Oral Capsule 75 MG for Influenza A for 5 Days, and Albuterol Nebulizer 4 times a day for 10 days. Observation of Resident #9's room on 1/5/26 at 12:00 pm revealed no isolation precaution sign posted around the door prior to entering the room. No isolation cart located outside the room for staff to protect themselves prior to entering the room. Progress note on 1/8/2026 at 2:50 pm documented a nursing intervention implemented to complete respiratory assessment and vital signs every shift until the end that day for due to Influenza A, encourage isolation for 7 days and additional 24 hours, and to use droplet precautions (gown, gloves, mask and face shield). 5. Review of Resident #31's MDS 12/11/25 revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed that Resident #31 utilized a nephrostomy tube (a small tube inserted through the skin in the lower back directly into the kidney to drain urine when there's a blockage or injury, diverting it to an external bag to relieve pain, prevent infection, and protect kidney function) as well as a urostomy. The MDS then revealed diagnoses of non-traumatic spinal cord dysfunction, renal insufficiency, neurogenic bladder, and paraplegia. Interview 1/05/2026 at 1:38 PM with Resident #31 revealed that he has nephrostomy tubes and that the tubes were just changed by the physician. Tubing was observed to have dark brown/red urine in the tubing. It was further observed at this time that Resident #31's urine drainage bag noted to be hanging in the trash can at this time. Observation 1/06/2026 at 3:05 PM noted Resident #31's urine drainage bag hanging on the trash can at this time. Observation 1/07/2026 at 2:52 PM noted Resident #31's urine drainage bag hanging on the side of the trash can at this time. Interview 1/07/2026 at 3:26 PM with the DON revealed that catheter/urostomy drainage bags should not be hanging on trashcans as this is a concern with infection control. 6. Interview 1/06/2026 at 7:57 AM with Staff B Housekeeping/Laundry revealed that she only wears gloves, and not gowns when separating the clothes. No gowns were observed in the laundry room, and clothes in bins had been separated at this time. Interview 1/07/2026 at 1:53 PM with the ADON/IP revealed that she would like to see laundry staff wearing gowns when separating laundry. Interview 1/07/2026 at 2:09 PM with the DON revealed that she would expect laundry staff to wear gowns when separating laundry as this would be standard precautions. Review of a facility provided policy titled, Handling Soiled Linen with and implementation date of 11.9.25 revealed: a. All linen should be handled using standard precautions and treated as potentially contaminated.

Based on facility document review, and staff interviews, the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager (CDM). The facility reported a census of 32 residents.Findings include: Interview 1/05/2026 at 10:20 AM with the Dietary Manager revealed that she does not have a CDM. The Dietary Manager then revealed that since the company was bought out that she had to stop taking the classes in September of last year. The Dietary Manager then revealed that when they get more staff in the kitchen she would go back to more office work, and restart the classes. Interview 1/07/2026 at 8:42 AM with the Administrator revealed that he would expect the dietary manager to have a CDM certificate, and to finish the classes required. Follow up interview 1/07/2026 at 1:23 PM with the Administrator revealed he was unsure if there was a policy related to CDM, but his expectation would be for the dietary manager to have the appropriate education to be the CDM.Review of a facility provided document titled, Dietary Manager-Job Description with a copyright date of 2023 revealed:a. Required qualifications: 1. Minimum requirements include one of the following: a. Certification as a dietary manager. b. Certification as a food service manager. c. Has similar national certification for food service management and safety from a national certifying body.

Based on clinical record review, observations, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 2 residents reviewed (Residents #27, #42) requiring the use of oxygen. The facility reported a census of 32 residents. Findings include: 1. Review of Resident #27's Minimum Data Set (MDS) dated [DATE] documented diagnoses of non-Alzheimer's dementia, Parkinson's disease, and depression. The Progress Notes in the Electronic Health Record (EHR) documented Resident #27 started receiving hospice services and was prescribed oxygen therapy via nasal cannula for comfort. An observation on 1/5/25 at 2:25 pm revealed oxygen was delivered via nasal cannula and the tubing attached to the oxygen concentrator located near the bed. The concentrator was turned on and set to deliver 2L/min of oxygen. The tubing did not have a label with the start date and staff initials. The tubing appeared flattened due to being jammed and stuck under the locked wheel of the bed on the left side of the headboard. Resident #9 had visible perspiration on his face and was breathing heavily. In an interview on 1/5/25 at 2:35 pm with Staff M, Certified Nursing Assistant (CNA) and Staff N, Hospice CNA after they provided hands-on cares to Resident #27, they did not notice the oxygen tubing was stuck under the wheel of the bed. After they provided the cares, the oxygen tubing was no longer stuck under the wheel of the bed. They checked vital signs on Resident #27 and his oxygen saturation level was at 90%. The oxygen concentrator after the CNAs provided cares was set at 4.5 L/min, both CNAs stated they didn't change the settings on the concentrator but they will notify the nurse about the settings. The CNAs also confirmed the nasal cannula oxygen tubing was not labeled. In an interview on 1/5/25 at 2:35 pm Staff C, CNA stated she checked on Resident #27 about every hour during her shift.On 1/5/26 at 2:58 PM Staff N, Hospice CNA returned back to Resident #27's room with a new tubing and a piece of tape, she stated the facility gave her new supplies and she will be labeling the new oxygen tube at this time. In an interview on 1/5/25 at 3:35 pm with Staff A, Licensed Practical Nurse (LPN), she revealed she did not complete an assessment on Resident #27 during her shift as there was no need for it because a Hospice nurse made a visit to assess the resident that morning. She also revealed she was not aware that Resident # 27's oxygen concentrator was set to 4.5L/min and CNAs didn't report it to her after they were aware it was set to 4.5L/min after they provided bedside cares.2. Review of Resident #42's MDS dated [DATE] documented an admission to the facility on [DATE]. The Electronic Health Record (EHR) review revealed a document titled Hospice orders on admission from Hospice services and on the orders it listed Oxygen therapy 1-4L via nasal cannula as needed for difficulty with breathing. An observation of Resident #42 on 1/5/26 at 1:30 pm revealed oxygen therapy was in place via nasal cannula and the concentrator set to 1.5L/min, the excess tubing was on the floor and kinked and no label with date/initials noted. Resident #42 appeared to be resting with eyes closed, not responding to a verbal greeting. A review of the EHR Medication Administration Record (MAR) and Baseline Care Plan for Resident #42 did not document a prescribed oxygen therapy. In an interview on 1/6/25 at 2:10 pm with Staff O, Registered Nurse (RN) hospice services, she reported Resident #42 was admitted to the facility with the oxygen order and the concentrator was delivered to the facility at the time of admission through their services. She confirmed the hospice company provided orders for oxygen as part of the admission documents since the resident was receiving hospice services through their company prior to admission to the facility. In an interview with the Director of Nursing (DON) on 1/6/25 at 2:40 pm stated her expectation was for the admitting staff to document oxygen therapy on the MAR and the baseline care plan at the time of the admission for new residents. The baseline care plan was to be completed within 24-48 hours of admission and she would follow up on the documentation. She also reported she didn't realize the oxygen therapy for Resident #42 was missed on the MAR and the baseline care plan and she will correct it. She stated the company policy for the oxygen tubing to be labeled and dated and replaced weekly.A company provided policy titled Oxygen Administration dated November 9, 2025 documented: oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Policy Explanation and Compliance Guidelines:Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists.Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:The type of oxygen delivery system.When to administer, such as continuous or intermittent and/or when to discontinue.Equipment setting for the prescribed flow rates.Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.Monitoring for complications associated with the use of oxygen.Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use.Cleaning and care of equipment shall be in accordance with facility policies for such equipment.

Based on document review, staff interviews, and policy review, the facility failed to refer a resident with a negative Level I result for the Pre admission Screening and Resident Review (PASRR), who had an identified mental disorder, intellectual disability, or other related condition that was not addressed on PASRR completed prior to admission to the facility, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 resident (Resident #24) reviewed for PASRR requirements. The facility reported a census of 32 residents.Finding include:The Minimum Data Set (MDS) dated [DATE] documented Resident #24 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS revealed Resident #24 had a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 2/7/25. The MDS documented Resident #24's admission date of 2/7/25.Review of document dated 1/30/25 titled, Preadmission Screening and Resident Review documented no diagnosis of PTSD under the diagnosis of mental health diagnoses portion of the screening. Review of document dated 8/8/25 titled, Notice of PASRR Level 2 Outcome documented no diagnosis of PTSD under the diagnosis of mental health diagnoses portion of the screening. On 1/6/26 at 3:17 PM Staff E, Social Services Supervisor stated she does not usually have to update the level 1 PASSR. Staff E stated there was an updated PASSR completed on 9/5/24. Staff [NAME] stated Resident #24 had a PASRR updated on 8/8/25. Staff E acknowledged Resident #24's PASRR was non-compliant. Staff E explained Resident #24's PASRR did not have the diagnosis of PTSD and it should have been documented on both PASRR documents for 1/30/25 and 8/8/25. On 1/6/26 at 4:29 PM the Director of Nursing (DON) stated her expectation was the PTSD diagnosis for Resident #24 would have been documented on the PASSR and resubmitted.Review of policy implemented 11/9/25 titled, Resident Assessment Coordination with PASARR Program documented the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review.

Based on Electronic Health Record (EHR) review, staff interviews, and policy review the facility failed to obtain bed hold notifications for 1 of 3 residents (Resident #40) reviewed. The facility reported a census of 32 residents.Findings Include: Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of anxiety disorder, bipolar disorder, adult failure to thrive, and chronic kidney disease. Review of Resident #40's EHR page titled, Progress Notes revealed an entry dated 12/31/25 documenting that Resident #40 was transferred to the emergency room for evaluation. Further review of the progress notes revealed an entry dated 1/5/26 that Resident #40 was re-admitted back to the facility from a hospital stay. Review of the EHR page titled, Clinical Census revealed that Resident #40 had been in the hospital from [DATE] until 1/5/26. Interview on 1/8/26 at 9:22 AM with the Director of Nursing (DON) confirmed that Resident #40 was sent to the hospital on [DATE]. The DON then confirmed that no bed hold was obtained on this day for the resident being sent to the hospital. The DON further revealed that she would expect a bed hold to be completed.Review of a facility provided policy titled, Bed Hold Notice with a date implemented of 11/9/25 revealed:a. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident within 24 hours.

Based on resident interviews, staff interviews, documentation reviews and facility policy review, the facility failed to thoroughly investigate and report immediately alleged violations related to mistreatment of 1 resident (Resident #12) out of 8 reviewed. The facility reported a census of 32 residents.Findings include:Review of Resident #12's MDS dated [DATE] documented an admission to the facility on 6/30/25 and a Brief Interview for Mental Status (BIMS) of 08 indicating moderate cognitive impairment The MDS documented the following diagnoses: hemiplegia, diabetes, and depression. The MDS revealed Resident #12 depended on staff for total assistance with personal hygiene, upper and lower body dressing, and bathing. During an interview with Resident #12 on 1/7/2026 at 4:15 pm she stated Staff P, CNA recently slapped her upper leg while putting her feet up in bed. She stated she was attempting to get out of bed and Staff P noticed her while walking by her room, she then entered her room, was very mean verbally and yelled at her, lifted her feet up and put them back in bed and at that time she tapped her upper leg. Resident #12 stated she told Staff P to get out of her room. During an interview with Staff P, CNA on 1/7/26 at 4:50 pm who worked at the facility for over 8 years, she revealed she assisted Resident #12 back into bed on 12/5/25 when she noticed that she was attempting to get out of bed. She was afraid that Resident #12 will fall since she couldn't walk on her own and all she could think about was safety. Resident #12 told her to leave the room and became visibly upset and said she hit her leg. Staff P stated she did not touch resident's upper leg during this action but Staff P went and reported it to the charge nurse immediately that she needed help with Resident #12. Shortly after the report, she was notified by the DON to leave the facility while they investigate the situation. A few days later she was notified by the facility that she was terminated. A personnel file review for Staff P revealed a document titled Corrective Action dated 12/8/25 documented On 12/5/25 Resident accused CNA of abuse, stating she threw my legs in bed and hit me. This DON did investigation-resulting in termination. Notice provided verbally by phone and signed by the the DON, Assistant DON and the Administrator on 12/8/25. In an interview with the DON on 1/07/2026 at 9:37 am who was in her position about 3 months revealed she did not make a report to the law enforcement about the abuse allegation by Resident #12 and Staff P hitting her leg. She stated she wasn't aware that a police report needed to be submitted at the time of the incident. She further revealed she did not interview any other residents if they felt abused. A review of the facility provided policy titled Abuse Prevention revised on 10/21/22 documented:The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members. Legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Procedure: steps to prevent, detect and report documented:Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others). In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment.Care will be monitored so that the resident's care plan is followed.The facility will not retaliate against any individual who lawfully reports a reasonable suspicion of crime.

Based on clinical record review, staff interview and facility policy review, the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 3 out of 5 sampled residents reviewed (Resident #5, #12, #20). The facility reported a census of 32 residents.Findings include:1. Review of Resident #5's Minimum Data Set (MDS) date 12/9/25 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS showed Resident #5 also took antidepressant medication during the review period. The MDS further revealed diagnoses of depression, diabetes, and respiratory failure.Review of Resident #5's Electronic Healthcare Record (EHR) page titled Medication Administration Record (MAR) revealed an order dated 9/19/26 for Citalopram 30 mg daily for major depressive disorder.Review of the Care Plan for Resident #5 with a revised date of 12/15/25 lacked non-pharmacological interventions and targeted behaviors with anti-depressant medications. 2. Review of Resident #12's MDS dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS documented Resident #12 also took antidepressant medication during the review period. The MDS further revealed diagnoses of depression, diabetes, and hemiplegia.Review of Resident #12's Electronic Healthcare Record (EHR) page titled Medication Administration Record (MAR) revealed an order dated 12/14/25 for Paroxetine 40 mg daily for major depressive disorder, Review of the Care Plan for Resident #12 with a revised date of 12/15/25 lacked non-pharmacological interventions and targeted behaviors with anti-depressant medications. 3. Review of Resident #20's MDS date 1/18/25 revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS documented Resident #20 received antidepressant medication during the review period. The MDS further revealed diagnoses of non-Alzheimer's dementia, depression, anxiety, and bipolar disorder.Review of Resident #20's Electronic Healthcare Record (EHR) page titled Medication Administration Record (MAR) revealed an order dated 9/19/25 for Depakote 125 mg daily for bipolar disorder, an order dated 11/8/25 for Venlafaxine 75mg daily for bipolar disorder, an order dated 9/19/25 for Donepezil 5mg daily for dementia with other behavioral disturbance. Review of the Care Plan for Resident #20 with a revised date of 12/15/25 lacked non-pharmacological interventions and targeted behaviors with anti-depressant medications. Interview on 1/08/26 at 12:52 pm with the Director of Nursing (DON) stated she expected non-pharmacological interventions to be placed in the Care Plan for residents with psychotropic medications. The DON further acknowledged there were no non-pharmacological interventions currently on Residents #5, #12, and #20 Care Plans. Review of a facility provided policy titled Medication Therapy revised April 2007 documented: Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks.Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments.All medication orders will be supported by appropriate care processes and practices.All decisions related to medications shall include appropriate elements of the care process, such as:a. Adequately detailed assessment;b. Review of causes of symptoms;c. Consideration of the clinical relevance of symptoms and abnormal diagnostic test results;d. Principles of prescribing for the elderly; ande. Each resident's wishes, values, goals, condition, and prognosis.Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) will review an individual's current medication regimen, to identify whether:a. There is a clear indication for treating that individual with the medication;b. The dosage is appropriate;c. The frequency of administration and duration of use are appropriate; andd. Potential or suspected side effects are present.

Based on observation, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide dignity and respect to 2 of 14 residents reviewed (Resident #8 and #12). The facility reported a census of 32 residents.Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS also documented diagnoses of quadriplegia, generalized muscle weakness and need for assistance with personal care. An observation on 1/5/26 at 1:19 PM Staff C, Certified Nurse Assistant leave room [ROOM NUMBER]. Staff C walked down the hall to join another CNA in room [ROOM NUMBER]. An observation of Resident #8 in bed with no sheets or clothes only a brief on. Staff D, Activities Director knocked on the door on 1/5/26 at 1:28 PM and entered the room. Staff D delivered mail to Resident #8. On 1/5/26 at 1:29 PM Staff C walked down the hall from room [ROOM NUMBER] to room [ROOM NUMBER]. Staff C spoke with the resident in room [ROOM NUMBER], went down the hall, returned up the hall with lift cloth and returned to room [ROOM NUMBER]. On 1/5/26 at 1:32 PM Resident #8 turned the call light on. Another CNA requested help in room [ROOM NUMBER] from Staff C. On 1/5/26 at 1:36 PM Staff C told the CNA from room [ROOM NUMBER] she would be right back to see what Resident #8 needed. Staff C took dirty linen down the hall. On 1/5/26 at 1:37 PM CNA entered Resident #8's room to answer the call light. On 1/5/26 at 1:37 PM Staff C answered the call light in room [ROOM NUMBER]. On 1/5/26 at 1:39 PM an observation of Resident #8 with a blanket on. On 1/5/26 at 1:19 PM Resident #8 stated staff left to go get him some linen. Resident #8 stated he felt uncomfortable without a sheet on. Resident #8 stated he did feel there was a lack of dignity provided when laying in bed without a sheet on. On 1/5/26 at 1:32 PM Resident #8 stated it usually did not take that long for staff to return to cover him and that was why he turned the call light on. On 1/5/26 at 1:39 PM Resident #8 stated Staff C had covered him up and that was what he wanted. On 1/7/26 at 3:57 PM Staff C, CNA acknowledged that she was working morning shift on 1/5/26 giving showers. Staff C stated she did forget to put sheets on Resident #8's bed that morning. Staff C stated she was told she was not supposed to have a bottom sheet on the air mattress. Staff C stated when she returned to answer Resident #8's call light he asked to have the blanket put over him. Staff C stated she explained to Resident #8 that she was sorry and she got sidetracked. On 1/7/26 at 4:46 PM the Director of Nursing (DON) stated she would expect Resident #8 would have been covered before the staff left the room with the blanket. The DON said Staff C should provide the most dignity that she could for Resident #8. Review of policy with implemented date of 11/9/25 titled, Promoting/Maintaining Resident Dignity documented it was the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintained or enhanced the resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. All staff will maintain the resident's privacy. 2. Review of Resident #12's MDS dated [DATE] documented an admission to the facility on 6/30/25 and a Brief Interview for Mental Status (BIMS) score of 08 indicating moderate cognitive impairment. The MDS documented the following diagnoses: hemiplegia, diabetes, and depression. The MDS revealed Resident #12 depended on staff for total assistance with personal hygiene, upper and lower body dressing, and bathing. During an interview with Resident #12 on 1/7/26 at 4:15 pm she stated Staff P, CNA recently slapped her upper leg while putting her feet up in bed. She stated she was attempting to get out of bed and Staff P noticed her while walking by her room, she then entered her room, was very mean verbally and yelled at her, lifted her feet up and put them back in bed and at that time she tapped her upper leg. Resident #12 stated she told Staff P to get out of her room. During an interview with Staff P, CNA on 1/7/26 at 4:50 pm who worked at the facility for over 8 years, she revealed she assisted Resident #12 back into bed on 12/5/25 when she noticed that she was attempting to get out of bed. She was afraid that Resident #12 would fall since she couldn't walk on her own and all she could think about was safety. Resident #12 told her to leave the room and became visibly upset and said she hit her leg. Staff P stated she did not touch resident's upper leg during this action but Staff P went and reported it to the charge nurse immediately that she needed help with Resident #12. Shortly after the report, she was notified by the DON to leave the facility while they investigate the situation. During an interview with the DON on 1/8/26 at 12:21 pm she stated her expectation was for Staff P to ask for consent prior to touching a resident, verbalize actions during any cares such as pushing them in a wheelchair, pericare, show dignity, make them feel safe and respected. A review of the facility provided policy titled Abuse Prevention revised on 10/21/22 documented:The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members. Legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Mistreatment: inappropriate treatment or exploitation of a resident. Protection: Any allegation of abuses, or neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.

Based on clinical record review, resident and staff interviews and facility policy review the facility failed to separate Resident #1 and Resident #3 to prevent a resident-to-resident altercation. The facility reported a census of 39 residents.Findings Include:1) According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 9/13/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS listed the following diagnosis for Resident #1: hypertensive heart disease, anemia, renal failure, psychotic disorder (other than schizophrenia), mild cognitive impairment, insomnia, and metabolic encephalopathy.A Care Plan Focus Area with an initiation date of 1/15/2025 documented Resident #1 had a history or potential for delusions due to her cognitive status. The care plan documented she is redirectable, her short-term memory is impaired so diverting her attention can be effective. The care plan directed staff to reorient Resident #1 to her surroundings and situation.Record review revealed the following Progress Note documented by Staff A Registered Nurse (RN):a. on 10/18/2025 at 5:43 PM this nurse was called by dietary staff due to resident being verbally aggressive towards another resident. Upon approach of the table resident noted to be standing by table holding onto side of table very upset. Reported from other resident that Resident #1 hit Resident #3 in the middle of the chest because she thought it was her silverware. Residents separated from each other.2) According to the Quarterly MDS assessment tool with a reference date of 9/10/2025, Resident #3 had a BIMS score of 13. A BIMS score of 13 suggested no cognitive impairments. The MDS documented the following diagnoses for Resident #3: traumatic spinal cord dysfunction, paraplegia, anemia, hypertension, renal failure, neurogenic bladder, anxiety disorder, depression, bipolar, and insomnia.A Care Plan Focus Area with an initiation date of 7/10/2019 documented Resident #3 had a history of or the potential for physical and verbal behavioral symptoms related to anxiety and schizophrenia. Staff are encouraged to attempt to redirect Resident #3 from the behavior and educate hi on why the behavior is not appropriate.Record review revealed the following Progress Note documented by Staff A:a. on 10/18/2025 at 6:07 PM this nurse called for by dietary due to resident being verbally aggressive towards another resident. Upon approach of the table Resident #1 noted to be standing by table holding onto side of table very upset. His tablemate reported she hit him in the middle of the chest because she thought it was her silverware. Resident #3 stated well she came up to my table and thought my silverware was her's; she said that. He told her they were his and then she hit him right in the middle of the chest. Then you came over. Residents separated from other.On 11/4/2025 at 1:56 PM Resident #3 stated Resident #1 hit him on the chest and put his hands on the center of his chest. He denied any injuries and indicated this was the first time anything like this has happened. After she hit him, staff came to remove Resident #1 from his table and kept her away. He denies having further issues with Resident #1.On 11/5/2025 at 9:07 AM Staff A stated Resident #1 had hit a different resident the day prior and was on one-to-one supervision on 10/18/2025. As she was assisting another resident that had fallen, the Dietary Manager approached her and let her know Resident #1 was getting in Resident #3's face. Staff A asked her if she separated them and the Dietary Manager denied doing so. Staff A went over and Resident #1 was not happy but no doing anything. Staff A asked Resident #1 hey let's go this way and they both walked away from Resident #3's table. When she returned to speak with Resident #3 to see what happened, he stated she hit him on the chest and grabbed his shirt. He denied injuries.On 11/5/2025 at 9:48 AM the Dietary Manager stated she had given Resident #3 his coffee and silverware then made her way to the TV room. She came back and saw Resident #1 at Resident #3's table with a coffee lid in her hand. Resident #3 had his coffee cup in one hand and his silverware in his other hand. Resident #1 was also gripping his silverware. Resident #1 stated this is mine, cursed at Resident #3, she was being forceful. The Dietary Manager noticed Staff A was in the TV room and got her to assist with the situation. She later learned that Resident #1 hit Resident #3 after she dropped of his silverware and coffee. When asked if she separated the residents she denied doing so because she had a coffee pot in her hand and did not want to sit it down so Resident #1 could grab it. She stated she put the coffee pot in the kitchen then got Staff A. The Dietary Manager stated Resident #1 and Resident #3 were at Resident #3's dining room table that was next to the kitchen where she placed the coffee pot. She would have walked past that table to get Staff A. She added she could have attempted to separate them but Resident #1 can be aggressive.On 11/5/2025 at 10:00 AM Certified Nursing Assistant (CNA) stated if she came across the incident between Resident #1 and Resident #3 she would go and redirect Resident #1 away from the situation. She would offer Resident #1 to sit with her which usually will calm her down.On 11/5/2025 at 10:28 AM Staff B CNA stated if she witnessed what happened between Resident #1 and Resident #3, she would have tried to separate the two, asked Resident #1 to come with her and notify the nurse.On 11/5/2025 at 11:10 AM the MDS Coordinator indicated she has been locked out the drive that provides policies, procedures and guidelines they utilize. She was unable to look for specific policies, procedures, guidelines related to resident-to-resident altercations.On 11/5/2025 at 11:50 AM the Administrator stated when there is a verbal altercation witnessed staff are to alert management or the charge nurse and ask them for help. When asked if staff should separate the residents involved, she stated well yes immediately. They should separate to help deescalate the situation.The facility provided a document, found in their email, titled Abuse Prevention, with a revision date of 10/21/2025. The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals.

Based on electronic medical record (EMR) review, resident interview, staff interviews, and policy review the facility failed to provide care and service to an individual with a feeding tube resulting in complication of enteral feeding and medication administration for 1 of 1 residents reviewed (Resident #1). The facility failed to identify the skills and abilities needed of the direct care staff when providing enteral medications to the resident resulting in 4 hospital visits including 3 overnight stays within 4 weeks. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 4/18/25 revealed the Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive deficit. The document revealed diagnoses of cancer, anxiety disorder, depression, psychotic disorder, spinal stenosis, oral phase dysphagia, and pharyngeal phase dysphagia. The document revealed that while a resident of the facility and within the last 7 days the resident had a feeding tube and mechanically altered diet. The assessment revealed the resident did not have a 5% weight loss in the past month or 10% in the last 6 months. Resident #1's Care Plan dated 6/4/25 revealed a focus area with an alternative nutritional intake via tube feeding initiated on 12/19/24 and resolved on 4/22/25. The interventions for staff included checking tubing placement and gastric contents/residual volume per facility protocol/record (initiated 12/19/24 and resolved 4/22/25), elevate the head of bed 45 degrees during and 30 minutes after tube feed (initiated 12/19/24 and resolved 4/22/25), and monitor/document/report any signs/symptoms of aspiration, tube dislodged, infection, tube dysfunction or malfunction (initiated 12/19/24 and resolved 4/22/25). An additional focus area of nutritional problem area initiated 10/1/24 with a revision on 4/22/25 included 12/16/24 severe dysphagia - resident receives nothing by mouth (NPO), receives nutrition via Percutaneous Endoscopic Gastrostomy (PEG) tube (holding), need for mechanically altered diet. Interventions for this focus area included administer medications as ordered initiated 10/1/24, monitor/record/report to physician as needed signs/symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months initiated on 10/1/24, provide tube feeding as ordered (holding) initiated 12/16/24 and revised 4/22/25, alternate liquids and solids, strict 1:1 bite to drink ratio, must be cued by staff at all meals to alternate liquids with solids and supervision with all oral intake, initiated on 4/16/25, and Registered Dietitian (RD) to make tube feeding rate recommendations as needed (PRN) initiated 12/16/24 and revised 2/24/25.The hospital Continuum of Care Transfer Report dated 12/12/24 revealed Resident #1 was admitted to the hospital with a planned surgical intervention of C4-C7 anterior cervical discectomy and fusion on 12/2/24; complications during the course of hospital recovery resulted in the placement of a PEG tube on 12/11/24, and recommendation for NPO due to severe pharyngeal dysphagia. The Medication Administration Record (MAR) - Treatment Administration Record (TAR) 12/24 revealed orders for flush tube with water with 200 milliliters (ml) 6 hours 4 times a day with an order dated of 12/12/24 and discharge 12/17/24, flush tube with water with 150 milliliters (ml) every 4 hours for flush with an order date of 12/17/24, tube feeding Osmolite 1.5 300 ml every 6 hours via PEG tube 4 times/day with an order date of 12/15/24. Increase water flushes for medications 60 ml every day and night shift with an order date of 12/21/24, check tube placement prior to feeding/medication administration with an order date 12/12/24, intake and output every 24 hour total from feeding tube with an order date of 12/12/24, and a highlighted For Your Information (FYI) resident is NPO, all meds crushed and given in bolus, give per G-tube, 30 ml flush before and after meds, at all times NPO with a start date of 12/12/24. The EMR Progress Note dated 12/12/24 revealed Resident #1 returned to the facility with a PEG tube in place, patent with flushes and the tube feedings infusing at 50 ml per hour, bolus water flushes 200 ml every 6 hours. The EMR Clinical Census reported the following hospitalizations:12/17/24 hospital <3 days with return on 12/19/241/5/25 hospital <3 days with return on 1/6/25.1/8/25 hospital <3 days with return on 1/9/25.The EMR Progress Notes beginning 12/17/24 revealed Resident #1's PEG tube had become clogged and the resident was transferred to the hospital. The resident returned to the facility with the hospital not addressing the clogged tube, and the resident was sent back to the hospital. An entry on 12/18/24 disclosed the resident was being admitted to the hospital for G-Tube replacement. The hospital document After Visit Summary dated 12/18/24 - 12/19/24 revealed the primary diagnosis for admission was Complication of Artificial Opening of Stomach. The hospital document Continuum of Care Transfer Report dated 12/19/24 provided diagnoses for admission Gastrostomy Tube Dysfunction and Feeding Tube Blocked. A Progress Note entry dated 12/19/24 revealed Resident #1 returned from the hospital with a G-Tube replacement. Progress Note entries dated 12/31/24 at 7:23 AM revealed Resident #1's G-Tube was clogged while medications were going in; medications were dissolved in warm water with very small particles present. The facility was unable to unclog and the resident was transferred to the hospital. An entry at 12:39 PM revealed the resident returned to the facility. The hospital document, After Visit Summary, dated 12/31/24 revealed Resident #1 was seen for Complication of Artificial Opening of the Stomach (G-Tube problem) and Obstruction of Feeding Tube. The resident had a Fluoroscopy of the Gastrointestinal Tube Placement imaging completed while in the hospital. Progress Note entries beginning on 1/5/25 at 3:55 PM revealed the resident was transferred via emergency transport to the hospital due to the PEG tube being clogged. An entry at 11:02 PM revealed Resident #1 was being admitted to the hospital due to the clogged tube. On 1/6/25 at 5:20 PM the resident returned to the facility with the G-Tube being patent. The hospital document, Care Port, dated 1/6/25 revealed the resident was sent to the hospital for a clogged G-Tube on 1/5/25. The document disclosed Resident #1 had a previous admission of a clogged G-Tube with Interventional Radiology (IR) being necessary to unclog the tube. The resident was admitted on [DATE] due to IR being unavailable on the weekends and would require IR intervention to declog the tube. Resident #1 was provided intravenous (IV) fluids for hydration until the procedure was completed. Progress Note entries beginning on 1/8/25 at 9:45 AM revealed Resident #1's PEG tube became clogged following medication administration. Entry with a time stamp of 11:15 AM revealed the resident was to be sent to the hospital. On 1/8/25 at 2:30 PM the Progress Note entry disclosed the hospital called and stated they were unable to declog the G-Tube due to being stuck with medications. The entry on 1/9/23 at 12:23 AM provided the resident was admitted to the hospital for the clogged G-Tube and if they were unable to replace the tube it would be replaced. The entry on 1/9/25 at 10:02 AM stated Resident #1 was having surgery for G-Tube replacement with a large size tube insertion. The entry at 12:38 PM revealed the resident returned to the facility with a larger size PEG tube. The hospital document, After Visit Summary, dated 1/8/25 - 1/9/25 revealed the resident was admitted for Complication of Artificial Opening of the Stomach and Obstruction of Feeding Tube.Review of EMR Weight and Vital Summary provided the following weights:11/7/24 150.4# wheelchair (w/c) - pre PEG tube12/13/24 141.4# standing - post PEG tube. Decrease of 9# (5.98%) from 11/7/24.12/23/24 142.2# w/c - post PEG tube placement. Decrease of 12# (5.45%) from 11/7/24.1/13/25 138.4# w/c decrease of 3.8# (2.12%) from 12/23/24. 1/27/25 138.6# standing2/17/25 138.3# w/c3/1/25 136.6# standing3/17/25 137.4# w/c4/16/25 135.6# w/c4/28/25 133.2# standing decrease of 3.4# (2.49%) from 3/1/255/19/25 136.4# w/c5/28/25 129.8# w/c decrease of 6.6# (4.84%) from 5/19/24 6/18/25 129.6# w/c6/25/25 124.6# standing decrease of 8.6# (6.46%)6/30/25 124.6# standing7/7/25 122.0# standing decrease of 2.6# (2.09%) from 6/25/25.The Weight Loss Summary for Resident #1 revealed the following: 11/7/24 to 5/28/25 the resident lost 20.6# (13.7%) - 6 month weight loss11/7/24 to 7/7/25 the resident lost 28.4# (28.88%) - 7 month weight loss12/13/25 to 7/7/25 the resident lost 19.4# (13.72%) - 6 month weight loss from post PEG tube placement On 7/2/25 at 12:36 PM Staff B, Registered Nurse (RN) stated Resident #1 was sent out multiple times from December to January for clogging of his PEG tube with the resident eventually getting a larger tube. The staff stated it had been a very long time since the facility had any residents with PEG tubes. Staff B stated there had been no training or education provided prior to Resident #1 returning to the facility with the PEG tube. The staff stated they were told to figure it out if they didn't know something; the staff recalled a PRN staff working who had not worked with a G-Tube in a very long time and asked for assistance from an Administrative Nurse and was told she was a RN and should know how to manage it. When asked if any training was provided when Resident #1 began having clogging of his PEG tube, the staff responded with no training being provided for the resident. Staff B stated training in the facility consisted of reading a clip board and signing your name with no hands on training or question/answer training provided. The staff stated the resident may refuse breakfast if he had his last PEG tube feeding too close to breakfast as feedings may be completed 1 hour before or after the scheduled time. Staff B indicated the increase in enteral feeding refusals appear to have increased since the feedings changed to overnight. The staff stated she had not spoken with the physician or dietitian regarding the refusals in oral or enteral intake. On 7/3/25 at 5:30 AM Staff S, Agency Licensed Practical Nurse (LPN), stated she had not been provided with any training by the facility regarding Resident #1 and his enteral feedings. The staff stated the only training she received was to refer to the nurse she was working with during her shift. Staff S stated Resident #1 will occasionally refuse the 4 AM enteral feeding. The staff stated she did not notify anyone if the resident refused a feeding.On 7/3/25 at 5:50 AM Staff T, LPN, stated Resident #1's tube became clogged as people did not know what to do regarding medication administration. Staff T stated other staff did not know to crush medications and place them in water to dissolve prior to placement in the PEG tube. The staff did not recall any training provided to staff prior to the resident ' s return with the new PEG tube or when re-hospitalization visits began due to the G-Tube clogging due to medications. Staff T stated Resident #1 had refused his enteral feedings, but had been eating more orally. The staff stated the resident did have the ability to recognize things about his body including the sensation of feeling full. Staff T stated the PEG tube feedings were considered supplemental feedings as the resident was eating all meals orally so notifications were not generated for refusals. The staff were unaware if the resident was losing weight. On 7/3/25 at 11:50 AM Staff F, Contract SLP, stated the enteral feedings could have an effect on the resident's oral intake. The staff believed the resident received more of his nutrients and hydration orally rather than enterally. The staff stated Resident #1 had told her he had lost more weight, was around 124#, and preferred to be around 150#.On 7/3/25 at 12:07 PM Staff G, RD, Licensed Dietitian (LD), stated the resident consumed a regular diet pureed and did not receive all nutrients through enteral feed. Staff G stated the resident needed to have an appetite in order to eat, and should be having an appetite if has an order to consume meals orally. The staff stated the resident could be considered a pleasure eater as he did have meal refusals and variable amount of intake when eating. Staff G was not aware of the resident's refusal of enteral intake, and continuous gradual weight loss since December. On 7/3/25 at 1:54 PM the RD, Staff H stated Resident #1 had originally been NPO post surgery in December and the plan was for the resident to eat safely as he did not like the PEG tube. Staff H stated she was unaware of the resident's gradual continuous weight loss from 12/24. On 7/7/25 at 10:57 the Assistant Director of Nursing (ADON)/MDS Coordinator with the Administrator present disclosed prior to Resident #1 returning to the facility in 12/24 with a new PEG tube, the facility had not had a resident for close to a year with a PEG tube. The ADON/MDS Coordinator stated she was unsure of what, if any, education the previous Director of Nursing (DON) had provided to the nursing staff. The ADON/MDS Coordinator stated she had completed hands-on training with a couple of nurses but could not provide training sheets for the training she completed or any training the previous DON may have completed. The ADON/MDS Coordinator stated following the second hospital visit for the clogged PEG tube new medication crushing machines were ordered but it took a few weeks to receive them. The staff stated since the new medication crushing machines were obtained and the resident received a new larger PEG tube there were no more problems. The ADON/MDS Coordinator with DON present stated the SLP was the guiding discipline in the transition to oral intake. The DON stated Resident #1 had been discussed in the previous week ' s Risk Meeting but due to the holiday notification to the RD had not been made. When asked about the length of time before having an IDT meeting regarding the oral and enteral intake refusals, and weight loss no answer was provided by the management leaders present. The facility's Tube Feeding Policy, last reviewed 8/21/24, revealed the PEG tube feeding will be monitored by the RD to ensure the nutritional needs of the resident were being met. The document disclosed the RD will complete assessments to include medication review, estimation of nutritional needs, and weight changes.

Based on resident interviews, staff interviews, clinical record review and staff file review, the facility failed to prevent accidents for 1 of 7 residents. Resident #36 slid from her wheelchair while being transported to an appointment in the facility van. The staff failed to ensure that the resident was stabilized by applying the shoulder strap of the seat belt. The facility reported a census of 47 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #36 had a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficits). She required substantial assistance with dressing, toileting, hygiene, and was totally dependent on staff for transfers. Her diagnoses included: peripheral vascular disease, renal insufficiency, diabetes mellitus, low back pain and unsteadiness on feet. The Care Plan updated on 6/9/25, showed that Resident #36 was at risk for falls and on 5/14/25, she had a fall from the wheelchair, sustained an abrasion to the left knee, treatment and order in place. Weekly treatment documentation would include measurement of each area of skin breakdown, width, length, depth and type of tissue and exudate. According to an Incident Report dated 5/13/25 at 7:30 AM, Resident #36 transferred to an appointment in the facility van and she slid out of her Wheelchair (WC) and onto the pedals of the WC. The resident was not making sense when she returned to the facility, and she had an abrasion to the left knee. All the van drivers were re-educated and demonstrated the proper way to secure residents who were in wheel chairs. A Progressive Discipline Request dated 5/14/25, for Staff M, Transportation Specialist, showed that on 5/13/25, he was driving to an appointment with two residents in the van. Staff M approached a red light too quickly and pressed hard on the brakes. The breaking caused Resident #36 to slide forward in her wheelchair, the cushion slid down onto the top of the foot pedals and her feet were on the floor of the van. Staff M failed to follow safety protocol in the van. The resident only had a lap belt on and not the shoulder strap. Staff M did not notify the residents nurse or take the resident to be evaluated. Staff M failed to report the incident to the administration and the event was reported by the resident. Staff M was terminated from employment on 5/15/25. On 7/7/25 at 3:00 PM, Resident #36 said that Staff M would drive fast in the van and he would stop very quickly. She said that his driving did scare her sometimes because he was careless, but she didn't tell anyone that it made her nervous or afraid. The resident said that she had a lap strap on but not a shoulder strap. Resident #36 said that she slid out of her WC and ended up sitting on the foot pedals. She had a scrape on her left knee. A Skin Observation Tool dated 5/13/25 at 10:00 PM, showed that Resident #36 sustained a left knee abrasion. The document lacked measurements or further description. An Order Audit Report showed that on 5/14/25 at 11:53 AM, staff were directed to apply ski prep to the left knee daily until resolved. On 7/1/25 at 10:30 AM, Resident #32 said that the previous van driver would drive like crazy. He said that he would drive fast, stop and go quickly. The resident said that the driving did not scare him. According to the Minimum Data Set (MDS) dated [DATE], Resident #32 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficits.) The resident was totally dependent on staff for toileting hygiene, showers, dressing and transfers. His diagnoses included: Neurogenic bladder, paraplegia, adult failure to thrive. On 7/7/25 at 3:10 PM, the Maintenance Director (MD) said that the van had room for two, wheelchairs. At the time of the incident with Resident #32, there was just one shoulder strap for the front WC chair. The strap was not working very well, it would get stuck, so he ordered two new straps and those had been installed. On 7/8/25 at 12:32 PM, Staff M said that Resident #32 didn't slide very far, and he got in trouble because he didn't have a nurse assess her right away. He said that he pulled over and assisted the resident back into the wheelchair, then took her appointment. He said that in hindsight, he should have gotten a nurse. He acknowledged that he hadn't used the shoulder strap to secure her in better. Staff M said that he thought he had proper training, it was just that when the light changed it was bad timing and a distance thing so he had to slam on the breaks. When asked if any of the residents ever expressed to him that his driving made them nervous he said that a couple of residents did tell him that he was a fast driver so he tried to keep it down. He said that for some reason, they were in a rush that day. On 7/7/25 at 5:00 PM, the Administrator, Director of Nursing, and Assistant Director of Nursing maintained that they had no knowledge that some residents had concerns about Staff M's driving or that the shoulder straps were not working in van. They said that they would expect that eventually, residents would mention these kinds of concerns in Resident Counsel, or to their Care Partners, (managers assigned to specific residents. They were to check in with them on a regular bases and build trusting relationships).According to the Driver Acknowledgement Form, included in the file for Staff M, as a condition of being permitted to operate or be in possession of a vehicle provided or owned by the company or to operate any other vehicle as part of his job duties for the company, the staff member acknowledged and agreed that when operating a company vehicle or any other vehicle while on company business, he would always wear his seat belt. He acknowledged that he was also responsible to ensure that all passengers were wearing their seat belts and would periodically inspect all seat belts for possible cuts in the fabric or fabric loosening at the buckle or anchor brackets. If involved in an accident, he would immediately call for medical aid and call supervisor or director of the facility.

Based on clinical record review, CDC guidelines, staff interviews, physician interview and facility policy review the facility failed to provide timely assessments and interventions for 3 of 13 residents reviewed (Resident #46, #8 and #37). Resident #46 had a urinary tract infection (UTI) and was on an antibiotic. Staff failed to conduct daily vital signs and did not contact the provider when his condition worsened. The resident went to the hospital in septic shock due to a kidney infection. Daily skilled nurse charting for Resident #8 and Resident #37 showed that staff used vital signs from previous days. The facility reported a census of 45 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #46 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (severe cognitive deficits). The MDS documented he was totally dependent on 2 staff for transferring, dressing and toileting. The Care Plan updated on 7/31/23 documented the resident had altered nutritional intake related to a tube feeding, and to monitor for aspiration. The Care Plan documented the resident had an indwelling urinary catheter due to neurogenic bladder and directed staff to monitor for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and/or change in eating patterns. The Care Plan documented diagnoses to include severe protein-calorie malnutrition, type 2 diabetes, fusion of spine and urine retention. The Progress Notes for Resident #46 in the electronic record revealed the following: On 8/12/23 at 2:00 AM resident refused catheter change, preferred that it be done during the day. On 8/12/23 at 10:45 AM lab results received and faxed to the doctor, awaiting orders. On 8/12/23 at 1:21 PM vital signs documented for the day were dated 8/9/23 1:11 PM. On 8/14/23 at 11:17 PM vital signs documented on this date were dated 8/9/23 1:11 PM. On 8/15/23 at 8:29 PM vital signs 97.3, 92, 18, 118/64, O2 saturations 96%. On 8/17/23 at 3:37 PM vital signs documented at this time were dated 8/15/23 at 8:32 PM. Noticed sludge in the tubing of the catheter, reminded staff to flush per order. On 8/18/23 at 4:18 PM an antibiotic was started for a UTI, vital signs included in this note were dated 8/15/23 at 8:23 PM. On 8/19/23 at 3:01 AM Foley patent, will start antibiotic at 8:00 AM. The notes lacked documentation of current vitals. On 8/20/23 at 5:50 AM the resident refused to allow the nurse to change his catheter. The notes lack any other documentation of vitals or urinary assessment. On 8/23/23 at 9:25 AM vital signs used in the documentation were dated 8/20/23 at 10:57 AM On 8/24/23 at 9:42 AM vitals used were dated 8/20/23 at 10:57 AM On 8/25/23 at 11:57 AM the resident reported tenderness in the abdomen. Abdomen was firm and provider notified. The vital signs included in this note were from 8/22/23 at 9:12 AM. On 8/25/23 at 12:11 PM, the provider was contacted and gave order to continue the antibiotic for 5 more days. On 8/26/23 at 10:04 AM, the resident was moaning in pain and grabbing his abdomen. Vital signs: temperature 99.8 Fahrenheit, respirations 34 per minute, oxygen saturation from 71%-84%. Unable to obtain a blood pressure. Supplemental oxygen applied, the resident was unable to respond to questions. The catheter was changed at that time and 2000 cubic centimeters (cc) of dark red urine with strong odor returned. The resident was sent to the hospital and they reported that he had been intubated. According to the hospital report dated 8/26/23, Resident #46 presented to the emergency room in respiratory distress and found to be in septic shock (severe infection in body) due to pyelonephritis (kidney infection). A bronchoscopy (examination of the lungs) was performed and he was found to have thick, brown mucus collection in the lungs. The diagnosis at the hospital included; septic shock, blood stream infection, acute hypoxic respiratory failure, acute kidney injury and gut distention/ileus (intestine stop moving). The report showed that on 8/27/23, in a 24-hour period, the resident had 2990 milliliters of urine output. According to the Center for Disease Control and Prevention. The normal urine output in a 24 period is between 0.5 - 1.5 cubic centimeters (cc) per kilogram of weight. Retrieved from Urine Output (cdc.gov) on 8/31/23. The census tab in the electronic chart showed that Resident #42 weighed 83.18 kilograms. Which calculated to [PHONE NUMBER] cc of urine output expected in a 24-hour timeframe. The Medication Administration Record (MAR) for Resident #46 showed the following output leading up to his hospitalization : a. 8/21/23: 1340 cc b. 8/22/23: 0 c. 8/23/23: 600 d. 8/24/23: 1200 e. 8/25/23: 0 According to the MAR, the resident had an order for Macrobid antibiotic 100 milligrams twice a day for 5 days. The MAR showed that staff failed to administer the two doses of antibiotic on the 21st and the 22nd and gave just one dose on the 23rd. On 8/29/23 at 12:43 PM, Certified Nurse Aide (CNA) Staff K stated that just before Resident #46 went to the hospital, she had noticed more bloody urine and she had last worked on 8/24/23. She reported this concern to nurse but didn't know if there was any follow up. On 8/29/23 at 12:50 PM, CNA Staff L stated she had noticed more blood in the resident's urine before he went to hospital and his penis was sore with a white substance around it. She told nurse, but she did not know if there was follow up. On 8/29/23 at 2:13 PM, CNA Staff M stated the resident would sit in his own feces for hours and it was difficult to get him to allow them to clean him. In the days leading up to his hospitalization , she did notice that his urine was bloody and there was barely anything in the catheter bag. She stated she reported it to the nurses. On 8/29/23 at 12:54 PM Licensed Practical Nurse (LPN) Staff E stated that when she walked into the room of Resident #46 on 8/26/23, he was lethargic, pale and could not hold a conversation. There was very little urine in his catheter and it was a dark red/brown. His abdomen was distended and when she listened to his bowel sounds, he grimaced when she put the stethoscope on his belly. They couldn't get a blood pressure reading and his oxygen level was very low. She said that it was the morning shift and when she got shift report from the overnight nurse, she had reported the resident had pain through the night and she had flushed his catheter and got 400 cc of urine returned. She and the Director of Nursing (DON) changed his catheter and there was 2000 cc of urine out. He was taken to the hospital shortly thereafter. On 8/29/23 at 2:27 PM, the Primary Care (PC) Physician, stated that he was not aware that the resident had been sent out to the hospital and was not aware of his condition. He checked the file and said that he got a fax on 8/14/23 with results of a urine culture and started the resident on an antibiotic. He was not notified of his change in condition that included increased pain, decrease in urine output and blood in the urine. He would have wanted to know about this especially since they had already determined that there was a UTI. He stated he would have wanted to know the 2000 cc's of urine was returned when they put in a new catheter because he would have wanted to explore why there was so much in his bladder. Staff should have noticed a decrease in output and contacted him for further orders. He stated that he had not been notified on the 25th of distended abdomen and increased pain. On 8/30/23 at 2:10 PM, the Assistant Director of Nursing (ADON) stated that on 8/25/23 she did not call the PC for Resident #42 when the resident had continued pain, but called the Nurse Practitioner (NP) for the medical director of the facility. She asked the NP for an extension on the antibiotic and agreed that the PC should have been contacted. On 8/30/23 at 2:30 PM, the DON stated the staff were expected to contact the primary care physician for the residents. A facility policy titled: Notification of Change, dated 11/1/18 showed that the guidelines for notification of the physician included significant change in condition or unstable vital signs, and signs and symptoms of infection. 2. According to the MDS dated [DATE], Resident #8 was totally dependent on 1 staff for eating, toileting and hygiene. The Care Plan updated on 8/3/23 showed that the resident had congestive heart failure and staff were directed to monitor for orthostatic hypotension (low blood pressure) and increased heart rate. The resident was on a feeding tube and staff were to monitor his heart rate and lung functioning. Daily Skilled Charting included the following in the electronic nursing notes: On 8/10/23 at 7:25 PM the vitals entered had been obtained on 8/8/23 at 1:17 PM. On 8/11/23 at 2:15 PM the vitals entered had been obtained on 8/8/23 at 1:17 PM. On 8/22/23 at 3:37 AM the vitals entered had been obtained on 8/17/23 at 5:45 AM. On 8/30/23 at 2:15 PM the Administrator stated that it was expected that staff would provide monitoring every shift for residents that had infections, this would include vital signs every shift and not using the vitals from previous days. 47673 3. The MDS dated [DATE] for Resident #37 revealed a BIMS of 00 out of 15 indicating severe cognitive impairment. The Progress Notes for Resident #37 documented the following: On 7/17/23 at 11:26 AM the resident returned from the hospital at 10:00 AM. Vitals include 97.2, O2 saturations 93%, 76, 144/70. On 7/17/23 at 2:28 PM a new verbal order from the physician for doxycycline monohydrate oral tablets to be given two times a day for aspiration pneumonia for 7 days. On 7/18/23 at 10:39 PM resident alert/confused, keeps removing clothes and throwing them on the floor, started on antibiotic with no adverse reaction. On 7/19/23 at 11:32 PM temperature 98.1, continues on antibiotic for aspiration pneumonia. Lung sounds have rhonchi throughout and audible wheezes. On 7/21/23 at 2:15 AM resident continues on antibiotic without any adverse reactions to treatment. Lung sounds course throughout, no audible wheezes noted at this time. On 7/21/23 at 12:55 PM provider spoke to family about hospice services and they are agreeable. On 7/22/23 at 3:00 PM resident fell out of wheelchair unwitnessed. All vitals and neuro good with no injury. On 7/24/23 at 9:12 PM received final dose of antibiotics. On 7/25/23 at 11:16 AM change in condition reported on due to abnormal vital signs. On 7/25/23 at 3:47 PM resident's condition continues to decline. Vitals 111/81, O2 saturations 97%, 27, 127, 97.8. Pupils did not fully contract to light. Breath sounds shallow and resident extremely sweaty. On 7/25/23 at 4:10 PM called power of attorney and nurse practitioner with verbal order for resident to be sent to the emergency room due to decline and being a full code for advanced directives. On 7/26/23 at 12:43 AM call to hospital to get an update and informed resident admitted for sepsis and altered mental status. Review of Resident #37's Vitals Summary's revealed vital signs not obtained 7/17/23 - 7/25/23 unless noted above in Progress Notes. Review of document titled Office Progress Notes service dated 7/27/23 revealed chief complaint was urinary tract infection/sepsis.

Based on interview, record review, and policy review, the facility failed to ensure the Licensed Practical Nurses (LPN) facilitated needed intervention (a hospital transfer) for 1 of 15 sampled residents (Resident (R) 38). This resulted in a delay of the hospital admission care which resulted in harm when R38 was admitted to the hospital on the following morning with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility identified a census of 36 residents. Findings include: Review of the facility policy titled ''Notification of a change in a resident's condition,'' reviewed 04/28/21, revealed the ''Guideline for Notification of Physician/Resident Representative included emesis/diarrhea, change in level of consciousness, and abnormal complaints of pain-ineffective relief of pain from current regime, glucose reading below 70 or above 200.'' Review of the ''Face Sheet,'' under the ''Profile'' tab in the electronic medical record (EMR), revealed R38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ''Progress Notes'' tab in the EMR for R38 dated 05/22/22 at 1:52 PM, Licensed Practical Nurse (LPN) 6 documented R38 was ''sitting up, felt dizzy, nauseous, in pain with vital signs [vs] blood pressure [BP] 110/48, pulse [p] 84, respirations [r] 18 and Oxygen saturation [O2sat] 95 % [percent]. The resident reported she was continually passing out, there were no signs of her passing out. Resident stated she wanted to go to the hospital to figure out what was going on with her.'' The resident blood sugar was checked, and results were 400, and resident did not eat lunch, rechecked her blood sugar at 1:30 PM with result 548. LPN6 called the physician to report the blood sugar results and obtain insulin orders. Review of the ''Progress Notes'' tab in the EMR for R38 dated 05/23/22 at 7:17 AM, revealed LPN 5 documented about R38, the Certified Nursing Assistant (CNA) requested LPN5 immediately assess R38 due to change in condition, that throughout the shift R38 complained of nausea and unresolved pain described by R38 as unbearable. Vital signs were BP 99/73, p 95 irregular r 20 and O2sat 95%. Resident was transferred to the hospital. Review of the ''Progress Notes'' tab in the EMR for R38 dated 05/23/22 at 9:33 AM, LPN4 documented ''received call from ER and [R38] was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .'' There were no additional progress notes in the EMR between 05/22/22 at 1:52 PM and 05/23/22 at 9:33 AM. Review of the ''SBAR'' report, completed by LPN5, under the Assessments tab in the EMR, dated 05/23/22, documented R38 vital signs as BP 99/73, p 95, r30, O2sat 95%. Review of the paper Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R38 was administered [MEDICATION(S)] four times a day on 05/15/22, twice on 05/16/22, twice on 05/17/22, four times a day on 05/18/22, three times on 05/19/22, five times on 05/20/22, and three times on 05/21/22; on 05/22/22 R38 received one tablet at 8:30 AM, no pain level documented; one tablet at 1:50 PM, pain level of 10 out of 10; and one tablet at 6:30 PM, no pain level documented. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation to show if the pain medication was effective. There was no additional documentation of pain assessments on 05/22/22 and 05/23/22. Review of the paper MAR for the month of May 2022 revealed R38 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R38 was administered [MEDICATION(S)] HCL once on 05/16/22, once on 05/17/22, and twice on 05/18/22. There were no additional documented administrations of [MEDICATION(S)]. Review of paper MAR for the month of May 2022 revealed R38 had an order of 8 units of Insulin [MEDICATION(S)], stated 05/13/22, to be given before meals and to notify the medical doctor of blood sugars over 400. R38's blood sugars were below 200, except for the following dates and times: On 05/19/22 at 4:00 PM, BS was 333. On 05/21/22 at 11:00 AM, BS was 397. On 05/21/22 at 4:00 PM, BS was 515. On 5/22/22 at 7:30 AM, BS was 326. On 05/22/22 at 11:00 AM, BS was 400. On 05/22/22 at 4:00 PM, BS was 310. It should be noted per the progress note above on 05/22/22 at 1:52 PM, on 05/22/22 at 1:30 PM R38's BS was 548. Per the nursing note, the LPN received orders for additional insulin. No additional blood sugar monitoring was documented on 05/22/22 between 1:30 PM and 4:00 PM, or after 05/22/22 at 4:00 PM until R38 discharged on the morning of 05/23/22. Review of the facility-provided hospital admission record dated 05/23/22 revealed R38 ''presented at the ER with complaints of LLQ [left lower quadrant] abdominal pain, nausea, vomiting and diarrhea over the last three days. Had blood in her stools according to the facility staff. Denies fevers or chills and is currently complaining of feeling very weak. Emergency department evaluation included CT of the abdomen with impression acute sigmoid diverticulitis and hemoglobin (hgb) 4.7 (down from 9.3 on 5/16/22 with baseline hemoglobin around 10).'' Further review of the hospital records dated 05/23/22, revealed the assessment and plan for R38 as the following: 1. Severe normocytic (red blood cell) blood loss [CONDITION(S)]; hgb 4.7 with melena (stool containing blood); type/cross and transfuse 2 units now; holding 2; goal hgb 7.0 or better. 2. Acute diverticulitis; no gas collection or abscess; start on lV [MEDICATION(S)] (antibiotic); general surgery to consult, keeping NPO (nothing by mouth), pain control PRN 3. Gl bleed; had maroon gelled stool in ER; started on intravenous (lV) [MEDICATION(S)] (medication to reduce stomach acid) infusion; requiring blood transfusion 4. [CONDITION(S)]; treated with [CONDITION(S)] protocol in ER; repeat potassium level 5. Acute kidney injury; no evidence of UTI; likely secondary to [CONDITION(S)]/volume depletion; continue with volume resuscitation. During a telephone interview on 06/02/22 at 10:19 AM, LPN6 was requested to recount the events during her shift on 05/22/22 from 6:00 AM until shift end at 6:00 PM. LPN6 recounted the CNA told her R38 wanted to go to the emergency room (ER) and when LPN6 checked on her found she was dizzy and checked her vital signs and blood sugar, which was high. LPN6 commented that R38 had been eating red candy in her room. The CNA showed her stool from R38 that was blackish brown with a smear of blood. LPN6 called the Assistant Director of Nursing (ADON) about the dizziness and the resident request to go to the ER. The ADON told LPN6 it was okay to send R38 to the ER and to call the I-DON and physician. LPN6 called the Interim Director of Nursing (I-DON) mentioning R38 wanting to go to ER due to dizziness, abdominal pain, and high blood sugar. Also called the Medical Director and reported information about the high blood sugar and got orders for insulin and to obtain a urine sample; LPN6 did not notify the Medical Director of R38's blackish stool, abdominal pain, dizziness, or reports of passing out. LPN6 reported R38 felt better after the insulin and pain medication. Two hours later R38 was asleep, snoring. The facility provided an internal investigation concerning R38 on 05/22/22 with statements written and signed by staff on 05/24/22. LPN6 documented the events of working the weekend day shift on 05/22/22. LPN6 documented R38 stated ''she did not feel right and wanted to go to the ER.'' LPN6 documented addressing R38's dizziness by placing her back in bed, applying oxygen and verbal reassurance. R38 may have gotten up too fast. LPN6 documented the CNAs changed R38 and the stool was unformed black to brownish in color with scant blood. Informed the ADON, I-DON and physician about the dizziness and blood sugar and reported the resident felt better after the insulin, pain medication, and [MEDICATION(S)] (anti-nausea medication). During a telephone interview on 06/02/22 at 10:06 AM, CNA12, who worked with LPN6 on the day shift on 05/22/22, remembered R38 used call light requesting a brief change. CNA12 noted the stool in the brief was maroon in color and brought it to the attention of LPN6 who responded she thought the maroon color was due to food R38 had eaten. CNA12 witnessed R38's eyes rolled back in her head after getting up to the wheelchair and R38 responded when her name was called. CNA12 reported this to LPN6, requesting her to assess the resident and reported another maroon stool. The facility provided an internal investigation concerning R38 on 05/22/22 with statements written and signed by staff on 05/24/22. CNA12 recounted the events of working with LPN6 on 05/22/22 day shift. CNA12 documented she (CNA12) went into R38's room to answer the call light about changing her brief. CNA12 noted the stool had some discoloration to it and she had puked up brown stuff. After R38 was cleaned up, she declined going to breakfast because she did not feel well. Before lunch she put on her call light and had another bowel movement and requested to be up in the wheelchair to see if she would feel better. R38 put on the light again and had another discolored stool. R38 was talking and her eyes rolled back in her head but responded when her name was called. After being placed in bed again, R38 asked for the nurse (LPN6) because she wanted to go to the ER. When LPN6 asked why she wanted to go to the ER, R38 said she was ''scared.'' Her eyes kept rolling back and she had 4-6 discolored stools. CNA12 documented that R38's stools were normal on Friday and Saturday (5/20/22 and 5/21/22). During a telephone interview on 06/02/22 at 9:41AM, LPN5 was requested to recount the events during the shift on 05/22/22 from 6:00 PM until shift end on 05/23/22 at 6:00AM. LPN5 recounted R38 complained of pain often. LPN5 would check on R38 and the resident was sleeping. LPN5 revealed sometimes R38's pain would also make her nauseous and she kept finding R38 asleep. The CNA working with LPN5 reported the stool was colored but he (LPN5) did not see what color it was. LPN5 knew R38 had pancreatitis and that stool could be clayish in color and the CNA did not show him the color of the stool. LPN5 reported R38 described her pain as a 12 on a scale of 1-10. LPN5 knew the physician had been called and the physician did not give an order to send the request R38 go to the ER. The facility provided an internal investigation concerning R38 on 05/22/22 with statements written and signed by staff on 05/24/22. LPN5 documented the events of working the weekend shift on 05/22/22 from 6:00 PM to 05/23/22 at 6:00 AM. LPN5 documented the CNAs were concerned about R38's stools because they were an odd color. The resident complained of nausea and LPN5 administered [MEDICATION(S)] and pain medication as ordered by the physician. The resident had a sudden change in condition at the end of the shift and was sent to the ER. During a telephone interview on 06/02/22 at 9:41AM, CNA10 was requested to recount the events during the shift on 05/22/22 from 6:00 PM until shift end on 05/23/22 at 6:00AM. CNA10 remembered working with LPN5 and got report from the day shift that R38 did not get up to eat that day and it was unusual and had emesis, vomiting a maroon color, stool was maroon and thought it was red candy R38 had eaten. When CNA10 looked in on R38 at the beginning of the shift, R38 looked like she did not feel good and asked for crackers. At about 3:00 AM, CNA10 changed R38's brief and R38 continued to say she did not feel well, something was wrong. R38 was pale and sweaty, and her legs were cold. CNA10 told LPN5 and LPN5 came into the room and asked if the medication had been effective and walked out, not addressing the issues or taking CNA10 seriously. As soon as the nurse for the day shift came onto the unit CNA10 had LPN4 come to R38's room and LPN4 began the process to send R38 to the hospital. During an interview on 06/01/22 at 1:56 PM, LPN4 recounted what occurred on 05/23/22 with R38 when LPN4 came on shift at 6:00 AM. LPN4 recalled the CNA from the night shift was shaking and saying LPN4 had to come right away to look at R38. LPN4 found R38 clammy, sweaty, in extreme abdominal pain, and begging to be sent to the hospital. LPN4 was hearing from the night shift CNAs that maroon stools were reported to LPN5 and nothing was done. LPN4 proceeded with the process to have R38 transported to the hospital. During a telephone interview on 06/03/22 at 1:22 PM, the Medical Director was requested to recount a phone call about R38 that occurred on 05/22/22. The Medical Director remembered a call about blood sugar being high and asking about the history of blood sugars. He ordered a sliding scale insulin and to increase the next morning insulin to be increased by 5 units. The Medical Director stated he was not informed about maroon stools, brown emesis, abdominal pain, or other symptoms R38 was experiencing. The Medical Director confirmed if he had known about the additional symptoms of maroon stools and brown emesis, he would have had R38 admitted to the hospital. The facility provided an internal investigation concerning R38 on 05/22/22 with statements written and signed by staff on 05/24/22. Included in the documentation of the event with R38 on 05/22/22-05/23/22 the conclusion of the investigation provided by the Administrator revealed LPN6 would be terminated, LPN5 would be terminated, and Nursing Management would monitor change in conditions for residents for proper assessment and notification of physician, family/Responsible Party. An interview on 06/03/22 at 1:18 PM, the Interim Director of Nursing (I-DON) confirmed for the reference for nursing practice the facility uses Lippincott Nursing Management. Review of Lippincott Nursing Management of Upper Gastrointestinal Bleeding, dated 01/2022, revealed assessment for GI bleeding included vomiting of blood or coffee-ground appearing material or melena. Patient symptoms include dizziness, light-headedness, cold/clammy extremities, upper abdominal pain, nausea, and emesis. Retrieved from www.nursingcenter.com/clinical-resources/nursing-pocket-cards/management-of-upper-gastrointestinal-bleeding.

Based on observations, record review, and resident and staff interviews, the facility failed to provide tracheotomy care, tracheal suctioning, and aerosol drug administration, in accordance with professional standards of practice for 6 of 7 residents reviewed (Resident #2, 3, 6, 7, 11 and 12). Resident #2 was dependent on a ventilator related to chronic [CONDITION(S)]. On [DATE] at 3:46 AM, his ventilator alarmed displaying low ventilation. The nurse suctioned him, but the ventilator continued to alarm. The facility called an ambulance and began rescue breathing with an ambu bag. When EMS arrived, they found Resident #2 unresponsive and suspected a plugged [CONDITION(S)]. They transported the resident to the hospital where he presented with [CONDITION(S)] (an absence of enough oxygen in the tissues to sustain bodily functions) and subsequent [CONDITION(S)]. The resident was provided CPR in accordance with his advanced directive. The physical exam revealed a completely occluded inner [CONDITION(S)] cannula. The Respiratory Therapist removed the cannula and could then easily (ambu) bag the resident. These findings costituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 32 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated [DATE]. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had severe cognitive impairment and required total assist of 2 staff for bed mobility, transfers, bathing and toilet use; and total assist of 1 staff for eating and personal hygiene. The MDS also documented the resident was short of breath when sitting, at rest, and when lying flat, received oxygen therapy, suctioning, and [CONDITION(S)] care and was on an invasive mechanical ventilator. The Care Plan dated [DATE] documented Resident #2 had a communication problem related to respiratory impairment, impaired cognitive function, and disease process. The care plan documented he had a [CONDITION(S)] and was dependent on a ventilator related to chronic [CONDITION(S)]. The care plan contained the following directives for staff: Ensure [CONDITION(S)] ties are secure at all times. Observe/document for respiratory rate, depth and quality every shift. Assess for signs and symptoms of [CONDITION(S)]. Observe for indications of tube obstruction and suction as needed. Observe oxygen saturation while on a ventilator every shift. Provide [CONDITION(S)] care twice in a 24-hour period, and change inner cannula one time in 24-hour period or more often as needed. Resident #2's Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Order Summary Report documented the following active orders for [DATE]: Change the inner cannula every day shift for [CONDITION(S)] care. CPR per the residents IPOST. Skin prep applied to [CONDITION(S)] site for breakdown every day shift for [CONDITION(S)] care. Provide [CONDITION(S)] cares every day and night shift. The Treatment Administration Record (TAR) for Resident #2 for July - [DATE] lacked documentation to show the nurses provided [CONDITION(S)] care every day and night shift as ordered. The TAR lacked documentation to show the nurses changed Resident #2's inner cannula every day shift during [CONDITION(S)] care and also lacked documentation to show the nurses applied skin prep to the [CONDITION(S)] site every day as ordered. The Respiratory and Oxygen Saturation Summary Report dated [DATE] - [DATE] lacked documentation of Resident #2's respiratory rate and oxygen saturation every shift in accordance with the resident's care plan. Resident #2's Progress Notes dated [DATE] - [DATE] lacked documentation to show the nurses provided [CONDITION(S)] care and completed respiratory assessments every shift. The Progress Notes revealed on [DATE] at 3:46 AM, the resident received rescue breathing and oxygen due to low ventilation and required an ambulance transfer to the hospital. The Emergency Department (ED) Provider Notes dated [DATE] at 4:24 AM documented an unresponsive Resident #2 presented to the ED via Emergency Medical Squad (EMS). The notes showed EMS staff found the resident at the facility in respiratory distress. The EMS staff started CPR, gave one dose of epi ([MEDICATION(S)]) with two rounds of CPR. The physical exam revealed a completely occluded inner cannula inside the resident's [CONDITION(S)]. The Respiratory Therapist removed the cannula and could then easily bag the resident. The [CONDITION(S)] Care facility policy dated [DATE] directed staff to provide [CONDITION(S)] care as ordered by the physician and as needed at a minimum of every 8 to 12 hours. After initial placement, the [CONDITION(S)] staff may need to clean and suction it more frequently. The policy also directed staff to verify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing (DON) on [DATE] at 1:05 PM she stated she expected the nurses to provide [CONDITION(S)] care twice a day, with each shift, and to suction as needed. She stated she expected the nurses to document [CONDITION(S)] care on the resident's TAR and also to document any respiratory assessments in the progress notes. She stated the facility does not have a Respiratory Therapist on staff and one does not come regularly, but they do have a contract with a company to come and set up any new equipment and also if they have trouble with the equipment. During an interview with the DON on 10//,d+[DATE] at 1:45 PM, she stated if there is no documentation on the TAR or nurses notes, then she would consider it (the task, assessment or intervention) not done. She stated the nurses complete a daily respiratory assessment on another resident so she does not know why it is not being completed for all residents with a [CONDITION(S)]. She added she is considering implementing that for all residents with a [CONDITION(S)] from now on, because she expects the nurses to complete, at a minimum, a daily respiratory assessment on all residents with a [CONDITION(S)]. 2. According to the MDS assessment tool dated [DATE] Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident remained in a persistent vegetative state, did not transfer or walk during the look back period; and required total assist of 2 staff for bed mobility, dressing, personal hygiene, bathing and toilet use. The MDS documented she received oxygen therapy, suctioning, [CONDITION(S)] care, and required an invasive mechanical ventilator. Review of Resident #3's Baseline Care Plan dated [DATE] revealed it was incomplete. The Care Plan dated [DATE] documented Resident #3 required a ventilator, had pneumonia related to being ventilator dependent, and also had a [CONDITION(S)]. The care plan directed staff to assess for signs and symptoms of [CONDITION(S)] (altered level of consciousness, irritability, listlessness, and cyanosis), monitor for changes in respiratory rate or depth, observe/document for use of accessory muscles, notify physician of significant changes, observe for indications of tube obstruction, s suction as needed/necessary, provide [CONDITION(S)] care twice in a 24-hour period, change inner cannula as necessary, monitor/document respiratory rate, depth and quality, and check and document every shift as ordered. The Nursing Admission Screening documented the resident admitted to the facility on [DATE] from the hospital with shortness of breath and in a persistent vegetative state. The form documented her respiratory rate at 20, her oxygen saturation at 97 percent via [CONDITION(S)], and lung sounds as normal. Resident #3's Clinical Record lacked daily respiratory assessments or [CONDITION(S)] care assessments. The Weights and Vitals Summary from [DATE] - [DATE] lacked documentation of respirations and oxygen saturations completed by facility staff at least daily. The clinical record lacked documentation of a TAR for [DATE] - [DATE]. During an interview with the DON on [DATE] at 12:05 PM, she stated Resident #3 did not have a TAR for that time period and added the TAR would be where she expected to find documentation related to care of the residents [CONDITION(S)], skin, and peg tube. The Progress Notes for Resident #3 documented the following: - On [DATE] at 6:08 PM new admission Resident #3 arrived at the facility at 12:20 PM via medivac on a ventilator. The resident also had a [CONDITION(S)], slight swelling in both hands and some bruising on her abdomen. Resident is resting in her room with the head of the bed elevated. - On [DATE] at 2:47 PM the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident is currently on vent per [CONDITION(S)] and appears to be dependent on this vent. Resident had a recent mitral valve surgery complicated by a post-operative stroke and is now mostly unresponsive. The resident also had a recent CABG and lengthy hospitalization . - On [DATE] at 11:14 AM resident sent to the emergency room at this time via local rescue due to temperature of 99.0, staff could not give medications through the resident's g-tube, and change of breathing pattern (labored) during [CONDITION(S)] cares with heart rate 92 and bounding. - On [DATE] at 5:47 PM the emergency room nurse reported they replaced the [CONDITION(S)] and suctioned it well. Respirations are no longer labored, although the resident had a urinary tract infection and the physician prescribed intramuscular (IM) antibiotics and increased [MEDICATION(S)] for a few days. Resident to return to facility around 7:00 PM. -On [DATE] at 5:33 AM, nurse notified that the resident's trilogy is alerting and her respirations increased to 40. Upon assessment, resident's current respiratory rate 26, oxygen saturations at 96 percent, afebrile, no indications of respiratory distress with no labored breathing or grimacing noted. Physician notified and gave staff new orders for complete blood count, COVID-19 test, and notify the physician if resident has respirations above 30 per minute. - On [DATE] at 6:29 AM, resident had a high respiratory rate. Staff replaced inner cannula and suctioned the resident three times with significant blood noted. - On [DATE] at 6:57 AM, physician aware of condition changes and gave order to send Resident #3 to the hospital for further evaluation. EMS transported the resident to ER at 7:53 AM. - On [DATE] at 12:49 PM, resident came back from the hospital - they she needed humidified air and scant amount of blood was normal, but notify provider if blood turns darker. - On [DATE] at 6:59 PM, resident on antibiotics for urinary tract infection, no adverse reactions, urine yellow in color and clear. - On [DATE] at 10:22 AM, antibiotic [MEDICATION(S)] given in left hip and resident tolerated it well. - On [DATE] at 10:26 AM, last dose of [MEDICATION(S)] given with no adverse reactions noted and vitals within normal limits. - On [DATE] at 5:42 PM, resident suctioned twice this shift and tolerated it well. Noted moderately thick red tinged secretions. - On [DATE] at 9:31 AM, resident's temperature 99.7 this morning and the nurse administered Tylenol. On follow up, her temperature increased to 101.4. Physician updated and received order to send to the hospital. - On [DATE] at 4:17 PM the DON spoke to the hospital - resident has bilateral pneumonia and is being admitted . - On [DATE] at 3:45 PM resident readmitted to the facility at 2:45 PM today. Resident continues on trilogy ventilator with home setting. Resident has a PICC line and will need intravenous antibiotics for 35 days. Family aware of readmit. The After Visit Summary from the hospital dated [DATE] - [DATE] for Resident #3 documented reason for hospitalization included bilateral interstitial pneumonia, bladder infection, and chronic [CONDITION(S)]. During an interview with the daughter on [DATE] at 9:30 AM she stated her mother remained in the ICU at the hospital but may be ready to be released back to the nursing home tomorrow. She stated she will be sent back on antibiotics but she is not sure where the infection is and is not sure if the hospital is knows. She stated her mother had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She added her mother had a stroke previously during surgery and that is why she was on a [CONDITION(S)] and at the facility. The daughter reported her mother admitted to the facility on [DATE] around 9:30 AM; they went to the facility around 5:00 PM to check on her and found the [CONDITION(S)] had crusty secretions in it. They called for a nurse and noted the facility did not even have suction set up at the bedside yet. She stated her mother had three trips to the hospital during 7 days at the facility, so it frightens her to have her sent back to the facility but they cannot find another facility that takes ventilator patients. She stated the last time she was sent to the hospital and admitted , the staff at the hospital told her the [CONDITION(S)] contained an obstruction the size of a pea and that was why she was having trouble breathing. The hospital staff told her the facility staff could not have been providing regular [CONDITION(S)] care and suctioning, or else her [CONDITION(S)] would not have been that obstructed. 3. According to the MDS assessment tool dated [DATE], Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored ,d+[DATE] on the BIMS which meant he demonstrated intact cognitive abilities. The MDS also documented the resident as independent with bed mobility, transfers, walking, and toilet use, required extensive assist of 1 staff for dressing, and required supervision of 1 staff for eating and personal hygiene. The Care Plan dated [DATE] documented Resident #6 had a [CONDITION(S)] and depended on the ventilator at night related to [CONDITION(S)]. The care plan directed staff as follows: Monitor oxygen saturations every shift or more frequently as needed. Provide routine [CONDITION(S)] care twice in a 24-hour period. Change inner cannula one time in a 24-hour period. Observe/document/report respiratory rate, depth and quality. Check and document every shift. Resident #6's TAR dated [DATE] and [DATE] lacked documentation to show nurses provided [CONDITION(S)] care every day and night shift and checked the oxygen saturation to titrate the oxygen to keep the saturations above 90 percent as ordered. Review of the Progress Notes revealed a lack of documentation to verify nurses provided [CONDITION(S)] care and respiratory assessments twice a day as ordered. During an interview on [DATE] at 3:40 PM, Resident #6 stated once the facility no longer had a respiratory therapist he did not receive regular [CONDITION(S)] care or suctioning. He stated the nurses would not do it at all unless he asked and then they would tell him they were busy or short staffed and he would have to wait. He added that some days he would not get it at all. 4. According to the MDS assessment tool dated [DATE], Resident #7 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident as independent with cognitive skills for decision-making and her memory was intact. The MDS also documented she required extensive assist of 2 staff for bed mobility, transfers, dressing, and toilet use, could not walk, required extensive assist of 1 staff for personal hygiene and was on oxygen therapy. The clinical record lacked a baseline care plan. The DON stated it was because the resident was in the facility less than 48 hours. The Hospital Discharge Documents dated [DATE] directed staff to administer respiratory nebulizer medications every 8 hours and every 4 hours as needed, and also administer four different hand held inhalers two times per day. The Nursing Admission Screening dated [DATE] documented the resident admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The form revealed the resident remained alert and oriented times four with shortness of breath, wheezes in her lungs, oxygen saturation (O2 Sat) at 95 percent, and extremities with [CONDITION(S)] but no pitting. The clinical record lacked any Medication Administration Records (MARS) or TARS to show staff administered Resident #7 medications and treatments per physician orders. During an interview with the DON on [DATE] at 2:20 PM, she stated the facility does not have any MARS or TARS for Resident #7 and no other documentation to validate staff administered medications and treatments according to orders. During an interview on [DATE] at 10:53 AM with Resident #7's sister, she stated her sister reported on [DATE] that she had not had any of her medications or respiratory treatments. She went to the nurse to check on them and the nurse told her the facility did not have any orders for the resident's medications and therefore she could not give them. The resident's sister stated she visited again on Sunday, [DATE]. The staff still had not given her any medications and the resident now complained of chest pain. The facility sent the resident to the hospital emergency room in accordance with the family's wishes. The hospital subsequently admitted her due to increased [CONDITION(S)] with weeping of both legs and increased shortness of breath. The sister added the hospital had to administer [MEDICATION(S)] to rid the resident of excess fluid. The Emergency Department Provider Notes dated [DATE] documented facility staff transferred Resident #7 to the hospital due to shortness of breath; when the resident arrived, hospital staff found her in poor condition with soiled clothing and an initial oxygen saturation of 76 percent with wheezing in her lungs. The note revealed she displayed tachypnea (rapid breathing) while utilizing her accessory muscles to breathe. The History and Physical (H&P) from the hospital dated [DATE] documented Resident #7's principal problem as acute on chronic [CONDITION(S)] with [CONDITION(S)] (low oxygen) and hypercapnia (excessive carbon [MEDICATION(S)] in the bloodstream, typically caused by inadequate respiration). The H&P documented the hospital admitted the resident for exacerbation of [CONDITION(S)]. 5. According to the MDS assessment tool dated [DATE] Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored ,d+[DATE] for the BIMS indicating he is cognitively intact. The MDS documented he required total care of 2 staff for transfers, bathing and toileting; total care of 1 staff for hygiene; extensive assist of 2 staff for bed mobility and dressing and extensive assist of 1 staff for eating. The MDS documented he received oxygen therapy, suctioning, and [CONDITION(S)] care. The Care Plan dated [DATE] for Resident #11 indicated he had a [CONDITION(S)] related to impaired breathing mechanics and sleep apnea. The care plan directed staff to suction as ordered if he is unable to clear secretions and to monitor/document respiratory rate, depth and quality every shift. The care plan documented the resident liked to be suctioned several times per day. Review of the clinical record dated ,d+[DATE]-[DATE] revealed the facility failed to complete Resident #11's respiratory assessment every shift. The Every Shift Charting form lacked documentation once per day on the following dates: [DATE]-[DATE], [DATE], [DATE]-[DATE], [DATE], [DATE]-[DATE], [DATE], [DATE]-[DATE], [DATE], [DATE], [DATE]-[DATE], [DATE], [DATE] and [DATE]-[DATE]. The TAR dated July, 2021 lacked documentation to validate that facility staff provided Resident #11's [CONDITION(S)] care twice a day as ordered on [DATE], [DATE]-[DATE], [DATE]-[DATE], and [DATE]-[DATE]. The TAR dated [DATE] lacked documentation that confirmed facility staff completed Resident #11's [CONDITION(S)] care twice a day as ordered on [DATE]-[DATE]. The clinical record failed to contain a TAR for [DATE] that documented the provision of Resident #11's [CONDITION(S)] care. The DON stated on [DATE] at 1:30 PM that she could not locate it. 6. According to the MDS assessment tool dated [DATE] Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 on the BIMS test and required limited assist of 1 staff for bed mobility and toilet use, extensive assist of 2 staff for walking, extensive assist of 1 staff for transfers, dressing, personal hygiene and bathing. The MDS also documented Resident #12 used oxygen and a non-invasive mechanical ventilator. The Care Plan dated [DATE] indicated for Resident #12 required oxygen therapy related to [CONDITION(S)] and heart failure. The care plan directed staff that she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan also directed staff to monitor/document/report as needed any signs or symptoms of heart failure (dependent [CONDITION(S)], shortness of breath and lethargy), assess oxygen settings, administer oxygen via nasal cannula as ordered and monitor for signs and symptoms of respiratory distress. The Progress Notes documented the following: - On [DATE] at 8:00 AM for Resident #12 the resident arrived in the dining room for breakfast and became unresponsive to all stimuli, including painful stimuli. Staff identified the resident's oxygen tank was off and her saturations were 50 percent. They turned the tank back on and within 2 minutes her oxygen saturation measured 96 percent, however the resident remained unresponsive with her eyes rolled back in her head. Staff called 911 and notified the resident's family. - On [DATE] at 4:00 PM, the resident returned to the facility from the emergency room with new orders for an antibiotic for a urinary tract infection. During an interview on [DATE] at 1:30 PM with Resident #12, she stated she admitted to the facility on [DATE]. She stated her cousin is her Power of Attorney (POA) and they both have concerns. The resident called the POA and got her on the phone. They are concerned with the facility not having enough staff and the time it takes for them to answer her call light. She stated recently she had her call light on because she couldn't breathe, the facility staff took 30 minutes to answer, although it seemed like an hour. The resident wore a watch and also had a clock on the opposite wall to her recliner. She stated when they finally came, her oxygen level was down in the 60's so they ended up sending her to the hospital. Her POA stated the staff keep telling her the resident is self-sufficient and should be able to put her own mask on, but the resident forgets and falls asleep. She added she has told the staff this repeatedly. During an interview on [DATE] at 10:05 AM with Staff D, she stated she was an agency nurse at the facility for only one night and then she requested the staffing agency not send her back. She stated the aides working that night told her they were regularly short staffed. Staff D reported she was concerned that [CONDITION(S)] care was not completed as ordered due to the short staff and the trachs were soiled with build-up around them when she provided cares that night. During an interview on [DATE] at 12:22 PM, Staff E she stated she worked at the facility for 2 months and then went to a staffing agency due to the lack of care and support at the facility. She stated she had never seen staff provide [CONDITION(S)] cares while she was there. She stated a [CONDITION(S)] had come unconnected and so she called for a nurse. She stated there was gunk around the [CONDITION(S)] and the nurse did not clean it or change it, they just hooked it back up; she asked the nurse if she was going to change it because it was so dirty. She reported the nurse told her she did not know how to change it. During an interview on [DATE] at 2:36 PM, Staff A stated the facility hired her on [DATE] and she had 3 days of training. She stated her friend that was a fell ow nurse at the time trained her, but she felt like she did not have formal training by the facility. She stated she did not feel confident that she was doing it right, so she watched videos online to train herself. She added some of the agency nurses had also told her they have not been trained on [CONDITION(S)] care and ventilators. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] at 4:15 p.m. The IJ was removed on [DATE] after the facility implemented the following: 1. The Director of Nursing (DON) completed an in-service with licensed staff related to [CONDITION(S)] Care/Suctioning Policy on [DATE] 2. The facility established [CONDITION(S)] Care and Suctioning Competency with return demonstration from all current staff after viewing the video education on [DATE] 3. The facility updated the Staffing Agency Orientation Checklist with [CONDITION(S)] Care & Suctioning Competency on [DATE] 4. The DON completed an in-service with licensed staff related to completing Respiratory Assessment documentation each shift 5. The facility reviewed guidelines for conducting Respiratory Assessments and made them available at the nurse's station for all existing and staffing agency staff on [DATE]. 6. The DON/Designee completed a 100% audit on residents to ensure staff completed [CONDITION(S)] Care/Suctioning on [DATE]. Auditing will continue daily. 7. No professional staff began their shift without validation of competency by DON or Designee utilizing competency forms. 8. DON/Designee will orient newly hired staff or staffing agency personnel regarding the [CONDITION(S)] Care/Suctioning Policy & Respiratory Assessment documentation effective [DATE].

Based on observation, record review, and resident, family, and staff interviews, the facility failed to complete assessments, implement interventions, and provide medication and wound care in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 admitted from the hospital on 7/23/21 for skilled care due to worsening of pulmonary hypertension and heart failure. The facility failed to provide daily assessments and failed to administer any of her medications; this resulted in re-hospitalization on [DATE] for chest pain, increased [CONDITION(S)] (swelling) with weeping extremities, and shortness of breath. Resident #15 admitted to the facility on [DATE] with a venous wound to her left lower leg. The facility failed to measure or complete a full skin assessment on the wound until 9/1/21. The facility also failed to document the facility staff provided wound care consistently as ordered and failed to update wound care orders on 9/1/21, which resulted in wound deterioration and infection. These findings constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 32 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 8/13/21, Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 8 of 15 possible points on the Brief Interview of Mental Status (BIMS) test, indicating she displayed moderately impaired cognitive skills. The MDS also documented Resident #1 required total assist of 2 staff for bed mobility, transfers, and toilet use, total assist of one staff for dressing, and extensive assist of one staff for bathing. The MDS identified Resident #1 as at risk for developing pressure ulcers and coded the resident had no pressure ulcers during the MDS lookback period. The MDS revealed the resident had a pressure reducing device for her chair, but not her bed, and was on a turn/repositioning program. The Care Plan revised 9/14/20 documented Resident #1 experienced an activities of daily living (ADL) self-care deficit related to pain, heart failure, and weakness at times. The Care Plan directed staff to provide extensive assist of one staff for bed mobility and transfers. The Care Plan identified Resident #1 as at risk for skin integrity impairment related to incontinence, impaired mobility, and need for assistance and directed staff to help the resident reposition herself during the day and night. The Care Plan showed she had a cushion for her wheelchair and a pressure relief mattress on her bed, and directed staff to observe her skin with cares and bathing and report new issues to the nurse (redness, bruising, skin tears, and rashes). The care plan failed to contain documentation or revisions of interventions pertaining to the new pressure injuries of 9/6/21. The Skin Monitoring: Comprehensive Shower Review documented on 9/6/21, the Certified Nursing Assistant (CNA) gave Resident #1 a bed bath and documented a wound on her left hip. Resident #1's Skin Observation Tool included the following documentation: -On 8/3/21 at 6:00 PM, no skin concerns -On 9/10/21 at 5:35 PM, noted bruising to Resident #1's left hip (suspected deep tissue injury) with no measurements or wound characteristics included -On 9/17/21 at 5:35 PM, no new issues -On 9/24/21 at 5:35 PM, a Stage II pressure area identified to Resident #1's left hip The Weekly Wound Observation documented the following: - On 9/24/21 at 2:01 PM, facility acquired (FA), Stage II, worsening pressure area on the resident's left back hip with slough present on 100 percent of the wound bed and no drainage or odor. The wound measured 2 cm length (L) x 4 cm width (W) x 0.5 cm depth (D). Staff notified the physician on 9/24/21 and family on 9/17/21. - On 9/24/21 at 2:55 PM, the worsening, Stage II, FA pressure ulcer on the resident's left front hip contained slough on 100 percent of the wound bed with no drainage or odor noted. The area measured 3 cm L x 1.5 cm W x 0.3 cm D. - On 9/30/21 at 6:51 AM, left lateral hip area worsening with 100 percent slough present in the wound bed. The area measured 3.5 cm L x 1.5 cm W x 0.1 cm D. - On 9/30/21 at 6:52 AM, staff identified a left heel, FA, pressure area that contained necrotic tissue and measured 3.5 cm x 2 cm. - On 9/30/21 at 6:52 AM, staff documented the worsening, FA, suspected deep tissue injury on the left medial hip contained 100 percent slough and measured 2.5 cm L x 1.5 cm W x 1 cm D. - On 10/7/21 at 1:13 PM, Resident #1's left lateral hip worsening, unstageable, and measured 3.5 cm L x 2 cm W x 2 cm D. Staff suspected infection and received [MEDICATION(S)] antibiotic order. - On 10/7/21 at 1:15 PM, staff documented the left medial hip wound had worsened with granulation and slough present. The area measured 3.5 cm x 2 cm x 1 cm D. - On 10/7/21 at 1:18 PM, left heel unchanged with 100 percent necrotic tissue present which measured 4.5 cm L x 22 cm W. Staff last updated the physician on 10/7/21 and family on 9/30/21. - On 10/7/21 at 1:20 PM, a facility acquired, unstageable, right heel pressure area with 100 percent necrotic tissue present measured 1 cm D x 1 cm W and failed to contain information to identify when the resident acquired the area. - Further review of the clinical record revealed no more wound assessments until 10/19/21. The Nutritional assessment dated [DATE] documented Resident #1 had inadequate oral intake of protein and calories related to an acute illness as evidenced by a significant weight loss. The assessment documented goals: Resident #1's intakes and appetite will improve on the low concentrated sweets diet, will monitor the need to liberalize to a regular diet due to her advanced age and no oral diabetic medications and resident will consume 50-75 percent of her meals for her wounds to improve. The dietician recommended the following: a house supplement or ensure twice a day for additional calories and protein; monitor food preferences and encourage appropriate intakes of diet, monitor and liberalize her diet order, and provide weekly weights to ensure the resident's weight stabilizes after a significant loss. The clinical record lacked a nutritional assessment for September 2021. During an interview with the Director of Nursing (DON) on 10/19/21 at 1:05 PM, she stated the Certified Nursing Assistants (CNAs) complete a skin observation when they bathe residents twice weekly and inform the nurses if they see any problems; the nurses are to complete a skin observation at least once a week on all residents. She stated if a resident has a pressure wound, the wound care nurse and/or the physician assesses them once a week and the nurses check the wound daily with cares. During an observation on 10/26/21 at 3:10 PM, the Assistant Director of Nursing (ADON) provided a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation revealed an air mattress on the bed for increased pressure relief. The resident grimaced and complained of pain during the wound care. The ADON stated the wound nurse measured the areas weekly on Fridays. During an interview with the DON on 10/26/21 at 3:35 PM, she stated nurses should assess the resident's skin upon admission or readmission. She added that since staff did not complete some of them, the ADON will complete all skin and wound assessments after readmission and weekly going forward. 2. According to the MDS dated [DATE] Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident remained in a persistent vegetative state and did not transfer or walk during the look back period. The MDS also documented she required total assist of 2 staff for bed mobility, dressing, personal hygiene, bathing, and toilet use, used an indwelling Foley catheter for urinary elimination, and was always incontinent of bowel. The MDS identified the resident as not at risk for developing pressure ulcers with no pressure ulcers at the time of the MDS assessment. The Care Plan dated 10/22/21 documented Resident #3 experienced a self-care deficit related to activity intolerance and directed staff to provide total care of two staff for bed mobility, repositioning, and turning. The Care Plan also directed staff to utilize a check and change routine to manage her incontinence, and transfer with assist of 2 staff and a full body lift. The care plan lacked documentation of active pressure ulcers, but did direct staff under the ventilator area of the care plan to monitor/document/report pressure ulcers as needed with preventative measures, turn every 2 hours, keep the head of her bed at less than 30 degrees with a side lying position, use a pressure relief mattress if indicated, follow prevention of pressure ulcers plan of care, and maintain nutritional needs. The Nursing Admission Screening dated 10/5/21 at 12:29 PM, documented Resident #3 admitted to the facility from the hospital in a persistent vegetative state with a well-nourished general appearance. Her skin assessment documented she had bruising of her abdomen, but did not note any other skin issues. Resident #3's Progress Notes documented the following: -On 10/5/21 at 6:08 PM, New admission Resident #3 arrived at 12:20 PM via medivac with a ventilator and [CONDITION(S)], slight swelling in both hands, and some bruising on her abdomen. She currently rests in her room with the head of the bed elevated. -On 10/12/21 at 9:31 AM, the resident's temperature measured 99.7 and the nurse administered Tylenol. Upon follow-up, staff noted her temperature had increased to 101.4, so they notified the physician who ordered staff to transfer Resident #3 to the hospital. -On 10/12/21 at 4:17 PM, the DON spoke to the hospital and they informed her Resident #3 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -On 10/21/21 at 3:45 PM, Resident #3 readmitted to the facility at 2:45 PM and continued on trilogy ventilator with home setting and an order to continue with previous feeding tube settings. Staff noted the resident's catheter showed moderate output and she remained minimally responsive. The resident wore Prevalon boots and foam dressing x 2 intact to buttocks. -On 10/29/21 at 3:56 PM, Staff called the physician and a left message regarding lab results. The medical provider called back and directed staff to speak with family to ascertain whether or not they wished for the resident to have a blood transfusion. Message left for family and awaiting return call. -On 10/29/21 at 4:09 PM, Resident #3's family returned the call and approved the blood transfusion; staff scheduled medical transport for that evening. -On 10/29/21 at 10:54 PM, transport arrived and took the resident to the hospital. -On 10/30/21, review of the record revealed no notes that addressed the resident's return to the facility and/or a skin assessment. -On 10/31/21 at 3:10 PM, the resident's daughter notified the nurse that her mother had wounds on the bottom of both heels and would like to know what treatments were ordered. Staff assessed the left heel as red in color and non-blanchable, with measurements of 4 cm L x 3 cm W. Staff identified the right heel as black/purple in color with measurements of 6.5 cm L x 3.5 cm W and documented no current orders in place. Staff applied Allevyn foam dressing to the areas. -On 11/1/21 at 2:54 PM, resident's family called to inform the facility Resident #3 would transfer to a new facility on 11/4/21 at 6:30 AM and also requested discharge orders. -On 11/1/21 at 7:20 PM, the nurse practitioner gave new wound orders. During an interview with the resident's daughter on 10/21/21 at 9:30 AM, she reported her mother remained in the ICU at the hospital, but might be ready to readmit to the nursing home tomorrow (10/22/21). She stated the hospital staff told her the resident returned to the hospital with a pressure ulcer on both of her heels and also on her bottom in the shape of a bedpan. The daughter reported her mother did not have an air mattress on her bed prior to hospitalization . The After Visit Summary from the hospital dated 10/12/21 - 10/21/21 documented on 10/12/21, Resident #3 had pressure ulcers on both heels and the upper posterior buttock. The note documented the wounds as characteristic of a deep tissue injury with full thickness and described the wound beds as covered with intact, non-blanchable dermis, discolored red/purple without an open area and exudate draining. The Skin Observation Tool dated 10/21/21 documented Resident #3 had shearing to her right and left buttock and unstageable pressure areas to both of her heels with measurements as follows: The left buttock measured 1 cm L x 2.5 cm W x no depth. The right buttock measured 1 cm L x 2.5 cm W x no depth. The left heel measured 4 cm L x 3 cm W x no depth. The right heel measured 3.5 cm L x 6.5 W x no depth. The Nursing Admission Screening dated 10/21/21 at 2:57 PM, documented Resident #3 returned from a hospitalization for bilateral pneumonia. The skin assessment documented she had pressure areas on both heels and buttocks. The Emergency Department (ED) Notes dated 10/29/21 at 9:56 PM, documented Resident #3 had pressure ulcers on bilateral heels, the great toe, and her sacrum. The ED Notes dated 10/30/21 at 7:30 AM, documented the resident had an open wound on her coccyx which her daughter reported looked worse and more open than a week ago during her last hospitalization . The resident's coccyx wound appeared open and bleeding and the daughter said the coccyx wound had not been there before. During an interview on 11/1/21 at 10:52 AM, Resident #3's daughter stated her mother went to the hospital on Friday 10/29/21 because she needed a blood transfusion; the hospital staff told her she had open wounds on her bottom and both of her heels. The hospital staff placed dressings on them and dated them 10/29/21. She commented her mother's labs had been okay and therefore she did not have to have a blood transfusion; Resident #3 transferred back to the facility. The daughter stated she visited on 10/31/21 and her mother's dressings were dated 10/29/21, which meant they were the same ones the nurses had applied at the hospital. She commented the charge nurse at the facility told Resident #3's daughter that she did not even know the resident had pressure sores. The daughter added that then nurse even let her see the documentation to show her the facility had no documentation of Resident #3's pressure sores. Review of Resident #3's clinical record revealed the facility did not document any assessments for the open areas on her skin after 10/21/21 until the family questioned staff about them on 10/31/21. 4. According to the MDS dated [DATE], Resident #7 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident as independent with decision-making with memory intact. The MDS documented she required extensive assist of 2 staff for bed mobility, transfers, dressing, and toilet use, could not walk, and required extensive assist of 1 staff for personal hygiene. The MDS revealed Resident #7 also used oxygen. Resident #7's clinical record lacked a baseline care plan. The DON stated it was because the resident was in the facility less than 48 hours. The Nursing Admission Screening dated 7/23/21 documented the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It documented she used 7 liters of oxygen via nasal cannula, remained alert and oriented times four, had oxygen saturations at 95 percent; displayed shortness of breath and wheezes in her lungs, and edematous, but not pitting extremities. Staff failed to complete the section of the screening designated for documentation of functional abilities. The Progress Notes documented the following: -On 7/23/21 at 4:30 PM, new admit Resident #7 arrived by transport van sitting upright on a cot in no apparent distress. Oxygen applied at 7 liters per nasal cannula. Resident was able to walk to the recliner chair. Medication list faxed to the pharmacy and physician notified of admit. -On 7/23/21 at 4:34 PM, completed admission paperwork with the power of attorney by Social Services. -On 7/26/21 at 10:30 AM staff called sister with condition report - resident doing better than yesterday, but does not wish to return to the facility. The sister will be in later today to get the rest of her things. The Progress Notes lacked any other documentation of assessments or information regarding the facility sending the resident to the hospital on 7/25/21. During an interview on 11/10/21 at 10:53 AM, Resident #7's sister stated resident admitted to the facility on a Friday afternoon (7/23/21) and facility staff had placed the resident on a unit with plastic dividing it from the rest of the facility. She stated she left the facility around 7 pm and her sister called her at 9:30 PM complaining that she had to go to the bathroom, had her call light on for over an hour, and had now wet her pants. The next morning, the resident's sister reported, she activated her call light again around 3-4:00 AM and the staff did not answer it until around 7:00 AM. The resident's sister stated she visited on Saturday (7/24/21) and saw the resident's light activated for over an hour again and she had to go and find help. She stated Resident #7 reported she had not had any of her medications or respiratory treatments, and when she (sister) checked with the nurse, the nurse told her the facility did not have any orders for her meds and could not administer them. The resident's sister stated she visited again on Sunday (7/25/21) and staff still had not given Resident #7 any of her medications and she began complaining of chest pain. The facility sent the resident to the hospital emergency room per family wishes and was admitted . The hospital discharged her a few days later and sent her to another nursing facility. During an interview on 11/15/21 at 10:05 AM, the DON stated the facility expected nurses to document in the progress notes at least once a day for 72 hours for newly admitted residents and also expected them to document in the progress notes any illness, change in condition, or transfer to the hospital. During a subsequent interview with Resident #7's sister on 11/18/21 at 3:30 PM, she stated Resident #7 readmitted to the hospital on 7/25/21 for increased [CONDITION(S)] with weeping of both legs and increased shortness of breath. She added the hospital had to administer [MEDICATION(S)] to remove Resident #7's excess fluid. During an interview on 11/19/21 at 3:30 PM, the Nurse Consultant stated the nurses should have documented more information in Resident #7's clinical record, because the facility expected the nurses to assess newly admitted residents every shift for 72 hours. If the new resident admitted to skilled care, the facility expected nurses to assess them every shift until they discharge from skilled care. The ED Provider Notes dated 7/25/21 documented facility staff transferred Resident #7 to the hospital due to shortness of breath; when the resident arrived hospital staff found her in poor condition with soiled clothing and an initial oxygen saturation of 76 percent with wheezing upon lung exam. The note revealed she displayed tachypnea (rapid breathing) while utilizing her accessory muscles to breathe. The History and Physical (H&P) from the hospital dated 7/25/21 documented Resident #7's principal problem as acute on chronic respiratory failure with [CONDITION(S)] (low oxygen) and hypercapnia (excessive carbon [MEDICATION(S)] in the bloodstream, typically caused by inadequate respiration). The H&P documented the hospital admitted the resident for exacerbation of her [CONDITION(S)]. 4. According to the MDS assessment tool dated 10/1/21 Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 on the BIMS test, which meant the resident demonstrated intact cognitive abilities. The MDS also documented Resident #15 required extensive assist of 2 staff for bed mobility, transfers and toilet use, and extensive assist of 1 staff for dressing, personal hygiene and bathing. The MDS revealed the resident had one venous ulcer and took an anticoagulant daily for 7 days during the lookback period. The Care Plan dated 6/14/21 indicated Resident #15 displayed a self-care deficit related to activity intolerance, fatigue, and limited mobility. The care plan directed staff to conduct skin inspections while providing cares. The care plan indicated she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed staff as follows: - Monitor the extremities for signs and symptoms of injury, infection or ulcers. - Document location of the wound, amount of drainage, periwound area, pain, [CONDITION(S)], and circumference measurements weekly. - Observe for signs and symptoms of infection such as green drainage, foul odor, redness and swelling, red lines coming from the wound, and excessive pain or fever. The Care Plan dated 6/14/21 identified a risk for abnormal bleeding related to anticoagulant medication use and directed staff to observe for and report to the nurse and physician any signs of abnormal bleeding. The Face Sheet documented Resident #15 admitted to the facility on [DATE] and listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital Discharge Documents dated 6/12/21 directed staff to cleanse Resident #15's left lower extremity with saline, pat dry, then apply Xeroform, ABD pad, Kerlix, and elastic wrap. Change every 7 days or if the dressings are saturated. The document instructed facility staff to call for an appointment the following Monday (6/14/21) for a follow up at the wound center. Review of the facility progress notes below revealed no documentation to show staff called for a follow up appointment. The Progress Note from the provider on 7/20/21 at 11:36 AM, documented hospital discharge orders with no follow up orders for wound care. The note also documented pedal pulses as weak, the resident had moderate [CONDITION(S)] in her lower legs and the drainage from the wound soaked through the bandages. The note revealed the resident had no follow up visits and documented a plan to increase the dressing changes to every 3 days. The facility Skin Observation Tool for Resident #15 documented she had vascular wounds on her left leg and left heel on 6/19/21. The Tool lacked any measurements or assessment of the wound. The facility nurses completed the tool weekly through 8/21/21 and documented she had vascular wounds with treatments, but lacked any measurements or assessment. The facility nurses completed another Skin Observation Tool for Resident #15 two weeks later on 9/5/21 and thereafter weekly through 9/26/21. They documented she had the vascular wounds but did not complete measurements or an assessment. The facility nurses started documenting Weekly Wound Observations on 9/17/21 and documented the following: - On 9/1/21, the wound measured (length-L x width-W x depth-D) 13 cm L x 14 cm W x 0.3 D cm. Full thickness loss, slough present and wound debrided. - On 9/17/21, staff documented the wound was declining and measured 12 cm L x 9 cm W x 0.1 cm D. - On 9/24/21, the nurse documented the wound as worsening and infected; the facility started the resident on antibiotics. The wound measured 9.5 cm L x 13 cm W x 0.1 cm. - On 10/7/21, staff documented the following wound measurements: 8 cm Lx 9 cm D with no change. - On 10/15/21, staff documented the wound measured 18 cm L x 20 cm W with no change. - On 10/22/21, staff documented the wound measured 9 cm x L 11.2 cm W and worsening. During an interview with the DON on 11/3/21 at 3:15 PM, she stated she could not find any other wound assessments for Resident #15. The hospital Wound Assessment Details dated 9/27/21, documented the left lower posterior leg venous ulcer measured 9 cm L x 14 cm W x 0.1 cm D. The hospital Wound Assessment Details dated 9/29/21 and 10/1/21, documented no changes in the measurements. The hospital Wound Assessment Details dated 10/27/21, documented the resident bled through the bandages immediately with fresh blood and they were unable to stop the bleeding. No picture or measurement taken due to the emergent situation. Staff escorted the resident over to the emergency room . The hospital Progress Note Details dated 9/27/21, documented Resident #15 had a large, full thickness wound to her posterior left lower leg. Arterial studies conducted on 6/4/21 identified diffuse atherosclerosis to both lower legs, and a venous reflux study showed mild reflux in the left lower leg. The hospital Progress Note Details dated 10/27/21, documented Resident #15 presented for re-evaluation of the wound to her left lower leg. The wound clinic last saw her on 10/1/21 and the facility told them they were canceling all future appointments because they had a wound care provider at the facility. The note showed the resident presented with a large wound entirely covered with clotted blood that bled continuously and the left lower leg looked pale and blue in color. The resident told hospital staff she sat at the facility in a pool of blood on the floor when her dressing was not changed. On 11/3/21 at 2:50 PM during an interview, the resident stated she always has some pain in her wound and it is worse since her physician grafted it. She rated her pain at 7-8 on a scale of 0-10 (0 = nothing, 10= the worst pain ever felt) and stated she just had a pain pill. She stated the nurses came in and looked at it every night and every day to make sure the dressing remained in place, but the resident could not say when they changed it or how often they should change it. Resident #15's Progress Notes documented the following: - On 6/12/21 at 4:23 PM, resident arrived to the facility via stretcher at 3:40 PM and transferred to bed via 2 staff and 2 emergency medical staff. Resident denied pain. - On 6/22/21 at 10:24 AM, the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . - On 6/30/21 at 6:52 PM, staff changed the dressing to the resident's left lower leg/calf area. When they removed the old dressing, it caused a significant amount of serosanguineous drainage as the dressing stuck to the wound. Staff cleaned it with saline wound cleaner and applied the treatment as ordered. The wound had an odor to it with no redness, warmth, or [CONDITION(S)] noted and the resident tolerated the dressing change. - On 7/15/21 at 3:56 AM, resident in bed and complaining of her left lower leg wrap feeling tight. Staff re-wrapped it and the resident stated it felt better. - On 7/15/21 at 6:39 PM, the resident had a shower on 7/14/21 and the left lower leg wound dressing became soiled. Staff removed the soiled dressing and noted large amounts of bloody drainage. Staff cleansed the area with no signs of infection, but noted the surrounding skin macerated. Staff took measurements and documented they would notify the physician. - On 7/20/21 at 11:36 AM, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders from the hospital discharge contained no follow-up orders for wound care. Pedal pulses weak and Resident #15 had moderate [CONDITION(S)] in her lower legs and drainage soaked through the bandages. Also noted the resident had no follow up visits - plan: increase dressing changes to every 3 days. - On 8/10/21 at 1:00 AM, Resident #15's dressing remained intact to left lower extremity wound. Treatment regimen remained in place for every 3 days and as needed. The resident denied pain or discomfort on assessment. Will obtain updated wound progress and measurements during next dressing change. - On 8/20/21 at 4:27 AM, left lower leg continues to show signs of progress. No signs of infection or odor. Dressing clean and intact. - On 9/11/21 at 7:29 PM, resident has a large wound on her left lower leg. Wound cleaned and dried, collagen wound dressing applied and covered with super absorbent, non-adherent dressing. - On 9/12/21 at 2:44 PM, Large wound on resident's left lower leg cleaned and dried with collagen wound dressing applied and covered with super absorbent non-adherent dressing. - On 9/13/21 at 3:39 AM, order for wound care from 9/5/21 noted and added to the electronic health record. - On 9/20/21 at 5:31 AM, dressing to left leg changed as it was saturated with blood. Staff cleansed the area with wound cleanser, dried with gauze, applied collagen dressing, ABD pads, and wrapped with rolled gauze. - On 9/21/21 at 3:34 PM, when staff gave the resident a shower, she complained of left leg pain at the wound site. - On 9/22/21 at 3:20 AM, the CA told the nurse Resident #15 complained of left lower extremity pain at wound site. Nurse found the resident crying and complaining about her leg. Pain medication obtained and odor noted from the wound when entering the resident's room, and worse when dressing removed. Wound cleansed and it bled so much that staff applied calcium alginate on the wound to help with the bleeding. - On 9/22/21 at 10:58 AM, staff updated the physician regarding the resident's left lower extremity wound and the physician ordered staff to send the resident to the emergency room . - On 9/22/21 at 1:28 PM, hospital nurse notified facility staff the resident would return that afternoon; wound was debrided at the hospital and two pain pills and intravenous antibiotics administered. The resident would return to the facility on oral antibiotics for 7 days and then seen in the wound care clinic on 9/27/21 at 12:30 PM. - On 9/27/21 at 10:30 AM, resident out of facility to appointment at the wound clinic. - On 9/27/21 at 2:04 PM, wound clinic called and reported they could not get the wound to stop bleeding and needed to place an Unna Boot on the area. The resident to return in 2 days for dressing change and then weekly for the hospital to assess the wound and change the boot. - On 9/28/21 at 1:20 PM, fax to provider per wound care provider suggestion to see if he wanted to adjust the resident's, blood thinner. Fax returned - no changes. -On 9/29/21 at 11:27 AM, resident going to appointment at wound clinic at hospital. Staff informed the resident the facility wound physician would be rounding next Thursday (9/30/21) and would see her weekly via telemedicine so she would not need to go to the clinic. Resident agreeable with her next appointment at the hospital clinic being her last. -On 9/29/21 at 3:25 PM, resident had her wound care visit with compression wrap changed. It will need changing twice a week due to drainage and the wound center will do it on Tuesdays and Fridays. - On 10/1/21 at 6:02 PM, the resident returned to the facility from the wound care center with orders to return to the clinic twice a week. DON stated the resident

Based on observations, record review, and staff and family interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and also failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for 3 of 4 residents reviewed (#1, 3 and 11). The facility did not demonstrate the pressure ulcer deterioration was unavoidable due to failure to provide weekly comprehensive skin assessments, care plan interventions, and pressure relief. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage 1 is intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. According to the Minimum Data Set (MDS) assessment tool dated 8/13/21 Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 8 of 15 possible on the Brief Interview of Mental Status test which meant she demonstrated moderately impaired cognitive skills. The MDS also documented she required total assist of 2 staff for bed mobility, transfers, and toilet se, required total assist of one staff for dressing; and required extensive assist of one staff for bathing. The MDS indicated the resident was at risk for developing pressure ulcers but did not indicate she had any pressure ulcers. The MDS revealed she had a pressure reducing device for her chair but not her bed, and was on a turn/repositioning program. The Care Plan with the revision date of 9/14/20 for Resident #1 indicated she has an activities of daily living (ADL) self-care deficit related to pain, heart failure, and weakness at times. The Care Plan directed staff to provide extensive assist of one staff for bed mobility and transfers. The Care Plan revealed she was at risk for alteration in skin integrity related to incontinence, impaired mobility, and need for assistance. The Care Plan revealed Resident #1 needed assist to reposition herself during the day and night, had a cushion for her wheelchair, and a pressure relief mattress on her bed. The Care Plan directed staff to observe her skin with cares and bathing and to report new issues to the nurse, such as redness, bruising, skin tears, and rashes. The care plan lacked documentation of revisions of interventions with the new pressure injuries 9/6/21. The Progress Notes for Resident #1 documented the following: - On 8/30/21 at 4:20 PM, the resident had bruising on her left hip which could possibly lead to a pressure ulcer. Staff called the resident's medical provider and left a message. - On 8/30/21 at 6:55 PM, the provider called back with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - On 9/6/21 at 7:32 PM, resident has the start of a pressure ulcer, area cleaned and [MEDICATION(S)] applied. - On 9/7/21 at 3:18 PM, staff gave Resident #1 a bed bath, and noted two wounds on her left hip. The nursing assistant reported the resident said that her legs hurt. - On 9/10/21 at 4:02 PM, resident has a 10 cm area of [CONDITION(S)] (redness) on her left hip. The erythematous area contained two areas within it that had slough in the wound bed. The anterior area measured 3.5 cm x 2.5 cm and a third area distal to the anterior area measured 0.5 cm x 0.5 cm. Staff called the resident's daughter and notified her of the wound and sent a fax to the primary care physician to obtain wound treatment orders. - On 9/11/21 at 7:28 PM and on 9/12/21 at 2:45 PM, staff noted the resident had a wound on her left hip covered by [MEDICATION(S)] dressing. - On 9/18/21 at 10:32 PM, the resident had a dry and intact [MEDICATION(S)] dressing on her left hip. - On 9/19/21 at 11:55 PM, the resident had a dry and intact on her hip. Staff repositioned Resident #1 frequently throughout the shift. - On 9/20/21 at 3:30 PM, the wound care nurse saw the resident and addressed and changed her dressing. Staff noted resident was up in her wheelchair most of the day. - On 9/30/21 at 7:07 AM, the wound physician evaluated the wounds on Resident #1's left hip and heel and updated treatment orders. Staff notified the resident's family. - On 10/7/21 at 1:38 PM, the wound physician saw the resident on rounds. - On 10/9/21 at 3:51 AM, staff cleaned the resident's wound and changed the dressing according to physician orders. - On 10/19/21 at 6:20 PM, the resident returned from the hospital with a wound vac for her left hip. Resident diagnosed with RSV and remained on oxygen. The Skin Monitoring: Comprehensive Shower Review documented on 9/6/21, staff provided a bed bath and noted a wound on Resident #1's left hip. Resident #1's Skin Observation Tool documented the following: - On 8/3/21 at 6:00 PM, no skin concerns. - On 9/10/21 at 5:35 PM, bruising to left hip and suspected deep tissue injury with no measurements or description. - On 9/17/21 at 5:35 PM, no new issues - On 9/24/21 at 5:35 PM Resident had Stage II pressure area on the left hip. Resident #1's Weekly Wound Observation documented the following: - On 9/24/21 at 2:01 PM, staff identified a facility acquired, worsening, Stage II pressure area to the resident's left back hip with slough present on 100 percent of the wound bed. Staff noted no drainage or odor. The area measured 2 cm length by 4 cm width by 0.5 cm depth. Staff notified the physician notified 9/24/21 and the family on 9/17/21. - On 9/24/21 at 2:55 PM, staff documented a worsening Stage II, facility acquired pressure area to the resident's left front hip with slough present on 100 percent of the wound bed and no drainage or odor noted. The area measured 3 cm length by 1.5 cm width by 0.3 cm depth. - On 9/30/21 at 6:51 AM, staff documented a worsening left lateral hip wound with 100 percent slough present in the wound bed. The area measured 3.5 cm length x 1.5 cm width x 0.1 cm deep. - On 9/30/21 at 6:52 AM, staff documented a left heel pressure area with necrotic tissue present that measured 3.5 cm long x 2 cm. wide acquired at the facility on this date. - On 9/30/21 at 6:52 AM, staff documented a worsening, facility acquired, left medial hip suspected deep tissue injury with 100 percent slough present. The area measured 2.5 cm long x 1.5 cm wide x 1 cm deep. - On 10/7/21 at 1:13 PM, staff documented a worsening, unstageable, left lateral hip area that measured 3.5 cm length by 2 cm width by 2 cm depth. Staff suspected infection obtained a [MEDICATION(S)] order. - On 10/7/21 at 1:15 PM, staff documented a worsening, left medial hip wound with granulation and slough that measured 3.5 cm long x 2 cm wide x 1 cm deep. - On 10/7/21 at 1:18 PM, left heel unchanged with 100 percent necrotic tissue present. The area measured 4.5 cm length by 2 cm width. Staff last updated the physician on 10/7/21 and the family last updated 9/30/21. - On 10/7/21 at 1:20 PM, staff documented an unstageable, facility acquired, pressure area with 100 percent necrotic tissue present that measured 1 cm depth by 1 cm width. The note failed to contain information to indicate when staff identified the area. Review of the clinical record revealed a lack of further wound assessment(s) until 10/19/21. The Nutritional assessment dated [DATE] documented Resident #1 had inadequate oral protein intake and calories related to an acute illness as evidenced by a significant weight loss. The assessment documented nutritional goals: 1) Resident #1's intakes and appetite will improve on the low concentrated sweets diet - monitor the need to liberalize to a regular diet due to her advanced age and no oral diabetic medications 2) Resident #1 will consume 50-75 percent of her meals for her wounds to improve. The dietician recommended the following: a house supplement or ensure twice a day for additional calories and protein; monitor food preferences and encourage appropriate intakes of diet, to monitor and liberalize her diet order, and weekly weights to ensure weight stabilizes after a significant loss. The clinical record lacked a nutritional assessment for September 2021. The Specialty Physician Wound Care Telemedicine initial evaluation dated 9/30/21 documented the resident had multiple wounds. Support surfaces currently in place include a group 1 for her bed, a pressure reduction cushion on her chair, and a pillow for her feet. a. Site 1 - left lateral hip unstageable due to necrosis and measured 3.5 cm x 1.5 cm x 0.1 cm (L x W x D). Plan of care: reposition per facility protocol. b. Site 2 - left medial hip Stage 4 which measured 2.5 cm x 1.5 cm x 1 cm. Plan of care: to obtain consent for debridement and to offload wound. c. Site 3 - left heel unstageable due to necrosis which measured 3.5 cm x 2 cm. Plan of care: recommend Prevalon boots for use in bed and to offload pressure to bilateral heels. d. Site 4 - right heel unstageable due to necrosis that measured 1.5 cm x 1.5 cm. Plan of care: float heels in bed, offload wound, recommend Prevalon boots for use in bed, offload pressure to heels, and reposition per facility protocol. The Wound Care Physician Follow up Evaluation dated 10/7/21 documented the resident continued to use the same support surfaces. a. Site 1 - left lateral hip measured 3.5 cm x 2 cm width x 2 cm (L x W x D) and unable to stage due to necrosis with deterioration in wound progress. b. Site 2 left medial hip measured 3.5 cm x 2 cm x 1 cm Stage 4 with deterioration present. c. Site 3 left heel measured 4.5 cm x 2 cm and unstageable due to necrosis with deterioration present. d. Site 4 right heel measured 1 cm x 1 cm and unstageable due to necrosis, area improved. The plan of care recommendations included continue to float heels in bed, offload wounds, recommend Prevalon boots for use in bed to offload pressure to bilateral heels, and reposition per facility protocol. The Treatment Administration Record (TAR) dated September 2021 directed staff to apply [MEDICATION(S)] every 72 hours to affected left hip for preventative measures ordered 8/30/21. The TAR lacked documentation to show staff provided the treatment as ordered on 9/8/21, 9/14/21, 9/17/21, and 9/29/21. The Emergency Provider (ED) Note dated 10/9/21 at 4:57 AM documented Radiologist interpreted the pubis ulcer at the level of the hip prosthesis had a large amount of artifact. The Acute Care Surgery Consult note dated 10/9/21 at 2:12 PM, documented the facility referred the resident due to pressure ulcers of the left hip. The resident had 2 associated ulcers with a skin bridge between them. Each measured between 2 and 4 cm in each axis. The slightly more anterior ulcer lost the dermis and penetrated to a necrotic bed of tissue with mild surrounding [CONDITION(S)] limited to the immediate skin edges. The lateral aspect toward the other pressure ulcer showed [CONDITION(S)] and [CONDITION(S)] of the skin. The more lateral ulcer showed dermal necrosis without full penetration or erosion though the dermis. The area was tender with [CONDITION(S)] and induration, which indicated a local [CONDITION(S)]. Plan: debridement of the ulcer. During an interview with the Director of Nursing (DON) on 10/19/21 at 1:05 PM, she stated the nursing assistants conduct a skin observation with each bath twice a week and let the nurses know if they see any issues; the nurses are to provide a weekly skin observation for all residents. She stated that once the resident had a pressure wound, the wound care nurse and/or the physician assessed them once per week and the nurses checked the wound daily with cares. She stated she expected the staff to reposition residents with pressure ulcers every two hours, but noted it was not documented. At 1:25 PM, the DON reported Resident #1 had Prevalon boots in her room for use but the facility did not have an air mattress or air overlay mattress on her bed. She stated all the residents in the facility had a standard pressure relief mattress. She added the resident is returning to the facility that day, so they are putting a low air loss mattress on her bed. During an observation on 10/26/21 at 3:10 PM, the Assistant Director of Nursing (ADON) provided wound care for the resident's left hip. The bed contained an air mattress. Observation also revealed he resident grimaced and complained of pain during the wound care. The ADON reported now the wound nurse measured the areas weekly on Fridays. During an interview with the DON on 10/26/21 at 3:35 PM, nurses should do skin assessments on admission or readmission. She added that since some of them were not done, the ADON would now be doing all skin and wound assessments every week and after readmission. She reported skin assessments had not been completed because the facility went a few months without a facility DON or RN. 2. According to the MDS assessment tool dated 10/28/21 Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident was in a persistent vegetative state, did not transfer or walk during the look back period; and required total assist of 2 staff for bed mobility, dressing, personal hygiene, bathing and toilet use. The MDS documented she had an indwelling Foley catheter and was always incontinent of bowel. The MDS documented the resident was not at risk for developing pressure ulcers and did not have any pressure ulcers during the MDS lookback period. The Care Plan dated 10/22/21 indicated Resident #3 had a self-care deficit related to activity intolerance and directed staff that she required total care of two staff for bed mobility, repositioning, and turning, required staff to check and change her to manage her incontinence, and transfer with staff assist of two and a full body lift. The care plan lacked documentation of active pressure ulcers, but did list an intervention under the ventilator area to monitor/document/report pressure ulcers as needed and turn every 2 hours; keep the head of her bed less than 30 degrees with a side lying position; use a pressure relief mattress if indicated; follow prevention of pressure ulcers plan of care; and maintain nutritional needs. The Nursing Admission Screening dated 10/5/21 at 12:29 PM, documented Resident #3 admitted from the hospital in a persistent vegetative state and appeared well-nourished. A skin assessment documented abdominal bruising and no other skin issues noted. The Pressure Injury Risk dated 10/5/21 identified Resident #3 as a very high risk for pressure related breakdown. The Progress Notes for Resident #3 documented the following: - On 10/5/21 at 6:08 PM, newly admitted Resident #3 arrived at the resident is a new admit and came in at 12:20 PM via medivac with a ventilator, [CONDITION(S)], slight swelling in both hands, and some bruising on her abdomen. Resident resting in her room with the head of the bed elevated. - On 10/6/21 at 2:47 PM, a physician progress documented Resident #3 is new to the facility and new to this provider. Resident is currently on vent per [CONDITION(S)] and appears to be dependent on this vent. Resident had a recent mitral valve surgery complicated by a post-operative stroke and is now mostly unresponsive. Bilateral lower extremity with 1+ [CONDITION(S)], lungs diminished, nothing by moth, and has gastrostomy tube (g-tube) in place. Incontinent of bowel with Foley catheter present and incontinent of urine. Multiple ecchymotic areas; resident had recent CABG (coronary artery bypass graft) and lengthy hospitalization . No documentation of other skin areas of concern. - On 10/7/21 at 11:14 AM, resident transported to emergency room via local rescue with temperature of 99. Staff unable to give medications per tube and breathing pattern changed significantly during [CONDITION(S)] cares. - On 10/7/21 at 5:47 PM, facility staff called the emergency room and spoke to the nurse. They replaced the [CONDITION(S)] and suctioned it well; resident has a urinary tract infection and will be on intramuscular antibiotics and have [MEDICATION(S)] increased for a few days. Resident to return to facility around 7:00 PM. - On 10/9/21 at 7:07 PM, on antibiotics for a urinary tract infection, no fevers, no adverse reaction and urine yellow in color and clear. - On 10/12/21 at 9:31 AM resident's temperature 99.7, nurse administered Tylenol. On follow up, her temperature increased to 101.4 and physician ordered staff to send the resident to the emergency room . - On 10/12/21 at 4:17 PM, DON spoke to the hospital and learned Resident #3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . - On 10/21/21 at 3:45 PM resident readmitted to the facility at 2:45 PM today. Resident continues continued to be minimally responsive. Prevalon boots on with foam dressing x 2 intact to buttocks. - On 10/25/21 at 8:49 PM, comprehensive progress note by nurse practitioner: multiple bruised areas including right hand from lab draws and right antecubital from intravenous medications and lab draws with poor skin turgor. Resident has 3+ pitting [CONDITION(S)] in left upper extremity and 1 plus pitting [CONDITION(S)] in right upper extremity. No other information related to skin condition noted. - On 10/29/21 at 3:56 PM called and left message regarding lab results. Provider stated check with family about blood transfusion. At 4:09 PM, staff documented family wanted transfusion. At 10:54 PM, medical transport arrived and resident sent to hospital for [CONDITION(S)]. - On 10/30/21, the records lacked documentation of resident's readmission to facility and also lacked documentation related to skin since assessment on 10/21/21. - On 10/31/21 at 3:10 PM, the resident's daughter notified staff that resident had wounds to the bottom of her bilateral heels and would like to know about any treatment orders. Areas assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Right heel black purple in color and measured 6.5 cm x 3.5 cm. No current orders in place. Allevyn foam dressing applied to bilateral heels. - On 11/1/21 at 2:54 PM, family informed the facility the resident would be transferred to a new nursing home on 11/4/21 at 6:30 AM. - On 11/1/21 at 7:20 PM, new wound orders per nurse practitioner. During an interview with the daughter on 10/21/21 at 9:30 AM she stated her mother was still in ICU at the hospital but may be ready to be released back to the nursing home tomorrow. She stated the hospital staff told her that her mother returned to the hospital with a pressure ulcer on both of her heels and on her bottom in the shape of a bedpan. She added the facility had not added an air mattress to the resident's bed prior to hospitalization . The After Visit Summary from the hospital dated 10/12/21 - 10/21/21 documented Resident #3 had pressure ulcers to bilateral heels and upper posterior buttock found 10/12/21. The hospital nurse wound care note dated 10/13/21 measured the wounds: a. Left sacrum 7 cm x 1.4 cm b. Right sacrum 5 cm x 1.4 cm. c. Left heel 3.5 cm x 3 cm d. Right heel 4.5 cm x 6.5 cm The hospital note documented the wounds as characteristic of a deep tissue injury with full thickness and wound beds described as covered with intact, non-blanchable dermis discolored red/purple, with no open area and without exudate draining. The TAR for October 2021 documented an order dated 10/22/21 for a weekly skin check by a licensed nurse and signed as completed by a nurse on 10/22/21. The Skin Observation Tool dated 10/21/21 documented the resident had shearing to her right and left buttock and unstageable pressure areas to both of her heels. It documented measurements: a. The left buttock measured 1 cm in length by 2.5 cm in width and no depth. b. The right buttock measured 1 cm in length by 2.5 cm in width and no depth. c. The left heel measured 4 cm in length by 3 cm in width and no depth. d. The right heel measured 3.5 cm in length by 6.5 cm in width and no depth. The Nursing Admission Screening dated 10/21/21 at 2:57 PM documented Resident #3 returned from the hospital for bilateral pneumonia. Her skin assessment documented she had pressure on her bilateral heels and buttocks. The Pressure Injury Risk dated 10/21/21 documented Resident #3 as at a very high risk for pressure related breakdown. The Nutrition assessment dated [DATE] documented the resident had a tube feeding of [MEDICATION(S)] 1.5 running continuously at 44 ml per hour. The assessment documented Resident #3 as at high risk for impaired skin integrity related to limited mobility and recent acute illness as evidenced by recent pressure areas. During an observation on 10/26/21, the resident lay on her back, asleep on a low air loss mattress and in a new room. During an interview on 11/1/21 at 10:52 AM, Resident #3's daughter stated her mother went to the hospital last Friday (10/29/21) because she needed a blood transfusion. She stated the hospital staff told her that her mother had open wounds on her bottom and both of her heels. The hospital staff placed dressings on them and dated them for 10/29/21. The resident's labs had been okay, so she did not require a blood transfusion after all and transferred back to the facility. The daughter reported she went to visit her mother at the facility on 10/31/21, and her mother had the same dressing in place dated 10/29/21. The charge nurse at the facility told her she did not even know the resident had pressure sores and she added the nurse even let her see the documentation to show her there was no documentation of pressure sores in Resident #3's record. The Skin Observation Tool dated 11/1/21 documented the resident had unstageable shearing to her right buttock and unstageable pressure areas to her bilateral heels. It documented measurements: a. The form lacked measurements for the left buttock. b. The right buttock measured 3.5 cm in length by 2 cm in width with no depth. c. The left heel measured 4 cm in length by 3.5 cm in width with no depth. d. The right heel measured 6.5 cm in length by 3.5 cm in width and had no depth. During an interview on 11/1/21 at 11:15 AM, the DON she stated the facility did not have any orders for any wound care, so that is why the staff did not change the dressings. She added the resident did not have those areas the second time she went back to the hospital. However, the DON acknowledged the facility was not aware of the pressure areas when she returned, although staff should have assessed the resident's skin upon admission or readmission if the resident left the facility for more than 24 hours. During an interview on 11/1/21 at 2:36 PM, Staff A stated she worked and took care of Resident #3 on 10/22/21, 10/23/21 and 10/24/21. She stated the resident had a small red area on her coccyx but did not have any other skin issues. The Provider Progress Note (SOAP) dated 11/1/21 by the nurse practitioner (NP) documented the resident had suspected deep tissue injury and friction injuries to both heels and buttocks. Factors that impact wound healing include comorbidities, nutrition, immobility, weight, and age. The NP documented the right heel as a black, unblanchable area that measured 3.5 cm x 6.5 cm with no depth. Left heel 3 cm x 4 cm x 0 cm darkened area with some areas that do blanch, but areas that do not. Right buttock: a partial thickness open area with exposed dermis that measured 2 cm x 3.5 cm x 0.1 cm. Left buttock partial thickness open area with exposed dermis that measured 1 cm x 3 cm x 0.1 cm. Both buttock wounds had the appearance of friction wounds caused by shearing. Resident lost 20.18 pounds from September to October which represents 11 percent of her body weight. The last [MEDICATION(S)] level done was 2.6 and she was recently transfused for a hemoglobin of 6.8. She is currently ventilator dependent, has functional [CONDITION(S)], and has to have the head of her bed elevated at least 30 degrees to prevent aspiration due to tube feedings, which puts further pressure on the buttocks. In addition, she is incontinent of bowel and would be incontinent of bladder if she did not have a Foley catheter. Given her myriad of issues that all impact wound healing and skin integrity, she will continue to be at risk for clinically unavoidable skin issues. During an interview on 11/10/21 at 2:10 PM, the provider stated she gave orders for wound care on 11/1/21 for Resident #3 following visualizing the wounds via telehealth. She stated she agreed with the facility's assessment that shearing caused the buttock wounds and pressure caused the bilateral heel wounds. She stated Resident #3 had so many comorbidities and complicating factors that she may never heal from these areas. She stated the facility is definitely at fault for not assessing and treating the wounds for 10 days, but it could go either way on whether the facility is at fault for causing the wounds to deteriorate. 3. According to the MDS assessment tool dated 9/11/21 Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 on the BIMS test (intact cognitive abilities) required total care of 2 staff for transfers, bathing, and toilet use, total care of 1 staff for personal hygiene, extensive assist of 2 staff for bed mobility, and dressing and extensive assist of 1 staff for eating. The MDS also documented he demonstrated impaired range of motion in his bilateral lower extremities, used an indwelling Foley catheter for urinary elimination, and was always incontinent of bowel. The MDS revealed the resident was at risk for developing pressure ulcers, had 1 (one) Stage 3 pressure ulcer and 2 (two) Stage 4 pressure ulcers. The Care Plan dated 9/8/20 for Resident #11 indicated Resident #11 showed a self-care deficit related to limited range of motion and use of assistive devices. The care plan directed staff to provide assist of 2 staff for bed mobility, transfers, bathing, and incontinence care. The care plan indicated he had actual skin impairment as evidenced by pressure ulcers and directed staff to measure areas per facility guidelines and complete weekly skin assessments. The Progress Notes revealed the resident was in the hospital 8/11-9/4/21 and 9/25-10/6/21. Review of Resident #11's skin sheets/assessments from 7/1/21 - 10/13/21 revealed the following documentation: - On 7/15/21, no measurements documented. - On 9/17/21, staff noted four (4), facility acquired areas located on the right gluteal fold, Stage 3 - Area 1 measured 7 cm L x 5 cm W x 1.6 cm D - Area 2 measured 2 cm L x 2 cm W x 0.2 cm D - Area 3 measured 1 cm L x 1 cm W x 0.1 cm D - Area 4 measured 4 cm L x 2 cm W x 0.1 cm D. - On 9/17/21, staff documented a worsening, Stage 4 pressure area on the resident's coccyx that measured 5.5 cm L x 9 cm W x 4 cm D and noted the area had been present upon admission. -On 9/17/21, staff noted a Stage 3 area on the right, upper gluteal area that measured 3 cm L x 3 cm W x 0.2 cm D -On 9/17/21, staff documented a Stage 3 pressure area on the left lateral leg that measured 8.2 cm L x 1 cm W x 0.2 cm D and noted the area had been present upon admission. -On 9/17/21, staff documented a worsening Stage 3 pressure sore on the resident's left heel that measured 4.5 cm L x 2 cm W x 0.5 cm D. -On 9/17/21, staff documented a Stage 2 pressure area on the resident's right ankle that measured 1 cm L x 1 cm W x .1 cm D. - On 9/17/21, staff documented right lateral leg pressure Stage 4, facility acquired FA 11 cm x 2.5 cm x 1 cm worsening Weekly Wound Observations recorded the following: - On 7/15/21, right gluteal fold x 3 (three) Stage 3 facility acquired pressure areas: Area 1: 5.2 cm x 5 cm x 0.6 cm Area 2: 2 cm x 2 cm x .2 cm Area 3: 0.5 cm x 1 cm x 0.5 cm - On 7/15/21 - coccyx: improving, Stage 4, present upon admit, measured 3 cm x 4.5 cm x 4.6 cm - On 7/15/21 - right upper gluteal fold: improving, Stage 3, facility acquired, measured 2 cm x 2 cm x 0.2 cm - On 7/15/21 - left lateral leg: unchanged, Stage 3, present upon admission, measured 4.8 cm x 3.5 cm x 0.1 cm - On 7/15/21 - left heel: unchanged, Stage 3, facility acquired, measured 3.5 cm x 2.4 cm x 0.3 cm - On 7/15/21 right lateral leg, stable, Stage 3, that measured 9 cm x 1.5 cm x 0.2 cm The clinical record failed to contain documentation that showed staff conducted routine weekly wound assessments. The TAR dated July, 2021 lacked documentation that showed staff provided Resident #3 wound care for the right gluteal area, coccyx, left gluteal area, left heel, and calf on 7/10/21, 7/18/21, 7/24/21 and 7/30/21. The TAR dated August 2021 lacked documentation to show staff provided wound care for the resident's right gluteal wounds, coccyx, left gluteal wounds, left heel, calf wounds, and right lateral ankle on 8/3/21, 8/5/21, 8/7/21, and 8/9/21. The TAR dated September 2021 lacked documentation to show staff completed wound care on any of Resident #3's wounds from 9/6-9/18/21. The orders lacked descriptions to direct staff where to apply the dressings. The Nutritional assessment dated [DATE] documented Resident #1 had inadequate protein and calories related to inadequate intakes of meals and tolerance to supplement as evidenced by multiple wounds, weight loss, and severe protein calorie malnutrition. Goal listed for resident to not refuse additional nutritional supplements. During an interview with the DON on 11/18/21 at 12:39 PM, she stated the resident did not have a dietician assessment this year prior to November 2021. She stated she expected one to have been completed prior to this due to his skin issues and feeding tube. The facility policy Skin Management Guidelines with the revised date 07/2017 documented clarification of an unavoidable pressure injury as follows: Per CMS guidelines, unavoidable means the resident developed a pressure injury even though the facility had evaluated the residents clinical condition and pressure injury risk factors (within 30 days); defined and implemented interventions consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated t

Based on resident record review, facility policy review, and staff and family interview, the facility failed to act in accordance with professional standards of practice related to assessment and intervention when a resident experienced a significant change in condition and also related to following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility sent a fax to the physician on [DATE] at 12:30 PM to inform him of Resident #3's change in condition. The physician returned a response on [DATE] at 3:14 PM to send to the emergency room (ER). The facility failed to send the resident to the ER because they did not see the return fax that contained the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:15 a.m., staff identified the resident was not breathing and they could not detect a pulse or a blood pressure. Staff initiated CPR and called 911. The ambulance arrived and transported the resident to the hospital at 2:38 a.m. At 3:15 a.m., the hospital notified the facility that Resident #3 had passed away. Review of the fax the physician had sent back to the facility on [DATE] revealed it had been noted by the nurse on [DATE] - 14 days later. These findings constitute an Immediate Jeopardy to resident health and safety. The facility identified a census of 25 residents. Findings include: 1. According to an admission Minimum data set (MDS) assessment tool dated [DATE], Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident had a Brief Interview for Mental Status test score (BIMS) score of 8, which meant the resident demonstrated moderate cognitive impairment. The MDS documented he required extensive assist of two staff for bed mobility and transfers. Review of Resident #3's care plan revealed a focus area that indicated he had a positive COVID-19 result on [DATE]. The care plan instructed staff to monitor for elevated temperature, respiratory symptoms such as cough, sore throat, or shortness of breath, and report to the physician if occurs (initiated [DATE]). The care plan encouraged staff to observe, document and report mental status changes and report changes to the charge nurse for further evaluation (initiated [DATE]). The care plan directed staff to monitor vital signs every shift and as needed (PRN), and monitor/document/report to physician mental status changes. The care plan also directed staff to monitor, document, and report fever, chills, cough, purulent sputum, pleuritic chest pain, tachypnea, an anxious/flushed appearance, [CONDITION(S)], confusion, and disorientation to physician PRN (initiated [DATE]). Review of Resident #3's Electronic Health Record (EHR) revealed a positive COVID-19 test result with an analyzed and released date of [DATE]. Review of Resident #3's Electronic Health Record (EHR) revealed chest x-ray results dated [DATE]. The reasons for the X-ray were listed as fever, dehydration, and COVID positive. Findings documented no acute abnormality. Review of Resident #3's EHR revealed a fax to the physician on [DATE] at 12:30 PM with the following reason for physician notification: resident very lethargic, refusing meal, and medications, positive COVID-19 test, remains in isolation, restless with the following vital signs listed: temperature 98.3, blood pressure ,d+[DATE], pulse 90, respiration 16, and oxygen saturation 88%. The fax was completed by Staff G Licensed Practical Nurse (LPN). The fax had a sent time stamp that showed the facility sent the fax on [DATE] at 12:44 PM, and a return time stamp that showed the physician returned the fax to the facility (with orders) on [DATE] at 3:14 PM. However, the fax contained a timed and noted date Staff B on [DATE] at 11:44 AM (14 days later). Review of Resident #3's EHR revealed the following progress notes: -[DATE] at 3:37 AM: Staff summoned to Resident #3's room to find him on floor where he lay next to his bed on his left side with left arm lying underneath his body. There was no bleeding noted, although staff assumed he did hit his head. The resident was rolled so his arm was out from underneath his body, and staff completed full range of motion (ROM) on his shoulder and he tolerated it well. No injuries noted. Resident was assisted by staff from the floor and into bed, and assessment and vital signs completed with no further injuries noted. -[DATE] at 3:00 AM: At 2:15 AM Resident #3 was observed unresponsive with no pulse, no blood pressure, and not breathing. Resident was warm to the touch, sternal rub completed and the resident was not responsive to tactile or verbal stimuli, so staff initiated CPR and called 911 at 2:17 AM. CPR resumed until ambulance and 911 staff arrived at 2:38 AM to transport the resident to the nearest hospital. - [DATE] at 3:39: at 3:15 am, the hospital called to report that the resident had passed away. Review of Resident #3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a family interview on [DATE] at 12:59 PM stated Resident #3's mother had talked to him the day before he died and reported he had been incoherent, moaning, and groaning. His mother told the facility staff the resident needed to see the doctor but was told no because the doctors were not coming to the facility due to COVID-19. The family member then stated that is when his significant other called his practitioner's office to see what needed to be done. The family member stated the practitioner's office called the facility about the resident's condition. During an interview on [DATE] at 10:11 AM, the resident's SO reported the resident's mom called him the morning before he passed, talked to him, and then called her and to say he did not sound good and could not hold a conversation. Resident #3's SO reported being significant other was upset because he needed to see a doctor. She stated she called the facility and told nurse he needed to see a doctor. The nurse stated the doctor comes in the evenings sometimes but has not been here since the outbreak. She stated she called his primary care provider (PCP) they used outside of the facility and told them they had a concern with Resident #3 and he needed a doctor. She told the PCP they could not get any help and that was when the PCP's nurse called to get an update and vital signs. The PCP's nurse called the significant other back and stated the facility doctor needed to see him and the facility nurse did not talk of the concerns that were relayed to her by the family. During a staff interview on [DATE] at 3:38 PM, Staff G was asked if she worked the day before Resident #3 died ([DATE]). She stated she was not sure because she had just switched to the day shift & needed to check her phone. When asked about the fax she sent on [DATE] she stated that was when anyone would pull paper off the fax machine and put it wherever they wanted. She stated recently staff were told to put a fax in the fax bin or let staff know it is important. She reported starting about a month ago, the Director of Nursing (DON) and Regional Nurse Consultant would keep up on faxes that would come through. She stated staff were educated to not just pull stuff off the printer and put it somewhere else. When asked if she talked to Resident #3's family the day he showed a decline, she stated she remembered talking to his SO. She described the resident as lethargic, just not himself, not eating, not drinking, and he opened eyes but did not acknowledge she was there. She stated when she would try to hand him his water or medication cup he would not take it, and would just looked at her. She stated she told Resident #3's SO she had sent a fax to the physician. She remembered talking with Resident #3's previous doctor and that she had told him he had declined. Staff G was asked if staff could have sent Resident #3 out without an order and she stated with his situation she needed an order because at that time it wasn't warranted to send out without an order. She stated if she followed up the next day and his condition at not changed, she would have called. She stated she also would have called if his condition had worsened during her shift. During a follow-up interview on [DATE] at 9:43 AM Staff G was asked if she passed the information on to the oncoming nurse related to her concerns about Resident #3. She stated she let Staff I LPN know during her report and she had written it on the 24 hour report paper. She stated Staff I was new to the facility so when she did her report she went to each resident room to show her who everyone was. When asked if the nursing staff charts their report anywhere she stated on the 24 hour report paper that is on a clip board on the row of the fax machine. Staff G was asked if the facility utilized hot charting she stated they have a hot charting binder which has everything they are to chart on for the day they worked. She stated there is a list of residents and what staff need to chart about each shift. Staff G stated the hot binder chart never used to be updated but now the DON makes sure it is updated every night. Staff G was asked what made her decide to fax the doctor rather than call the doctor, she stated he had a change in condition. She stated about a month ago she had been educated that if there was change in condition to call the doctor, not to fax them. During a staff interview on [DATE] at 12:10 PM Staff E CNA was asked to describe Resident #3, she stated when he first got here he was easy going and liked to sit in his recliner, but when he had COVID he was not doing too well. She stated the day before he passed away his oxygen was down, he wasn't not talking and wasn't himself because he had declined. She reported she was there breakfast and lunch and he would not eat. She stated he usually drank Mountain Dew but that day he would not drink it and spit it on himself like he had no strength to hold anything in his mouth. He was on oxygen and didn't normally require it. During a staff interview on [DATE] at 1:03 PM Staff L CNA was asked to describe working with Resident #3, she stated she only worked at the facility a couple nights when he was at the facility, liked to sleep in his chair, would reposition him every 2 hours during the night shift. Staff L worked with him on [DATE] on the night shift and he was not talking and on oxygen. He wouldn't drink his Mountain Dew. She stated in report staff stated they were trying to feed him, but he was not eating. She stated they tried to give him fluids throughout the night but he refused. She added he was not normally on oxygen and was normally a quiet guy that would talk for a little bit but had to sit with him. She stated that night he looked like he was not doing very well and they checked on him more frequently than normal. She reported Staff I, LPN worked that night, was and did not work there long. Attempts were made to contact Staff K and Staff I on [DATE] and messages were left requesting a return call. Neither Staff K nor Staff I called back. During a staff interview on [DATE] at 9:32 AM the Medical Director was asked if Resident #3 should have been sent to the hospital and he stated the staff should have send him to the ER according to his order. He stated unless there was refusal from the Power of Attorney (POA) or resident, because of their right to refuse, there should not have been a reason for him not to go the ER. When asked if staff could have sent Resident #3 to the ER without an order he stated they could have sent him out without an order then called later for one, given the information on the fax that was sent to him. During a staff interview on [DATE] at 10:50 AM Staff B RN was asked if she took care of Resident #3, she stated she did not do a lot of care with him. Staff B was asked if a resident had a decline how would she notify the doctor, she stated she would make a telephone call to the physician. She added any change in condition would require a telephone call, it has always been that way. When asked about the fax she noted on [DATE], 14 days after it had been faxed to the facility, she stated she was catching up on notes and had noted the doctor had signed the order. During a staff interview on [DATE] at 10:26 AM the DON was when would staff notify a doctor about a resident via fax versus a phone call? The DON stated any change in condition would require a call to the doctor right away. She stated any time a resident is in distress or needs treatment within an hour would justify a call to the doctor. The DON stated if a resident was experiencing symptoms of a urinary tract infection they routinely would fax the doctor. The reason to call versus fax the doctor is highly variable based on the amount of distress the resident is in. The DON was asked if a resident had a change in condition such as refusing meds, meals, very lethargic, oxygen saturations below 90%, on oxygen when not normally, with positive COVID test and a fax was sent to the doctor, how long would you wait until you called or followed up? She stated that would require a call right away. She stated to her that person is showing signs that they are declining and sending a fax is not appropriate for that. The DON was asked if she would send a resident to the ER without a doctor's order and she stated that should never happen. If the resident was in active respiratory distress and cannot get hold of doctor, then call 911. The priority becomes the resident's care and safety. During a family interview on [DATE] at 1:04 PM the family member stated she talked with Resident #3 the day before he passed away. She stated it was not a good conversation. She stated she had a hard time hearing him, talking very low. She stated she asked the facility staff is he saw a doctor and they told her that the doctor did not come because of COVID-19. The nurse told her she would try to get a doctor but not sure he would come out. During a staff interview on [DATE] at 11:50 am Staff C RN/previous DON said Resident #3 developed COVID-19 and she knew him a little bit, but when he started to decline but she was off work because she had COVID-19. She remembered she had received a call from the nurse that night that he passed and she had told that staff member he was a full code and they needed to do everything they could for him. Staff C was asked if the nurse that took care of him noticed a decline, had faxed the doctor but never heard back, what should she have done? She stated the nurse should have made a phone call instead of sending a fax. She stated she had preached that over and over to her nurse. She stated she often had conversations about when to call the doctor, if anything was alarming enough to contact the doctor they should have called. Review of the facility's Policy and Procedure: physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Notification of a Change in a Resident's Condition policy with a last reviewed date of [DATE] revealed staff are to notify the physician/resident representative when there is a significant change in unstable vital signs, symptoms of any infectious process, change in level of consciousness, and unusual behavior. The facility was notified of the Immediate Jeopardy on [DATE]. The facility abated the IJ on [DATE] by implementing the following actions: a. Medical Director notified he will receive phone calls in place of faxes ,d+[DATE] in the event a resident has a change in condition. If the physician is not available, the facility will call his after-hours clinic number. The DON has his cell number and she can reach out to him as well. b. 100% audit completed on all residents to ensure there were no immediate changes in condition. c. Inservices provided to all licensed staff on proper protocol and procedures for responding to a resident's change in condition including assessment/intervention, physician notification, and documentation of the event. d. Facility will monitor change in condition through clinical meeting 5 times weekly through 4 weeks then monthly to ensure ongoing compliance. Monitored findings will be brought to monthly QAPI for review. e. Regional Nurse Consultant will educate licensed staff on completing head to toe assessments and identifying early changes of conditions. 2. According to a quarterly Minimum Data Set (MDS) with a reference date of [DATE] revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS indicated she required limited assistance of 1 staff for bed mobility, personal hygiene and extensive assistance of 2 staff. The MDS listed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan revealed a focus area with an initiation date of [DATE]: she had potential for impaired skin integrity related to diabetes, excessive weight-skin folds, incontinence, thin fragile skin. On [DATE], coccyx non pressure moisture, see wound log. The focus area revealed the following interventions with an initiation date of [DATE]: air mattress to her bed, weekly head to toe assessments by a licensed nurse, review skin risk factors via pressure injury assessment and clinical observation/assessment, encourage frequent repositioning in bed and chair, apply chair cushion to her wheelchair, keep her clean and dry, use barrier cream, good pericare and observe skin with all cares, report any changes to the nurse. The care plan encouraged staff to check and change Resident #2 with rounds with an initiation date of [DATE] and added a Roho cushion to her wheelchair on [DATE]. Review of Resident #2's clinical record revealed a fax to the physician dated [DATE] at 2:15 PM that was sent from Staff B Registered Nurse (RN). The reason for physician notification: resident has moisture area to coccyx which has declined. The facility would like to change treatment from triad cream to [MEDICATION(S)] extra to wound and place bordered dressing twice a day (BID) and as needed (PRN) if saturated until healed. The fax was time stamped as sent on [DATE] at 2:04 PM from the facility. On [DATE] the physician replied ok. The order was not time and noted by the facility. The fax was time stamped as being returned on [DATE] at 3:28 PM from the physician's office. Review of Resident #2' Electronic Health Record (EHR) revealed Resident #2's completed and discontinued orders from [DATE]-[DATE] revealed the following orders: apply Dermesyn and [MEDICATION(S)] extra to coccyx wound bed, cover with sacrum dressing until healed with a start and end date of [DATE]; iodosorb to coccyx wound bed with gauze dressing and apply bordered gauze with a start date of [DATE] and end date of [DATE]; clean wound to coccyx with wound cleanser, apply Dermesyn and collagen powder to the wound and cover with bordered dressing daily and as needed (PRN) if saturated until healed with a start a start date of [DATE] and an end date of [DATE] and [MEDICATION(S)] with calcium alginate to coccyx wound daily and PRN soiling, cover with sacral foam dressing with a start date of [DATE] and an end date of [DATE]. Review of Resident #2's [DATE] Treatment Administration Record (TAR) revealed the order to change treatment from triad cream to [MEDICATION(S)] extra to wound and place bordered dressing BID and PRN if saturated until healed, was not on the TAR.

Based on observations, record review, staff and resident interviews, the facility failed to implement a comprehensive infection control program to mitigate the risk of spread of infection during a COVID-19 outbreak. The facility failed to complete infection control surveillance consistently on residents according to CMS and CDC guidelines and failed to isolate residents for a minimum of 10 days after the presence of COVID-19 symptoms first appeared. The facility also failed to provide care in accordance with accepted infection control standards and practices. Staff did not properly sanitize the sit to stand lift after use, wore incomplete or improper PPE, and failed to complete hand hygiene when indicated during resident personal care for 11 of 13 residents reviewed (#1, 2, 3, 4, 5, 6, 7, 9, 10, 11 and 13). During the COVID-19 pandemic, 30 residents and 17 staff tested positive for COVID-19 and 7 residents died due to complications of COVID-19. As a result of these findings, an Immediate Jeopardy (IJ) was identified to resident health and safety. The facility reported a census of 31 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident scored ,[DATE] on the Brief Interview for Mental Status (BIMS) test which indicated the resident demonstrated moderate cognitive impairment. The MDS also documented he required extensive assist of 2 staff for transfers, walking in his room and toilet use, and extensive assist of 1 staff for dressing. The Care Plan dated [DATE] documented Resident #1 as at risk for contracting Covid-19 and also at risk of developing fatal complications. The Care Plan directed staff to follow CDC guidelines and recommendations for Covid-19. A care plan revision dated [DATE] included precautionary isolation through [DATE] and directed the licensed nurse to complete a comprehensive respiratory assessment and monitor and document vital signs every shift. Review of the clinical record revealed no vital signs or comprehensive assessments documented on [DATE]. The Progress Notes from ,[DATE]-[DATE] revealed Resident #1 placed in quarantine due to an outside doctor appointment on [DATE]. On [DATE], the Progress Notes documented the resident leaned to his left, displayed increased confusion and his skin became gray in color. He was sent to the hospital and admitted to rule out a [MEDICAL CONDITION] (stroke). The Emergency Department (ED) note dated [DATE] revealed the resident sent to ED for weakness. The physician documented the resident had a CT scan and he did not see any significant change since the last scan. The Hospital Infectious Disease Results dated [DATE] revealed Resident #1 tested positive for 2019 Novel Coronavirus. During an interview on [DATE] at 12:35 PM with a representative of the county public health department stated the facility had 7 reported deaths related to Covid-19 complications as any death within 28 days of a positive Covid-19 test counts as a Covid-19 death. The representative stated the facility's communication is getting better with the Iowa Department of Public Health (IDPH), but there is still room for improvement. The representative said they call and speak to the facility daily for testing and results, but the facility does not complete the workbook in its entirety as required. During an interview on [DATE] at 9:45 AM with a representative of the county public health department stated they have been trying to get the facility to follow IDPH guidance since [DATE] with regard to reporting requirements. The representative added it took 4 days to get a partial workbook of information completed, but the facility is not doing it daily as required. Spreadsheets provided by the facility titled COVID Testing and dated [DATE] revealed 30 residents had tested positive for COVID-19. One page titled COVID Positive Staff revealed 17 staff had tested positive for COVID-19. During an interview on [DATE] at 10:40 AM with Staff H, she stated the transition hall (precautionary isolation) had never been shut or sealed. The plastic put in place and pulled back signified the facility used it as a transition hall for new admissions or residents with unknown infection status. Staff H reported staff wear goggles and masks in the transition hall, but not gowns or gloves. She added that in March or April she was educated on the new requirements for cleaning, but there are days she thinks they don't have enough housekeepers to keep up. During an interview on [DATE] at 11:00 AM, the Director of Nursing (DON), reported nurses work 12 hour shifts and are expected to complete a temperature and Covid-19 Risk Assessment every shift for every resident. During an interview on [DATE] at 12:35 PM with the Assistant Director of Nursing (ADON), she stated she has worked at the facility for 3 years. She reported the facility never sealed or separated the transition hall from the rest of the facility, although they kept the residents' doors shut. She also reported staff wore masks and goggles but did not consistently wear gowns in resident rooms on the transition hall. During an interview on [DATE] at 12:50 PM with the DON she stated all new admissions, readmissions, or residents that have been out for appointments go to the transition hall. She added they do not keep the hall closed or sealed and the staff are to wear their masks and goggles but have never been required to wear gowns on the hall. 2. According to the quarterly MDS dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident scored ,[DATE] on the BIMS indication he displayed intact cognition. The MDS revealed he was totally dependent on 2 staff for transfers and totally dependent on 1 staff for dressing and toilet use. The Care Plan dated [DATE] revealed Resident #2 was at risk for contracting Covid-19 and also at risk for fatal complications. The Care Plan directed staff to follow CDC guidelines and recommendations for Covid-19. Review of Resident #2's clinical record revealed no documentation of vitals and a comprehensive assessment on ,[DATE], ,[DATE], ,[DATE] and [DATE]. 3. According to the quarterly MDS dated [DATE], Resident #3 had [DIAGNOSES REDACTED]. The MDS documented she scored ,[DATE] on the BIMS which indicated the resident demonstrated intact cognition. The MDS indicated she required extensive assist of 1 staff for transfers, dressing and toileting; and was independent with set up help for eating. The Care Plan dated [DATE] revealed Resident #3 was at risk for contracting Covid-19 and also at risk for fatal complications. The Care Plan directed staff to follow CDC guidelines and recommendations for Covid-19. Review of Resident #3's clinical record revealed it lacked documentation of vital signs and a comprehensive assessment on ,[DATE], ,[DATE], ,[DATE] and [DATE]. Further record review revealed only one set of vital signs with a corresponding comprehensive assessment on one shift on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. Observation on [DATE] at 1:00 PM revealed Resident #3 in a hospital gown in the shower room with Staff E and Staff I present for cares and shower during transfer from the Covid Isolation Hall (no longer had a positive COVID-19 test) back to her previous room. Both aides washed their hands and donned clean gloves. Staff E moved the lift while Staff I provided cares. Staff raised the resident's bare feet were raised and placed them on the visibly dirty lift platform. The front edge of the platform contained dirt and loose, varied types of small debris. Staff applied the sling around the resident's waist and Staff E raised the lift which assisted the resident to stand while connected to the lift. Staff I removed a urine soaked brief but did not remove her soiled gloves. She then unattached the sling from the lift with her dirty gloves and removed the sling from around the resident. Staff I then removed her gloves and used hand sanitizer. After the resident's shower, both aides present used hand sanitizer and applied clean gloves. Staff E moved the lift and helped Staff I attach the sling to the resident. Staff E raised the lift while Staff I dried the resident's backside. She then removed her gloves, sanitized and donned new gloves before applying a clean brief and pulling up the resident's clothes. Staff applied a mask to move Resident #3 to the hall and through the hallway to her room. After delivering the resident to her room, staff moved the lift to the hall without sanitizing it. During a tour of the halls of the facility on [DATE] at 1:45 PM identified sit to stand lifts numbered 3, 4 and 6. All were visibly dirty and contained dirt and small particles and debris on the foot platform, on the top of the leg cushion, and on the handle bars where the resident had to grip to stand when staff raises the machine. During an interview with the Director of Nursing on [DATE] at 2:10 PM she stated the facility has 5 sit to stand lifts to share between all the residents and staff are to sanitize the lifts between each resident and each hall. 4. According to the annual MDS dated [DATE], Resident #4 had [DIAGNOSES REDACTED]. The MDS documented he scored ,[DATE] on the BIMS which indicated he showed an intact cognitive status. The MDS indicated he was independent with transfers, dressing and toilet use and required set up help with supervision for eating and minimal assist of 1 staff for his bath. The Care Plan dated [DATE] revealed Resident #4 presented with positive lab results drawn on for Covid-19 on [DATE]. It directed staff to follow CDC guidelines and recommendations for Covid-19, monitor vital signs every shift, and initiate and maintain droplet isolation precautions. Review of Resident #4's clinical record revealed it lacked documentation of vital signs and a comprehensive assessment on ,[DATE], ,[DATE], ,[DATE] and [DATE], and only on one shift on ,[DATE], ,[DATE], ,[DATE] and [DATE]. The Director of Nursing provided a facility Resident Isolation Spreadsheet on [DATE] which listed all the residents that tested positive for Covid-19 with their start and stop dates for isolation. It listed Resident #4's test date as [DATE] and start date for isolation [DATE]. The Progress Notes revealed Resident #4 was in isolation on [DATE] and then moved from the isolation hall on [DATE] (9 days). The Progress Notes dated ,[DATE]-[DATE] documented Resident #4 as lethargic. The Temperature Summary for Resident #4 revealed he had a fever of 99.9 on [DATE]. The facility policy Discontinuation of Transmission Based Precautions Covid-19 revised [DATE] instructed staff to discontinue transmission based precautions for individuals with confirmed Covid-19 using a symptom-based, test-based or time-based strategy. Definition: a. Symptom-based strategy: afebrile for 24 hours without the use of fever reducing medications AND improvement in respiratory symptoms AND at least 10 days since symptom onset. b. Test-based strategy: individuals with critical illness and are severely immunocompromised AND at least 20 days from the date of the positive Covid-19 test AND negative results form of an FDA authorized Covid-19 test (2) consecutive respiratory specimens collected more than 24 hours apart. c. Time-based strategy: asymptomatic AND at least 10 days from the date of the positive Covid-19 test. 5. The annual MDS dated [DATE] revealed Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident experienced severe cognitive impairment and was totally dependent on staff for bed mobility, transfers, toilet use, and dressing. The Care Plan dated [DATE] revealed the resident [MEDICAL CONDITION] at his gastrostomy tube site and is at risk for contracting Covid-19 with fatal complications. During an observation of cares on [DATE] at 1:00 PM, Staff A and Staff B, Certified Nursing Assistants (CNAs) wearing mask and goggles, don gown and gloves to enter Resident #5's room. The resident's room door had a sign posted on the outside of the door that directed the resident was on droplet precautions. The aides stated the resident is not positive for Covid-19, but was on droplet precautions due to his ventilator. The resident's room contained small, random debris on the floor on both sides of the bed on the floor. The nursing assistants rolled the resident to his left side and Staff B removed a urine soaked brief and provided perineal care with wipes that sat at the foot of the bed. Staff B completed perineal care on the right side and then adjusted her goggles on her face with the same gloves she had been wearing during cares and then assisted Staff A to roll the resident on his right side. Staff A rolled up the dirty brief and discarded it in the trash next to her and then used wipes to provide care on the resident's left side. She then put a clean brief under him, but did not remove her dirty gloves. They rolled the resident to his back and Staff A provided perineal care for the resident's front, then they pulled up the brief between his legs and then rolled him slightly to his left side to finish adjusting the brief. Neither aide had removed their dirty gloves or completed any hand hygiene since entering in the room. Staff B adjusted the bed with the bed remote in her dirty gloved hand and Staff A adjusted the gastrostomy feeding tube and then the vent tube. Staff B then retrieved paper towels and a graduate to empty the Resident #5's gastric catheter. She did not change her gloves or do complete hand hygiene between perineal care and gastric catheter care. After all cares were completed, both CNAs removed the gloves they donned prior to entering the room and then washed their hands before leaving the room. During an interview with the Respiratory therapist that walked by as everyone exited the room, she agreed the floor was dirty and stated she believed it was food because the resident's roommate had been known to throw food. She stated she would have it cleaned immediately. 6. According to the quarterly MDS dated [DATE] for Resident #6 scored him at ,[DATE] for the Brief Interview of Mental Status indicating moderately cognitively impaired. The MDS coded him as independent with bed mobility, transfers, dressing and toileting and independent with eating with set up help only. It listed [DIAGNOSES REDACTED]. The Care Plan dated [DATE] for Resident #6 revealed he was at risk for contracting Covid-19 and was at risk for fatal complications. The Care Plan directed staff to follow CDC guidelines and recommendations for Covid-19. The CDC website specific for Nursing Homes, updated [DATE] and still current as of [DATE], titled Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/Coronavirus/2019-ncov/hcp/long-term-care.html included the following guidelines about facilities screening residents daily for signs/symptoms of COVID-19: Evaluate and Manage Residents with Symptoms of COVID-19. Ask residents to report if they feel feverish or have symptoms consistent with COVID-19. Actively monitor all residents upon admission and at least daily for fever (T=100.0oF) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below. Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0oF might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. The CDC link for symptoms consistent with COVID-19, updated [DATE], included the following recommendations on watching for symptoms: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear ,[DATE] days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea This list does not include all possible symptoms. CDC would continue to update this list as we learn more about COVID-19. Record review of the clinical record revealed Resident #6 lacked documentation of vitals and a comprehensive assessment on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. The facility Resident Isolation Spreadsheet revealed Resident #6 was started on isolation [DATE] and stopped isolation on [DATE] which totaled 9 days in isolation. The Progress Notes dated [DATE] for Resident #6 revealed he had rhonchi in his upper lobes and was having loose stools. Review of the Progress Notes revealed he continued to have abnormal lung sounds through [DATE] when he was taken out of isolation. During an interview with Resident #6 on [DATE] at 10:55 AM he stated he just came off isolation for testing positive for Covid-19. He stated he is still having nausea but is negative as far as he knows. The CDC website specific for Nursing Homes updated [DATE], titled Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html included the following guidelines about keeping a new or readmitted resident in quarantine for 14 days: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. The facility removed Resident #6 from isolation on [DATE] while he still exhibited the respiratory symptom of abnormal lung sounds. 7. The quarterly MDS dated [DATE] for Resident #7 listed [DIAGNOSES REDACTED]. The MDS documented the resident scored ,[DATE] on the BIMS test which meant the resident displayed moderate cognitive impairment. The MDS documented the resident as totally dependent on 1 staff for transfers, dressing and toilet use. The Care Plan dated [DATE] documented Resident #7 as at risk for contracting Covid-19 and also at risk for fatal complications. The Care Plan directed staff to follow CDC guidelines and recommendations for Covid-19. Record review of the clinical record lacked documentation of vitals and a comprehensive assessment provided for Resident #7 on [DATE] and ,[DATE]-[DATE]. The Resident Isolation Spreadsheet revealed Resident #7 began isolation on [DATE] and left isolation on [DATE], a total of 9 days in isolation. A Progress Note dated [DATE] revealed the resident had an oxygen saturation of 84 percent, which was the first documented abnormal symptom, however the clinical record on ,[DATE]-[DATE] lacked any documentation of a lung assessment. 8. According to the quarterly MDS dated [DATE], Resident #9 had [DIAGNOSES REDACTED]. The MDS documented the resident scored ,[DATE] on the BIMS test which indicated she demonstrated moderately impaired cognitive abilities. The MDS showed the resident required extensive assist of 1 staff for transfers, dressing, toilet use, and bathing. The Care Plan dated [DATE] documented Resident #9 as at risk for contracting Covid-19 and also at risk for fatal complications. The Care Plan directed staff to follow CDC guidelines and recommendations for Covid-19, monitor vital signs every shift, and report any status changes to the physician. Resident #9's clinical record lacked documentation staff completed temperature and lung assessments every shift on ,[DATE] and [DATE]. Record review of the Progress Notes revealed: a. On ,[DATE] and [DATE] the resident's respirations were labored with lung sounds diminished. b. On [DATE] the resident had shortness of breath and diminished lung sounds with an oxygen saturation of 79% c. On [DATE] the resident's oxygen saturation went from 43% to 70% percent by adding 10 liters of oxygen. d. On [DATE] the resident had clammy and pale skin and exhibited intermittent confusion with episodes of combative behavior and oxygen saturations of ,[DATE]% on 10 liters of oxygen. The nurse notified the physician and sent the resident to the emergency room . 9. According to the annual MDS dated [DATE], Resident #10 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assist of 1 staff for transfers, dressing and toilet use. Observation on [DATE] at 11:15 AM revealed Staff D and Staff B entered Resident # 10's room, washed their hands, and donned gloves. Staff D moved a sit to stand lift in front of the resident and explained cares to her. The resident lifted her sock covered feet onto the platform that was covered in dirt and debris and grabbed the hand grip bars as the CNAs put the sling around her waist and attached the strap around her lower legs. Staff D raised the lift as Staff B removed a urine soaked pad from under Resident #10. Staff B then removed her gloves, sanitized her hands and donned new gloves. Staff D handed Staff B the wipes as Staff B cleansed the resident's back side with three wipes used to wipe the right back, left buttock and rectal area. Staff B removed her gloves, sanitized her hands and donned new gloves. She then placed a new clean brief in the recliner and both CNAs moved the lift to the recliner and lowered the resident into it. Staff did not cleanse the resident's front, including the vaginal area. Towels hung under the front side of the resident's gown, and Staff D reported the resident had towels in her skin folds due to redness and excoriation. Both CNAs removed their gloves, sanitized their hands and donned clean gloves. Staff B picked up the room while Staff D sanitized the sit to stand lift. She used bleach wipes and sanitized the handles the CNAs had used, the control panel, and the top rail above the resident hand grips. Staff D did not sanitize the bars the resident grasped during the transfer or the platform under her feet. She then moved the lift to the hallway. Observation on [DATE] at 9:55 AM revealed Staff D, CNA exited a resident's room wearing her mask properly, but wearing her goggles on top of her head. She used hand sanitizer and then proceeded down the hall. The facility was notified of the IJ on [DATE]. The facility abated the Immediate Jeopardy on [DATE] by taking the following actions: a. The Director of Nursing/Designee completed an audit to ensure COVID-19 assessments were completed on each resident on [DATE] at 4:00 PM. Each resident had a COVID-19 assessment completed [DATE] and will have at least one assessment completed daily moving forward. b. The facility has educated all staff regarding completion of daily respiratory assessments for signs/symptoms of COVID-19 for all residents; the discontinuation of transmission-based precautions, proper use of PPE, and instructions on what PPE should be used in what parts of the facility; and cleansing of the lifts between resident uses. Facility policy H9 Novel Coronavirus COVID-19 dated [DATE] and facility policy H5 Discontinuation Transmission Based Precautions COVID-19 dated [DATE] were reviewed with all staff with completion date [DATE] by 6:15 PM. c. Audits will be completed by the Director of Nursing/Designee periodically on the day and night shifts. d. Audits will be taken to the QAPI monthly meetings for review. 11) According to the Minimum Data Set (MDS) dated [DATE]th 2020 Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognitive response. According to the MDS she required extensive assistant with the help of one person for transfers, dressing, bathing and toileting. According to the physician's orders [REDACTED].#11 had [DIAGNOSES REDACTED]. The POS indicated an order for [REDACTED]. According to a care plan dated [DATE], the resident had a left above knee amputation, was at risk for bleeding due to anticoagulant therapy, potential for impaired skin related to diabetes and had an activities of daily living self-performance deficit. In an observation on [DATE] at 1:10 PM Staff W CNA was assisting Resident #11 with her meal. The resident was in bed with nasal cannula and oxygen set on 3 liters. As Staff W went over the bedside she stood on the oxygen tubing that was laying on the floor. Upon closer inspection it was discovered that the tubing lacked information indicating when it had been last changed. In an interview on [DATE] at 10:30 AM Staff Y, respiratory therapist, said that she had just gotten back to work on ,[DATE] after having being out for a couple of weeks. She had with her the sheet she uses to document when oxygen tubing is changed. She said that when she changes it, she will document the date on a piece of tape. The resident was started on oxygen on the 13th so that's when the tubing would have been put on. DON stated that she would reeducate nursing staff on weekly changes of tubing and dating when it's started. Upon further review of the chart revealed that the resident did not have a physician's orders [REDACTED]. 12) According to the MDS dated [DATE], Resident #13 had a BIMS score of ,[DATE] which meant he displayed a moderate cognitive deficit. The MDS documented the resident as independent with transfers, ambulation, dressing and toilet use. The care plan last updated [DATE] documented a potential for acute and chronic pain related to [DIAGNOSES REDACTED] and also documented the resident as at risk for falls and a self-care performance deficit. The care plan included [DIAGNOSES REDACTED]. In an observation on [DATE] 10:50 AM, Staff E CNA offered Resident #13 a shower. The shower room had a whirlpool tub that Staff E verified had not worked for at least 5 months and also verified the residents used this shower room only. A shower chair was in the corner next to a hand-held shower wand that hung on the wall and a very soiled shower curtain hung next to the door and separated the shower area for privacy purposes. Resident #13 was independent with his shower, he removed his clothes, sat in the shower chair and used the hand-held shower wand to wash himself. Several times he propelled himself closer to the CNA and pulled back the curtain. When the resident was clothed and left the room, Staff E sanitized the shower chair and folding chair with sanitizer, but failed to spray the curtain, shower wand, floor, or wall. Staff E immediately rinsed and wiped the sanitizer off of the chair. When asked about the required contact time of the sanitizing agent, she was unable to say for sure. In an interview on [DATE] at 10:00 the Director of Nursing (DON) went into the shower room and observed the dirty shower curtain, floor, walls, and the dust filled window vent. When asked about her expectations for cleaning of the area between uses she said that it would be expected to clean the shower chair and the handles and hand held shower wand. The DON reported she would educate staff regarding the contact time for the sanitizer and would make sure the to have the curtain changed and surfaces thoroughly cleaned.

Based on observation, interview, and record review, the facility failed to provide the required nursing services for urinary catheter care to prevent complications for 4 of 4 residents reviewed for catheter cares (Resident #15, #18, #16, & 17). The facility failed to obtain catheter orders for routine catheter care, failed to assess and intervene when abnormal signs/symptoms of urinary function presented, and failed to properly insert a catheter which caused a torn urethra that required surgical repair (Resident #15). The resident presented to the hospital with [MEDICAL CONDITION] with septic shock (complication of infection in the blood), scrotal abscess, acute blood loss, and sacral decubitus (pressure sore). The facility reported a census of 31 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment tool dated August 7, 2020, Resident #15 had [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which meant the resident demonstrated intact cognitive abilities. The MDS documented the resident as totally dependent on 2 staff for transfers, dressing, and toilet use. According to the electronic record census page, Resident #15 was admitted to the facility on [DATE] and had 6 hospitalization s throughout his stay. The care plan last updated on 5/5/20 indicated that the resident had altered respiratory status, difficulty breathing and had a [MEDICAL CONDITION]. The care plan stated that he had potential for altered nutritional status related to bolus tube feeding and was paraplegic related to a spinal injury, with no feeling from the nipples down. The care plan indicated that he had actual skin impairment and staff were directed to measure areas per facility guidelines with weekly skin assessment and to provide treatments to wounds according to the physician's orders [REDACTED].#15 was on anticoagulant medication which put him at risk for abnormal bleeding and had an indwelling catheter. The care plan directed staff to change the catheter according to physician's orders [REDACTED]. According to hospital report dated 8/23/20, Resident #15 presented at the emergency roiagnom on [DATE] at 8:57 AM with scrotal bleeding. The hospital report documented the nursing home reported the bleeding started on 8/22/20. The hospital record contained a (CT) scan completed at the hospital that revealed malposition of the urinary catheter. The catheter balloon had been inflated in the urethra (rather than in the bladder), which caused the urethra to tear. Further review of the hospital record showed a cystoscopy (a procedure that allows the physician to examine the lining of the bladder and urethra - the tube that carries urine out of the body - with a hollow tube called a cystoscope. The scope is equipped with a lens that is inserted into the urethra and slowly advanced into the bladder) was completed to evaluate the urethral injury and evacuate any clots. Then, emergency surgery was performed to repair the urethral tear. The hospital assessment listed the presenting problems as follows: [MEDICAL CONDITION] with septic shock, scrotal abscess, acute blood loss and sacral decubitus (pressure) ulcer of the sacral region. In an interview on 8/31/20 at 8:30 AM the urologist that performed Resident #15's emergency stated due to where the new catheter balloon had been inflated, the resident would have had some urinary output and may have had leakage around the catheter site. With proper placement in a male, a catheter will protrude approximately 6 inches; if it had been misplaced, staff should have noticed more of the catheter had been exposed than normal. The doctor reported that within a couple of hours of misplacement, he would have expected bladder spasms and leakage to occur. The doctor added he would have expected the nurse that inserted the catheter to have met with some resistance as the balloon was being inflated, and should have discontinued the procedure at that time. He said he typically expected staff to change catheters about every 4 weeks and as needed. Resident #15's medical record revealed the most recent physician's orders [REDACTED]. On 8/25/20 at 6:30 PM, the Licensed Practical Nurse (LPN), Staff O, that had inserted Resident #15's urinary catheter documented a late entry into the electronic record and dated it as 8/19/20 at 10:06 AM. In the nursing note, Staff O, LPN charted a Certified Nursing Assistant (CNA) reported to her the resident's catheter had been leaking with very little urinary output, so she then inserted a new catheter. Staff O wrote she did not encounter resistance when she inflated the balloon and noted no problems or concerns regarding the resident's response to the catheter insertion. In an interview on 9/1/20 at 3:00 PM, Staff S, CNA stated she had been on vacation from 8/10 - 8/14/20 when she returned to work on 8/15/20 she learned the resident's catheter had been changed sometime while she was on vacation. She said she noticed swelling of the scrotum on Resident #15 on the 8/15/20 and reported it to a nurse at that time. The next time she worked was 8/18/20 and she noticed the swelling had doubled from when she saw it previously. She stated she reported it to the nurse, but did not know if there was follow-up at that time. On 9/2/20 at 11:15 AM Staff X, CNA verified she worked 8/14 - 8/16/20 and 8/19 - 8/20/20. She said she had provided catheter cares for Resident #15 on 8/14/20 and noticed a decrease in urine output and leaking of the catheter. She stated on 8/15/20, she noticed swelling and she reported it to Staff J, Assistant Director of Nursing (ADON). She added she did not know what type of, if any, assessments or measures the nurse took after she reported it to the nurse. In an interview on 9/1/20 at 1:00 PM, Staff P, Certified Med Aide (CMA) said she had been working with Staff T, CNA on an overnight shift when she noticed the resident displayed scrotal swelling and blood tinged urine. She stated she had reported it to a nurse, but did not remember which nurse it was or if there had been follow-up completed at that time. A review of the timesheets revealed that Staff P and Staff T worked together on the overnight shifts on 8/12 - 8/14/20 and 8/17/20. In an interview on 9/1/20 at 4:00 PM, Staff D, CNA said she was with Staff O, LPN when she inserted the resident's new catheter. She said she hadn't noticed if the LPN had any difficulty inserting the catheter but remembered there was a lot of urine output after the insertion. She also remembered she had worked the following day and at that time noticed swelling of the scrotum and reported it to Staff J, Assistant Director of Nursing (ADON). She recalled this was a weekend shift and the ADON directed her to keep an eye on it. Staff P reported she had a couple of days off, but the next time that she worked, the scrotum had swollen to twice the size. A review of the timesheets for August revealed Staff D and Staff O worked together on 8/10, 8/14, 8/16, and 8/19/20. Staff D worked with Staff J on 8/14 - 8/15/20. During a conversation on 9/1/20, Staff P, CMA determined the catheter must have been inserted on 8/14/20 and she noticed the swelling and reported it on 8/15/20. She then figured she came back to work on 8/19/20 and noted the swelling was much worse. In an interview on 9/2/20 at 8:30 AM with Staff O, LPN, she was asked to clarify her documentation dates. She was asked since she had entered the nursing note on 8/25 and dated it 8/19, could she have been mistaken about the date she inserted Resident #15's catheter? Staff O hesitated and said she remembered Staff D, CNA was with her and she was pretty sure it was the 8/19/20. Staff O reported she had inspected the catheter site after insertion and it had drained fine. She remembered that she worked on 8/21/20 and did not notice any concerns until at the end of her shift, when one of the CNA's reported to her the resident's scrotum was very swollen. She said that she had already clocked out, so she passed the information along to the night nurse, Staff L, RN. Staff O was informed the resident did not have an order for [REDACTED]. She said she decided what size of catheter to insert for Resident #15 from inspecting the size that he had in previously. When asked if Staff O could recall how much of the catheter may have been exposed after insertion, she said she thought it was about 3 inches. In an interview on 9/10/20 at 6:16 PM, Staff L, RN recalled the night that Resident #15 had gone to the hospital and commented it took over an hour for the ambulance to get to the facility that night. She stated she had been very concerned about the blood loss because they had changed the linens on the bed at least three times before the ambulance arrived around midnight. The resident record revealed a nurse's note had been entered into the electronic record on 8/26/20 and dated 8/22/20 at 2:00 PM. In the note, Staff J, ADON documented staff alerted her to Resident #15's scrotal bleeding and she assessed the area as hard and swollen with blood coming from an open area on the scrotum that measured 1 centimeter (cm) long by 1 cm wide. She reported she called the medical provider and was directed to call the urologist. Staff J then talked with the urologist on call that evening. She said he stated as long as the resident was stable through the night, she should arrange for him to be taken to the emergency room the next morning for an evaluation. A review of the clinical chart revealed the resident's vital signs on 8/22/20 at 3:00 PM were as follows: blood pressure: 96/47, heart rate: 92, temperature: 97.2, respirations: 18, and oxygen saturation: 96% on trach. In an interview on 9/1/20 at 4:22 PM, Staff J stated that the day before the resident had gone to the hospital she had assessed him earlier in the day and hadn't noticed any swelling, redness, and decrease in urine output. She said that later on 8/22/20 was the first that she became aware of swelling or bleeding because Staff W, CNA reported it to her. She said she called the urologist and he said that as long as his vitals were stable and the resident was not lethargic that they should arrange to get him in the next day. When asked about the routine for catheter changes, Staff J said that the night shift nurses would generally do them and the standard is every 30 days. When asked how she or anyone else would know when it was time to change the catheter if it was not listed on the Treatment Administration Record (TAR), she said she really did not have an answer to that question. When asked how the nurses know which size catheter to use if there is no order, she said they would look at the size of the catheter the resident had in at the time. Staff J reported stated that she had worked the weekend before the resident went to the hospital (8/14 - 8/15/20), nobody had come to her with concerns regarding swelling or blood in the catheter. She maintained the resident had no signs of infection and there was no reason to suspect misplacement of catheter. She added that until the day that the resident went to the hospital, his catheter was flushing just fine. When asked about nurse trainings and competencies, she said that DON does the trainings and she wasn't sure what was covered. In an interview on 8/31/20 at 2:55 PM Staff M, LPN said that she had worked at the facility for less than one year and hadn't ever changed a catheter for Resident #15. She said she did not have any training when she started at the facility and no competency skills checks had been completed for her. In an interview on 9/4/20 at 9:00 AM, the urologist confirmed the conversation that he had with Staff J on the evening of August 22nd. He had a note about the conversation and said that it had been reported to him the scrotal swelling was first noticed on Friday evening the 21st and by Saturday morning a small opening developed on the anterior scrotum. He said the nurse reported the resident's vitals had been stable and the nurse flushed the catheter a couple of times. The first time it flushed readily with a bit of blood, but on the second flush all of the fluid came out through the hole in the scrotum. He advised that as long as the resident was stable, they should get him in to the next morning. According to a nursing note, the resident transferred from the hospital and back to the facility on [DATE]. In an interview on 8/31/20 at 12:35 PM Resident #15 stated he understood he had been in the hospital for a torn urethra. When asked about his most recent catheter change at the facility he explained that he did not see what the nurses do when they change the catheter and since he has no feeling from mid-chest or below, he didn't know if anything unusual happened during insertion. He remembered that a couple of days after the insertion of the catheter an aide mentioned that she noticed he had some swelling and he had less urine output, but he did not remember which CNA said had told him or what date it had been. 2) According to an MDS dated [DATE], Resident #18 had [DIAGNOSES REDACTED]. The MDS showed a (BIMS) score of 15/ 15, which meant the resident demonstrated intact cognitive abilities. The MDS documented the resident required extensive assist of 1 staff for transfers, dressing, and toilet use and bed mobility. The census tab in the electronic record documented the resident admitted to the facility on [DATE], admitted to Hospice services on 8/8/20, and passed away on 8/11/20. The care plan for Resident #18 dated 6/22/20 documented the resident had a suprapubic catheter related to [MEDICAL CONDITION] of the prostate, [MEDICAL CONDITION] with [MEDICAL TREATMENT] treatment, and a history of [MEDICAL CONDITION] and kidney stones. The care plan directed staff to provide catheter cares as ordered. A hard copy of the Treatment Administration Record (TAR) documented an order dated 11/30/19 that directed staff to maintain a 22 French supra pubic catheter and to change it on the last day of the month. The April TAR for Resident #18 lacked documentation of a catheter change in the Month of April. According to a nursing notes, on 5/21/20 at 15:00, the resident complained of abdominal pain and staff reported that there was blood in the catheter bag. According to the nursing notes, the resident continued to have pain and blood in his urine over the following days. On 5/23/20 at 9:30 AM the doctor was called and the resident was admitted to the hospital with [REDACTED]. A review of the chart revealed staff changed his catheter on 6/30/20, but the July 2020 TAR lacked documentation of a catheter change in the month of July. Further review of the resident's record showed an order beginning 5/28/20 to irrigate the suprapubic catheter every day and night shift and to clean the supra pubic catheter every day and night shift. According to the census page in the electronic chart, the resident had been in the hospital 8 days in the month of July 2020. A review of the charting revealed staff missed an opportunity to irrigate the suprapubic catheter 20 times in June 2020 and 8 times in July 2020. Staff also missed the opportunity to clean the catheter 16 times in June and 7 times in July. 3) According to the MDS dated [DATE]th 2020, Resident #16, could not participate in the BIMS test and experienced severely impaired cognition. cit. The MDS revealed he was totally dependent on two staff for transfers, dressing, and toilet use. The care plan dated 5/5/20 documented Resident #16 had [DIAGNOSES REDACTED]. According to the care plan, the resident had lower body paralysis, numerous bladder issues, and used an indwelling catheter and a suprapubic catheter. The Care plan directed staff to provide catheter cares every shift and to change the catheter and collection system per order/policy. An order dated 3/06/20 directed staff to cleanse the suprapubic wound site with wound cleanser, apply zinc and stoma adhesive, and cover with a drain sponge twice a day. An order dated 9/7/19 directed staff to irrigate with acetic acid one time a day. The resident's record lacked orders regarding the size of catheter used and how often to change it. A review of the electronic record revealed a nurse's note dated 7/1/20 that showed staff changed the catheter due to leakage. The record from 2/1/20 to present had no other documentation of a catheter change. A review of the Treatment Administration Record (TAR) revealed the order to irrigate the catheter one time a day lacked initials 14 out of 30 opportunities in the month of June 2020. In the month of July 2020, the opportunity was missed 5 times. A review of the TAR revealed the order to cleanse the suprapubic wound site and cover with a drain sponge twice daily lacked initials 14 times in June 2020 and 6 times in July 2020. In an interview on 9/2/20 at 11:15 AM, Staff X, Certified Nursing Assistant (CNA) stated Resident #16's catheter leaked a lot. 4) According to an MDS dated [DATE], Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS identified the resident scored 11/15 on the BIMS test which meant he experienced moderate cognitive deficits. According to the MDS, the resident required extensive assist of one staff for transfers, ambulation (walking), and dressing, and was totally dependent on one staff for toileting needs. The care plan for Resident #17 dated 7/1/20, documented the resident had an indwelling catheter due to a prostate disorder directed staff to change the catheter according to physician orders. A physician's orders [REDACTED]. A review of the TAR for the month of July 2020 revealed no documentation to show catheter had been changed on the 13th of the month or any other day in July. In an interview on 8/31/20 at 2:50 PM, the DON verified acknowledged the charts lacked documentation of catheter changes and therefore the nurses had no way of knowing if/when the catheters had been changed. She said the facility would be that nurses would change a catheter with clogging or sediment. The Catheter Care policy dated October 2016 documented the purpose of the policy: maintain consistent and adequate hygiene standards for residents with indwelling catheters. The procedure included hygiene guidelines only and did not include instruction or guidance for proper catheter placement, standards for timely catheter changes, or directives for following physician's orders [REDACTED].

Based on record review and interview, the facility failed to provide consistent and adequate wound care to prevent the development and worsening of pressure sores, and failed to provide sufficient wound assessments and documentation for 1 of 1 residents reviewed (Resident #15) for wound care. Resident #15 admitted to the facility on [DATE] and had been admitted to the hospital a total of 6 times during his stay. The resident had [DIAGNOSES REDACTED]. The resident's care plan dated 5/5/20 identified he had altered skin integrity (open areas) and listed intervention that directed staff with regard to his care. The resident's record showed staff failed to measure, assess and document wounds on a consistent basis and also did not always complete wound and pressure sore treatments on a regular basis. As a result, new wounds developed and the resident's existing wounds showed an increase in size. The facility reported a census of 31 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment tool dated 8/7/20, Resident #15 had [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) test score of 15/15 which meant the resident demonstrated intact cognitive abilities. The MDS also documented the resident as totally dependent on 2 staff for transfers, dressing, toilet use, and bed mobility. According to the census page in the electronic record, Resident #15 admitted to the facility on [DATE] and had been transferred to the hospital 6 times during his stay. A care plan last updated on 5/5/20 documented Resident #15 experienced altered respiratory status and difficulty breathing. The care plan also identified the resident had a [MEDICAL CONDITION]. The care plan revealed a potential for altered nutritional status related to bolus tube feeding and a [DIAGNOSES REDACTED]. According to the care plan, Resident #15 also had a problem with impaired skin integrity and staff were directed to measure the areas according to facility guidelines with weekly skin assessments and to provide treatments to wounds according to the physician orders. The care plan documented he took anticoagulant medication, which put him at risk for abnormal bleeding, and also documented he utilized an indwelling catheter for urination. The care plan directed staff to change the catheter according to the physician orders. According to a report from the hospital dated 8/23/20, Resident #15 presented to the emergency roiagnom on [DATE] at 8:57 AM with scrotal bleeding and underwent emergency surgery at that time to repair a torn urethra caused by improper placement of a urinary catheter. The nursing notes documented the resident returned to the facility on [DATE]. A review of the clinical record revealed physician orders [REDACTED]. 1) On 6/20/20: Clean left back thigh and apply zinc oxide twice daily. 2) On 6/20/20: Clean right buttock open area and apply zinc oxide twice daily. 3) On 6/20/20: Clean sacral area and apply zinc oxide twice daily. 4) On 6/20/20: Moisten gauze with sterile water, pack right hip, and cover with bordered foam twice daily. 5) On 6/20/20: Moisten gauze with Dakins Solution, pack right buttock wound bed, and cover with bordered foam twice daily. 6) On 6/20/20: Moisten gauze with Dakin's solution, pack sacral wound, and cover with bordered foam twice daily. 7) On 6/20/20: Clean PEG tube site, apply zinc oxide to area, and apply 4 x 4 twice daily. 8) On 4/07/20: Apply [MEDICATION NAME] twice daily. 9) On 4/15/20: Ensure heel protectors remain on at all times wound prevention twice daily. 10) On 5/20/20: Apply skin prep to right heel, apply [MEDICATION NAME], and wrap with kerlix once daily. 11) On 7/15/20: Cleanse right heel, apply Dermesyn, and cover with foam daily. According to a hard copy of the Treatment Administration Record (TAR), staff failed to complete the following treatments in the months of June and July of 2020: Order #1 began on 6/21/20 and staff missed it 8 times in June and 15 times in the month of July. Order #2 began on 6/21/20 and staff missed it 8 times in June, and 14 times in July. Order #3 began on 6/21/20 and staff missed it 8 times in June and 14 times in July. Order #4 began on 6/21/20 and staff missed it 8 times in June and 22 times in July. Order #5 began on 6/21/20 and staff missed it 8 times in June and 21 times in July. Order #6 began on 6/21/20 and staff missed it 8 times in June and 20 times in July. Order #7 began on 6/21/20 and staff missed it 4 times in June and 13 times in July. Order #8 began on 4/7/20 and staff missed it 15 times in June and 14 times in July. Order #9 began on 4/15/20 and staff missed 15 times in June and 14 times in July. Order #10 began on 5/20/20 and staff missed it 7 times in June (order discontinued in July). Order #11 began on 7/15/20 and staff missed it 5 times in July. A review of the skin assessments in the medical chart revealed from 6/23/20 through 8/11/20, the chart included only 8 documents that contained only this narrative: weekly skin assessment completed and no new skin concerns noted. A review of the medical chart revealed: a. A wound assessment dated [DATE] that detailed wound location with corresponding measurements: Site 25) Right hip: 1 centimeter (cm) length (L) x 0.6 cm width (W) x 2.2 cm depth (D). Site 53) Sacrum: 1 cm (L) x 1 cm (W) x 2.5 cm (D) Site 55) Right gluteal fold: 1 cm (L) x 0.6 cm (W) x 2.2 cm (D) Site 49) Right heel: 1 cm (L) x 1 cm (W) x 0.0 (D) b. The next wound assessment dated [DATE] that listed wound locations with corresponding measurements: Site 53) Sacrum: 1 cm (L) x 1 cm (W) x 0.1 cm (D) Site 31) Right buttock: 2 cm (L) x 0.7 cm (W) x 0.1 cm (D) Site 36) Left thigh: 2.5 cm (L) x 1.7 cm (W) x 0.1 cm (D) Site 14) Abdomen 4 cm (L) x 4 cm (W) x 0.1 cm (D) c. A would assessment on 8/18/20 listed the following sites, but did not contain any measurements: Site 53) Sacrum Site 49) R heal Site 50) L heal Site 55) R gluteal fold Site 25) R trochanter hip A review of the documentation revealed that the assessment on 6/20 and 8/18 had only one wound site in common (sacrum) According to the hospital report dated 8/24/20 a wound care specialist saw the resident while at the hospital. The wound report included 11 sites, including the surgical wound on the scrotum. The following four sites were listed on the hospital report but were not included in any of the facilities reports: 1) Left lateral foot: 1.5 cm (L) x 1.5 cm (W) x 0.1 cm (D) 2) Right ischium: 1 cm (L) x 1 cm (W) x 3 cm (D) 3) Left gluteal cleft: 0.5 cm (L) x 0.5 cm (W) x 0.1 cm (D) 4) Right lateral foot: 0.3 cm (L) x 0.3 cm (W) x 0.1 cm (D) Due to incomplete charting the only area that could be determined as the same sight measured and recorded at both the hospital and at the facility (Site 25 Right trochanter hip) measured 1 cm x (L) 0.6 cm (W) x 2.2 (D) on 6/2/20 and at the hospital it measured 2 cm (L) x 1.5 cm (W) x 0.1 cm (D). A review of the chart revealed many of Resident #15's wound assessments lacked measurements. In an interview on 8/25/20 at 2:20 PM, the DON stated she documented the wound measurements on a flash drive and sent them to the corporate office on a weekly basis, but reported the flash drive with the wound documentation was at home. In an interview on 8/27/20 at 11:35 AM, the wound specialist from the hospital stated he was familiar with the resident and understood that Resident #15 had some chronic wounds that are problematic. He said he noticed some new wounds, several of which were pressure sores during the resident's most recent hospitalization . He added it would be important to continue treatments as ordered, reposition the resident frequently, and ensure protective devices remained in the wheel chair and on the heels. In an interview on 9/14/20 at 9:45 AM the nurse consultant acknowledged that wound care has been a challenge at the facility. The nurse consultant stated they had started working on utilizing the wound specialist to attend to residents' high level wounds.

Based on clinical record review, staff and physician interviews, and facility policy review, the facility failed to provide needed referrals, treatments and staff communication of status changes regarding a skin abrasion that worsened to the point that the Achilles tendon, fat, and connective tissue were visible. The area became infected,[MEDICAL CONDITION] developed, and the resident required hospitalization , surgery, and a right leg (below the knee) amputation for 1 of 2 discharged residents reviewed (Resident #3). The facility identified a census of 41 current residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 3/13/19, Resident #3 had [DIAGNOSES REDACTED]. The assessment documented the resident had an intact memory and cognition as evidenced by a brief interview for mental status score of 15. The assessment recorded Resident #3 did not walk, required the assistance of two staff with transfers and dressing and the assistance of one staff with bed mobility, eating, toilet use and personal hygiene. Resident #3 had the risk of developing pressure ulcers and had one Stage 3 ulcer at the time of the assessment. The MDS documented treatments that included pressure reducing devices for her chair and bed. The resident's Care Plan, revised on 1/14/19, documented Resident #3 had the potential for skin breakdown related to obesity, diabetes, peripheral [MEDICAL CONDITIONS] and previous wounds. Interventions included to consult with the wound clinic per orders and to consult with a would nurse specialist as needed. The Care Plan also directed staff to provide wound treatments as ordered. During an interview on 9/30/19 at 3:15 p.m. the DON (Director of Nursing) stated she is the facility's primary wound nurse. When asked, she reported she documented assessments in the Skin QI logs but had not transferred them to the facility's electronic health record yet. A Nurses note dated 4/17/19 at 11:49 p.m. documented a dressing to the resident's right Achilles as clean, dry, and intact. The progress notes did not identify a source of the right Achilles wound. During interview on 10/2/19 at 9:35 a.m., the DON stated the facility had no incident report, no progress note entries, and no investigation as to the injury to the resident's right Achilles. She thought the injury may have occurred during a surface to surface transfer or a bath. The Skin Quality Improvement (QI) Log for Non-Pressure skin conditions (used by the facility to document wound assessments and treatments) recorded the following information: a. 4/16/19 - Resident #3 had an abrasion to her right Achilles which measured 2 by 2 cm (centimeters) and had no depth. The treatment included a collagen matrix covered with a bordered foam dressing to be changed daily (the resident's clinical record did not contain an order for [REDACTED].>b. 4/23/19 - The right Achilles abrasion measured 2 by 2 cm and treatment continued with collagen matrix covered with a bordered foam dressing to be changed daily. c. 4/30/19 - The right Achilles abrasion now measured 3 by 1 cm with a depth of 0.1 cm, worsening, with a treatment documented as moistened [MEDICATION NAME] covered with a foam dressing and Kerlix (the resident's clinical record did not contain an order for [REDACTED].>d. 5/7/19 - Measurements and treatment remained unchanged from 4/30/19. e. 5/14/19 - The right Achilles abrasion measured 2.5 by 2 cm with a depth of 0.1 cm with continued treatment of [REDACTED]. f. 5/21/19 - Measurements and treatment remained unchanged from 5/14/19. g. 5/28/19 - The right Achilles abrasion measured 2.5 by 2.5 cm with depth of 0.3 cm. The log documented treatment of [REDACTED]. Staff documented the wound had worsened. h. 6/4/19 - The abrasion measured 2.8 by 2.0 cm with a depth of 0.2 cm., improving, with treatment of [REDACTED]. i. 6/11/19 - The resident's right Achilles abrasion measured 4 by 3 cm with a depth of 0.2 cm, improving, with treatment of [REDACTED]. j. 6/18/19 - The right Achilles abrasion now measured 6.5 cm by 3.9 cm with a depth of 1 cm. Treatment included [MEDICATION NAME] with a foam dressing and Kerlix wrap. k. 6/25/19 - The wound measurements and treatment were unchanged from 6/18/19. During interview on 10/2/19 at 10:10 a.m., the DON stated she would call the physician's office to find the orders for Resident #3's wound care as documented on the 4/16 and 4/30/19 documented in the Skin QI Log for Non-Pressure skin conditions. On 10/14/19 at noon, the DON stated she looked through all of Resident #3's records and could not find the wound treatment orders of 4/16 and 4/30/19. The resident's Progress Notes documented the following: a. 5/27/19 at 7:51 p.m. - A Nurses note documented the open area of the resident's Achilles wound as slightly reddened around the edges with an open area of connective tissue and a faint, foul odor. b. 5/31/19 at 2:58 p.m. - A Skin/Wound Note documented an odor and some drainage present to the right Achilles wound. c. 6/1/19 at 4:35 a.m. - A Skin/Wound Note documented a minimal amount of drainage present to the wound, with an odor noted and appearance of different stages of healing. d. 6/8/19 at 2:22 p.m. - A Skin/Wound Note documented the wound continued to have an odor and had a small amount of drainage at that time. e. 6/12/19 at 1:52 p.m. - A Skin/Wound Note documented staff changed the right Achilles dressing, noting scant drainage and continued odor. f. 6/13/19 at 10:14 a.m. and 6/14/10 at 10:37 am - Both documented moderate drainage and odor from the right Achilles wound. g. 6/19/19 at 2:08 p.m. - Treatment to the right Achilles recorded and the wound had no odor. The note documented the resident currently received an antibiotic. h. 6/20/19 at 1:38 p.m. - During a dressing change, staff noted a foul odor to the wound with scant drainage and redness and warmth to her right leg. i. 6/24/19 at 8:05 p.m. - Staff cleansed the resident's right Achilles wound and noted a foul odor present in the room without dressing removal. j. 6/26/19 at 2:49 p.m. - The resident complained of right leg pain at a 10 on a 0-10 scale, with 10 being the worst imaginable pain. Staff gave the resident two Tylenol per orders. k. 6/27/19 at 9:58 a.m. - The resident admitted to the hospital with [REDACTED]. On 10/14/19 at 10:20 a.m. the DON stated nurses would not document the appearance of a resident's wound when providing treatments, but would document the appearance of a dressing (despite the presence of odor with dressing changes). Review of the resident's clinical record revealed no physician orders for the treatments documented in the Skin QI - Non Pressure Log on 4/16 and 4/30/19. On 10/14/19 at noon, the DON stated the 4/16/19 and 4/30/19 wound treatment orders could not be found. The Physician's Order and Progress Notes dated 6/14/19 revealed Resident #3 transferred care from her previous physician because she did not wish to travel for visits to her prior physician's office. The resident's new care provider documented the resident had a post calf wound being addressed by (the) wound care (clinic) and ordered a wound care consult, [MEDICATION NAME] (an antibiotic) 100 mg twice daily for 14 days, and blood tests. The Wound clinic progress note dated 6/18/19 documented Resident #3 had a new ulcer on the back of her right ankle with an exposed tendon and a foul odor. The note revealed the resident had no [MEDICAL CONDITION] or redness of the foot or ankle and did not complain of pain during the visit. The Wound clinic staff identified the wound as a Stage 4 wound with etiologies (the cause(s) or manner of causation of a disease or condition) of pressure and diabetic wound ulcers of the lower extremities. The right ankle wound measured 16.4 by 4 cm with a 1 cm depth with visible tendon, fat layer and fascia (a band or sheet of connective tissue beneath the skin that attaches, stabilizes, encloses, and separates muscles and other internal organs). The wound showed a large amount of drainage and a foul odor after cleansing. Wound clinic staff identified a small area of granulation (healing) tissue in the wound bed and large amount of necrotic (dead) tissue in the wound bed. The facility's Discharge list documented Resident #3 discharged from the facility on 6/27/19. Resident #3's Hospital Discharge Document dated 7/8/19 documented she admitted directly to the hospital on [DATE] for septic shock from right acute on chronic wound infection. The resident was found to [MEDICAL CONDITION] (blood infection) due to a right foot infection. She immediately started on intravenous fluids and broad spectrum antibiotics. The resident underwent [REDACTED]. On 10/7/19 at 9:22 a.m. the resident's former physician stated she last saw Resident # 3 in (MONTH) of (YEAR). The resident should have had a follow up appointment in (MONTH) of 2019, but did not come or was not scheduled. The physician's records showed little information regarding the right Achilles tendon tear and she had no records of facility staff requesting treatment changes on 4/16 or 4/30/19. The physician stated if facility staff contacted them after hours, clinic staff would phone or fax orders. The facility then sent the orders back for signature and they scan them into the clinic EMR (electronic medical record). The physician stated they had no records for any wound orders for 4/16 or 4/30/19. The facility sent the physician faxes on 5/16/19 and on 6/5/19 stating the right Achilles tendon wound was healing well. In (MONTH) 2019, she received a call from the wound care physician. He informed her the resident's Achilles wound was infected and he could see her tendon; he asked what they should do and she recommended the resident be seen in the hospital. Following review of the facility's documented assessments, the physician wondered how the wound have changed so much in that short period of time. However, if the wound was worsening, they should have contacted the physician or the Wound clinic immediately. Resident #3 had been seen for a long time by the Wound clinic, so they were familiar with her care. The resident also stayed in close communication; she cared about her own health. They really should have been looking at her wounds every day, weekly would not have been sufficient for her. On 10/15/19 at 10:50 am, when asked why Resident #3 had no referral to the Wound clinic until 6/19/19, the DON stated they made the referral in (MONTH) when the resident started seeing a new physician. The DON stated the wound appeared to be healing and she is usually pretty good at healing resident wounds. When the wound worsened, she requested a Wound clinic referral. On 10/29/19 at 1:46 p.m., Staff A, RN (Registered Nurse) stated that if she assessed changes in a resident's wound, she would communicate the changes to the DON via a phone call or text and tell the oncoming shift. Staff A stated she has called the DON if she was really concerned. On 10/29/19 at 1:50 p.m., Staff B, RN stated put any changes in a resident's wound status on the facility's 24 hour report and in the resident's clinical record. She would also tell the oncoming shift. On 10/29/19 at 1:54 p.m., the DON stated nurses usually tell her of any changes to a resident's wound. She did not recall anyone telling her the resident's right Achilles wound had an odor, but sometimes wounds have odors. She did not recall any odors when assessed Resident #3's wound. The facility's Skin Management Guidelines, revised 7/17, and primarily offered information about treatment of [REDACTED]. The guidelines instructed that At-Risk review meetings would be conducted to review/discuss residents identified at risk or with compromise, treatment modalities and interventions and recommendations based on interdisciplinary evaluation. Under the section titled Lower Extremity Ulcers, the guidelines instructed staff to monitor the area closely during treatment to evaluate the appropriateness of the treatment regimen and that consultation with a Certified Wound Care Nurse or surgeon may be appropriate.

Based on observation, record review and physician and staff interviews, the facility failed to implement appropriate precautions and interventions after the facility added an air mattress to a bed frame with side rails which caused an entrapment hazard that resulted in death of Resident #1. This created an immediate jeopardy situation for the health and safety of a resident. The sample consisted of 3 residents and the facility identified a census of 44 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident as unsteady, could only stabilize with staff assistance and required extensive assistance of 1 staff person for all ADLs (activities of daily living). According to the MDS, the resident displayed delusional behaviors and had a BIMS (brief interview for mental status) score of 3 out of 15. A score of 3 identified the resident had a severe cognitive impairment. According to the Care Plan, the following interventions pertained to Resident #1: The resident's needs should be anticipated as of [DATE]. Nonskid strips had been applied in front of the toilet on [DATE]. Ensure the resident wore gripper socks at night as of [DATE]. The accordion door removed from the bathroom on [DATE]. The resident requested not to be toileted or repositioned at bed time as of [DATE]. Staff should check on the resident frequently for safety as of [DATE]. Non-ambulatory as of [DATE]. Assist the resident with toileting before meals, after meals, at bedtime and as needed. The Care Plan also noted the resident's tendency to refuse help. The floor mat should be next to the bed when he lays down in it as of [DATE]. Required extensive assistance of one person for transfers as of [DATE]. Hospice provided an air mattress on [DATE]. Relied on staff to propel his wheelchair as of [DATE]. Wheelchair pedals (foot rests) should be removed when staff not assisting as of [DATE]. The wheelchair should be folded and stored in the bathroom while in bed as of [DATE]. A list of ten incidences noted Resident #1 either fell in the bathroom or self-transferred from his bed or the toilet between [DATE] and [DATE]. The Care Plan did not contain interventions for precautions, interventions, potential risks or hazards related to the use of the air mattress and side rail combination. The document titled Fall Scale-Morse and dated [DATE] indicated the resident at a high risk for falling. The document titled Safety Device Audit Assessment Tool dated [DATE] noted Resident #1 would benefit from an enabler/assistive device for repositioning. The documents titled physician's orders [REDACTED]. The physician also ordered safety measures: call bell/light in reach, bed low position, and oxygen safety precautions. The Medication Review Report dated on or after [DATE] noted Resident #1's physician ordered him to be admitted to Hospice Care at Oakland Manor on [DATE]. The document titled, Hospice/Long Term Care Checklist for Reporting Death, dated [DATE], noted Resident #1 died as a result of accidental asphyxiation by bed rail. The document titled Preliminary Report of Investigation by Medical Examiner and dated [DATE] indicated Resident #1 was pronounced dead on [DATE] at 6:17 a.m. by Staff C, RN. The author indicated asphyxiation due to compression of the head and neck by the bed rails had been identified as the probable cause of Resident #1's death. The narrative summary of circumstances surrounding the death indicated Resident #1 was checked on and seen sleeping comfortably at about 5:00 a.m. on [DATE]. According to the document, the staff found the resident about an hour later, partially on the floor and pinned on the side of the bed by the bed rail. The reported identified the resident did not have a pulse, was not breathing and the nurse pronounced him dead at that time. After review of the history, circumstances and photographs, the medical examiner believed Resident #1 died accidentally while trying to get out of bed and became pinned between the mattress and bedrail which caused a compressive force on the right side of his face and neck. On [DATE] at 12:00 p.m. the Administrator was interviewed and stated the door to the resident's room was locked and the facility left everything the way they found it, except stripping the bed of soiled linen. The Administrator stated the CNAs (certified nursing assistants) chart by exception. According to the Administrator, their rounding (of each resident assigned) only got documented if they found something out of the ordinary. When asked about the frequency in which they reposition residents, the Administrator stated the DON (Director of Nursing) told her turning and repositioning are standards of practice that are done frequently and as needed. When asked to clearly define frequently, the Administrator said they do not quantify by hours on the care plans. According to the Administrator, she has personally observed the CNAs reposition residents if they are found in awkward positions. The Administrator stated the staff offered to intervene if they see residents with grimaces on their faces or if they voice a desire to be repositioned. The Administrator stated a Care Plan that specified a numerical value, like every two hours; may be an infringement on their right to stay in the same position to watch TV or whatever else they might prefer to do. On [DATE] at 1:00 p.m. Staff C, registered nurse, was interviewed and stated she went down Resident #1's hallway about 5:00 a.m. when she started her medication administration pass. Staff C stated the resident usually liked his door closed, but she kept it half way open because of the resident being [AGE] years old. Staff C stated she went into his room but did not disturb him because she visually saw him sleeping. Staff C stated she tried to visualize each resident every two hours, but two hour rounding was the CNAs responsibility. Staff C stated as she sat at the nurse's station with 3 other nurses at about 6:15 a.m. during shift change. According to Staff C, Staff A, CNA and Staff B, CNA approached them and reported they found Resident #1 on the floor next to his bed with his head caught between the mattress and the bed rail. Staff C stated she, Staff D, LPN (licensed practical nurse), Staff E, RN and Staff F, LPN went to the resident's room. Staff C stated they found him in a kneeling position on the floor mat beside the bed with his head between the mattress and the bed rail. According to Staff C, they found him with the left side of his face against the mattress and the other side against the bed rail. Staff C stated his head was stuck and they removed it easily. Staff C stated she recalled the call light being attached to the sheet that partially covered him. Staff C stated he had not been tangled in the sheet. According to Staff C, one of the resident's hands gripped the bed rail as if he tried to stand himself up. Staff C said he had a history of [REDACTED]. The RN described Resident #1 as being physically incapable of standing himself up. Staff C said the facility had a policy of not using bed alarms. On [DATE] at 1:37 p.m. Staff B (certified nursing assistant) was interviewed and stated she received a shift report from Staff A about 6:15 a.m. According to Staff B, Resident #1's door was partially closed so they opened it and found him kneeling/leaning against the side of the bed with his head between the mattress and the bed rail. The CNA stated his left shoulder and upper back were against the bed and he faced forward with the left side of his face against the mattress and the right side against the bed rail. Staff B stated he did not have any color and did not appear to be breathing. The CNA stated she stayed with the resident and Staff A went to get the nurses. Staff B stated Resident #1 still needed the side rail for repositioning. Staff B stated she had not seen Resident #1 stand on his own for weeks because of a recent decline. According to the CNA, Resident #1 had a history of [REDACTED]. Staff B stated she remembered the call light being within reach, but did not remember its exact location. Staff B stated she heard the CNAs talking about Resident #1 needing a low bed because she thought he slid his feet out of bed. When asked, Staff B stated she did not know if that resulted from him moving around in bed or attempting to get up on his own. The CNA stated Resident #1 did not like to be positioned in the center of the bed. According to Staff B, Resident #1 frequently self-transferred to the bathroom before a recent hospitalization . Staff B stated the resident was unsteady and should have used his call light, but would not. Staff B stated the resident was readmitted from the hospital with a catheter. Staff B stated within the first day or two after being readmitted , she found him on the floor of his bathroom doorway. According to Staff B, he must have forgotten he had a catheter. The CNA stated the drainage bag was still attached to the bed frame. She said the catheter had not gotten pulled out, but the tubing had gotten stretched tightly. Staff B stated she wondered why they had not issued a low bed for Resident #1 after his return; especially since he had fallen again after being readmitted from the hospital. Staff B stated she thought all cognitively impaired residents with balance issues should have low beds that go all the way to the floor. The CNA stated she overheard Staff G talking to someone else about Resident #1 needing a low bed. On [DATE] at 3:05 p.m. Staff E (registered nurse) was interviewed and stated she received shift report from Staff C when Staff A approached them and said it looked like Resident #1 was caught in the bed rail and it appeared he passed away. According to Staff E, when they arrived at Resident #1's room they found him on the floor mat next to the bed. Staff E stated he was in a kneeling position, but almost appeared as if he were sitting on his legs. Staff E stated the resident's upper body leaned forward with his head between the mattress and the bed rail facing forward and his right hand grasped the hand rail. Staff E stated Resident #1 wore a brief and a night gown. According to Staff E, she could not remember the location of the call light. Staff E stated Resident #1 had a history of [REDACTED]. Staff E stated the resident had the ability to use his call light, but whether or not he did varied from day to day. Staff E stated Resident #1's head was lodged between the mattress and the side rail and they had to push against the mattress to relieve some of the pressure to remove his body. Staff E stated it was difficult to get him out of the position they found him in. On [DATE] at 3:30 p.m. Staff A, CNA, was interviewed and stated she last saw Resident #1 asleep in bed about 3:30 a.m. Staff A stated she found the resident with his head caught between the mattress and bed rail at 6:15 a.m. According to the CNA, she did rounds every two hours, and her last rounds were at 4:00 a.m. Staff A stated she started the rounds a little early to ensure she got them all done. Staff A stated she and the oncoming CNA stopped at Resident #1's room during shift report about 6:15 a.m. According to Staff A, she found the door slightly open and when she pushed it open all the way, she and the oncoming CNA found Resident #1 kind of slumped over to the side kneeling on the floor mat next to the bed with his body at kind of an angle. The CNA stated his left hand gripped the bed rail and his other hand had just kind of fallen along his side. The CNA stated the resident's head was lodged in between the mattress and the bed rail, facing forward with the left side of his head against the mattress and the right side against the rail. According to Staff A, she had to push the rail outward to relieve enough pressure to get his head out. Staff A said it looked like he had moved the call light because the cord stretched across the side rail and the stuffed animal attached to the end of it dangled above the floor. Staff A stated Resident #1 typically did not use his call light; he just screamed if he needed something. Staff A stated Resident #1 had a history of [REDACTED]. Staff A stated the resident did not have a real high low bed. According to her, Resident #1's bed would only lower to about mid-thigh or knee level, but not all the way to the floor. The CNA said she suggested getting an actual high low bed to a couple nurses on separate occasions when she caught him trying to get up on his own. Staff A stated they would look into it, but nothing had ever been done about it. Staff A recalled the 1st time she suggested the high low bed was a couple months before the incident. The CNA said she suggested it again a couple weeks before his death. According to the CNA, she happened to be passing by Resident #1's room when she saw him trying to get up on his own and then suggested it again. Staff A stated she doubted if the incident would have happened if his bed had been lowered all the way to the floor. According to her logic, Resident #1 would have been in a much better position to help him because his whole body would have been on the floor. The CNA stated it looked like he had been gripping the rail trying to pull him out. According to Staff A, she was so upset she mentioned to Staff C if he had a high low bed it wouldn't have happened. Staff A stated the facility had not conducted an in-service or provide individual education related to the situation. Staff A stated the only thing the Administrator did was take our statements. Staff A stated the Administrator didn't ask how it could have been avoided or anything else. Staff A stated she believed any resident with the inability to self-transfer, but has a history of doing so should have a bed that goes all the way to the floor. Staff A stated despite having a fall mat next to the bed, the resident could have fallen and broken a hip from that height. Staff A stated it appeared as if he had been hanged. On [DATE] at 8:30 a.m. with the ME (Medical Examiner) identified that although an autopsy had not been performed on Resident #1, it seemed apparent that significant pressure had been applied after getting his head caught between the mattress and the bed rail. According to the ME, Resident #1 had an indentation on the side of his face and ecchymosis (bruise; primarily formed when blood vessels near the surface of the skin are damaged, usually by impact from an injury) across the maxillary (jawbone) facial area and the right neck. According to the ME, providing appropriate interventions to keep someone with a history of self-transferring safe would be the prudent thing to do. A subsequent interview on [DATE] at 9:40 a.m. with Staff C (Registered Nurse) revealed Staff G spoke to her about Resident #1's need for a low bed and they both agreed. Staff C stated she found it difficult to speak to the maintenance department because she worked the overnight shift; therefore she never relayed that information. According to Staff C, they tried to keep Resident #1 near the nurse's station during his waking hours because inevitably he would try to self-transfer if they were not monitoring him. Staff C stated Staff G, LPN told her she had previously spoken to the ADON (assistant director of nursing) about arranging for Resident #1 to have a low bed, but unfortunately it never happened. Staff C stated she believed Resident #1 would have been sitting on the mat instead of the position they found him in if he had a bed that went all the way to the floor. Staff C stated other residents that cannot stand are found on the floor when they are equipped with a low bed. On [DATE] at 10:35 a.m. Staff G (licensed practical nurse) was interviewed and stated she no longer worked at the facility and unaware of the side rail incident with Resident #1. Staff G said she worked the day shift and always tried to keep Resident #1 at the nurse's station, the lobby or in activities; somewhere he could be supervised. According to Staff G, staff would shut his door when he was in his room because he wanted it shut and would yell if they left it open. Staff G stated he was not safe in his room with the door shut because of being a fall risk. Staff said Resident #1 did not always use the call light. Staff G stated if he did activate the call light and someone did not respond in a few minutes; he would transfer himself. On [DATE] at 11:25 a.m. with Staff F, LPN revealed that was the first night she trained on Resident #1's hall. According to Staff F, she walked to the end of his hall at 5:20 a.m. to remote start her car. According to Staff F, she had not heard anyone calling for help. When asked, the LPN could not recall if Resident #1's door was opened or closed. Staff F said they were at the nurses' station reporting off to the day shift when Staff A came to the desk and told them Resident #1 appeared to have died because of getting his head caught between the bed rail and mattress. Staff F said she, Staff C and Staff E went down to his room. The LPN said he appeared to be on his knees with the left side of his body against the bed. Staff F said she could not tell if his buttocks touched the floor mat or just his knees because he had been wearing a gown. Staff F said the side rail was in the up position and Resident #1 faced downward with the left side of his head against the mattress and the right side against the side rail. Staff F said she saw the rounded corner of the side rail under his jawbone. The LPN said the resident's head had been lodged. According to the LPN, indentations had been left due to the pressure from the bars of the side rail and his right hand gripped the bottom of the bar. Staff F also said she saw the call light directly under the bed on the floor about 8 (inches) just to the left of him. Staff F said she helped physically lift the resident and reposition him so Staff C could assess his pulse. According to Staff F, she assumed Resident #1 choked because of his head being compressed between the bed rail and mattress. On [DATE] at 2:40 p.m. the Nurse Consultant was interviewed and stated the facility did not have a side rail policy; they considered the use of side rails as a standard of practice. On [DATE] at 8:15 a.m. the MDS Coordinator was interviewed and stated she agreed; there should have been something on the Care Plan about precautions related to the use of side rails and an air mattress. The MDS Coordinator stated the Maintenance Supervisor periodically checked beds. The MDS Coordinator stated that is his thing The MDS Coordinator stated she did not know what the Maintenance Supervisor specifically looked for. The MDS Coordinator confirmed and agreed a collaborative approach with the Maintenance Supervisor may be more effective in developing specific precautions and interventions related to the use of side rails and air mattresses to ensure resident safety. On [DATE] 8:25 a.m. the Maintenance Supervisor was interviewed and stated Hospice provided the air mattress for the resident's bed. The Maintenance Supervisor stated he checks the condition of all mattresses and beds once a month at which time he also measures to ensure they have the appropriate distance between the mattress and bed rails. On [DATE] at 10:00 a.m. the DON (Interim Director of Nursing) was interviewed and stated Resident #1's bed had already been equipped with an air mattress and side rail before she started working for the facility on [DATE]. When asked to explain the process that leads to the decision to equip a resident's bed with bed rails and/or an air mattress, the DON stated each resident's comorbidities and ability to move around are factors. According to the DON, they use the values generated by the skin assessment tool and then reference online resources (not one in particular) to determine their risks and whether an air mattress and/or bed rails should be used. The DON stated if residents don't need bed rails to reposition themselves, then the rails should not be put on the bed. According to the DON, the Maintenance Supervisor determined if the side rails were safe after the installation of the bed rails. A subsequent interview on [DATE] at 11:00 a.m. with the Administrator identified they stopped using that specific bed frame and mattress immediately after Resident #1's death on [DATE]. According to the Administrator, she locked the door as soon as the funeral home took the resident's body. The Administrator stated the facility had no other bed frames/rails or mattresses like the one Resident #1 had in his room. Per an interview with the Administrator on [DATE] at 12:00 p.m., the Administrator stated there was an air mattress on the bed (not tethered) which was still functioning when she was in the room on the day of the resident's death. Observation of facility beds during the investigation identified no other beds posing a hazard. The document titled Guidance for Industry and FDA staff and Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], directed the following: Additonal caution should be taken when using these products to ensure a tight fit of the mattress to the bed system. If a powered air mattress is replacing a mattress on a bed system that meets the recommendations in the guidance with the original mattress, the resulting bed system with the new air mattress may still pose a risk of entrapment. When these products are used, we recommend that steps are taken to ensure that the therapeutic benefit outweighs the risk of entrapment. NOTE: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. The facility self corrected the immediate and serious jeopardy on [DATE] by securing and removal of bed/side rails in order to prevent further usage. The facility investigated the other beds in the facility and found none after removal of the bed/side rails that Resident #1 used.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision to one out of three residents (Resident #6); and failed to ensure safe transfers for 2 of 3 residents (Resident #5 and Resident #4). Record review revealed Resident #6 had a history of [REDACTED]. The resident demonstrated signs of an unsteady gait and fell at 2:50 p.m., and 3:15 p.m., and again at 4:45 p.m., requiring sutures for a head laceration. The facility failed to use an appropriate sized gait belt for safe transfers for (Resident #5); and failed to pull up a disposable brief from around Resident #4's knees while assisting the resident with walking from their bedside to the bathroom. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #6 had [DIAGNOSES REDACTED]. The MDS also noted Resident #6 had long and short term memory problems and a severely impaired cognitive status with inattention and disorganized thinking. According to the MDS, Resident #6 had delusions and wandered on a daily basis. The MDS documented Resident #6 received antipsychotic, antianxiety, antidepressant, anticoagulation and diuretic medications and had two or more falls with injuries since being admitted to the facility. The care plan noted Resident #6 exhibited signs of confusion, depression and being confused to person, place and time of day, which contributed to anxiety. According to the Care Plan, staff should allow Resident #6 to ambulate around the facility, check on him/her frequently and intervene as needed for safety. According to the revision dated 1/13/14, Resident #6 has a history of urinary tract infections (UTI). The Care Plan indicated that changes in usual routines and diminished functional abilities should be observed and reported. Resident #6 ambulates independently throughout the facility. The 1/30/17 revision instructed staff to intervene and attempt to lower Resident #6 to the floor if they observed a fall in progress. According to the 2/26/17 revision, when Resident #6 appeared to be tired, staff should sit with the resident in his/her room in hopes h/she falls asleep. On 7/9/17 staff received education about not following Resident #6 too closely while they are supervising him/her. According to the 3/18/17 Care Plan, Resident #6 receives diuretic medication, which may cause dizziness, fatigue and an increased risk for falls. Record review revealed eleven falls were documented on the resident's Care Plan between 2/26/17 and 7/23/17. A document titled #482 Fall and dated 4/14/17 at 12:32 a.m. noted the nurse saw Resident #6 walk/running down the hall. According to the documentation, as the nurse prepared to tell him/her to slow down, she saw Resident #6 trip and fall to the floor. A document titled #491 Fall and dated 5/14/17 at 11:00 a.m. noted that Resident #6 had a ground level fall and sustained a 2.5 centimeter (cm) laceration to the back of the head. A document titled #517 Fall and dated 6/27/17 at 11:57 a.m. noted that as a CNA assisted Resident #6 with cares, h/she made movements (stutter stepping) that indicated h/she might fall. According to the document, the CNA prevented the fall by guiding the resident to the floor. A Nurses Note dated 6/28/17 at 11:00 a.m. noted Resident had increased wandering. A document titled #525 Fall and dated 7/9/17 at 3:03 p.m. noted that Resident #6 had been walking in the hall when staff witnessed him/her stop for a brief moment and then went to his/her knees. A document titled #526 Fall and dated 7/9/17 at 3:16 p.m. noted that staff witnessed Resident #6 fall again at 3:10 p.m. A document titled #527 Fall and dated 7/9/17 at 4:50 p.m. noted that Resident #6 had been found on the floor by the Service Aid. According to the document, Resident #6 sustained a 3 cm x 0.5 cm laceration to the back of the head. A Nurses Note dated 7/9/17 at 6:33 p.m. revealed staff contacted the physician due to Resident #6's falls and laceration to back of head, the physician gave orders for possible stiches and head CT (computed tomography). At 7:05 p.m. noted Resident #6 had been transported to the ER by a family member. At 7/9/17 at 10:22 p.m. Resident #6 returned to the facility. A Nurses Note dated 7/10/17 at 3:24 a.m. noted Resident #6 had 3 staples in the back of his/her head to approximate (close) the skin. A Nurses Note dated 7/11/17 at 3:49 a.m. noted Resident #6 had been up ambulating independently earlier in the shift. A Nurses Note dated 7/12/17 at 2:01 a.m. noted Resident #6 had gotten out of bed and started walking around. A document titled #535 Fall and dated 7/19/17 at 2:47 a.m. noted that the nurse heard a loud thump in the living area. According to the document, the Aide said come into the living area. The nurse documented she found Resident #6 on the floor in a fetal position crying. According to the author, once vital signs had been obtained, Resident #6 immediately started to walk off. A Nurses Note dated 7/21/17 at 12:49 a.m. noted Resident #6 had been up walking in facility by him/herself. A Nurses Note dated 7/22/17 at 1:19 a.m. noted Resident #6 continued on 15 minute checks and had been walking up and down the halls. A Nurses Note dated 7/23/17 at 2:17 a.m. noted Resident #6 had been up walking most of the shift and continued to be on 15 minute checks to prevent falls. A document titled #538 Fall and dated 7/23/17 at 5:36 p.m. noted that Resident #6 had been on 15 minute checks. According to the document, a CNA heard a loud thump and the resident crying. The nurse documented the CNA found the resident on the floor bleeding from his/her nose, forehead and possibly mouth. Resident #6 cried immediately after the fall and staff called 911. The nurse was unable to obtain a good pupil reaction due to the resident kept his/her eyes closed. The emergency department report dated 7/23/17 documented Resident #6 sustained a laceration on his/her forehead, closed fracture of nasal bone and head injury. A Nurses Note dated 7/24/17 at 3:34 p.m. noted that Resident #6 walked throughout the facility and continued on 15 minute checks. Documents titled Resident #6 15 Minute Check and dated 7/21/17 through 7/26/17 had been submitted to verify checks had been done. When asked for a policy on safe transfers, the DON provided the agenda she used to evaluate staff's clinical skills on 1/27/17. Transfer with gait belts had been included on the agenda. An observation on 7/19/17 at 1:25 p.m. revealed the following. As this surveyor worked in room #206, the door handle turned and Resident #6 entered the room unsupervised. The resident appeared very confused. After about 30 seconds, a CNA walked past the room. The CNA seemed to be preoccupied and did not notice Resident #6 standing in the doorway of another room (206). Without disturbing Resident #6, this surveyor alerted the CNA and intervened at this surveyor's prompt. Resident #6 had been redirected out of room #206. An interview on 7/18/17 at 1:00 p.m. with Staff G, CNA, revealed her description of a movement Resident #6 typically made that sometimes preceded a fall and indicated the resident should be monitored for unsteadiness. Staff G said she worked 7/9/17 when Resident #6 fell three times. The CNA said h/she did this jerking thing that caused him/her to become unsteady. The CNA said it reminded her of someone seizing up and thought it might be possible to prevent at least some of his/her falls if someone had been monitoring the resident closely enough. According to the CNA, Resident #6 had been exhibiting those signs more than usual that day. Staff G said Resident #6 had days h/she did not do it at all and other days when h/she does it once in a while. The CNA said Resident #6 had been doing it about every 5 minutes all day long while h/she was awake on 7/9/17. According to the CNA, Resident #6's first two falls on 7/9/17 happened as a result of his/her jerking. Staff G said I know because I was standing right there. The CNA said that although her back had been turned, the housekeeper witnessed one of them and said the jerking thing caused the fall. According to Staff G, the housekeeper could not intervene, so the fall could not be prevented. Staff G said they do not have enough staff to assign someone to walk with Resident #6 all the time. Staff G said they were able to prevent other falls that day because they were able to steady Resident #6 six or seven other times h/she exhibited the same signs between the first fall and the third fall. According to Staff G, there were only 3 CNAs and 2 nurses in the facility that day. Staff G said Staff A told them I hate to do it to you guys, but I have to pull one of you to watch Resident #6. The CNA said Staff A asked another CNA to stay with Resident #6 in his/her room until h/she fell asleep after the 2nd fall. According to Staff G, once the resident fell asleep the other CNA left the resident's room. Staff G said after the other CNA left Resident #6's room, the Service Aid reported to the nurse at about 4:45 p.m. that he found Resident #6 on the floor of his/her room bleeding from his/her head. The CNA said once Staff A assessed Resident #6 and got him/her cleaned up, they laid the resident back down. Staff G said another CNA stayed with the resident until after 6:00 p.m. at which time the Service Aid provided one to one supervision. According to Staff G, she believed the falls might have been prevented if someone had been with Resident #6 the whole time. The CNA said they are not staffed well enough to do that. Staff G said that included the bath aid and RA, which only left three CNAs on the floor about 90% of the time. According to Staff G, there were only two CNAs on the floor from 2:00 p.m. to 6:00 pm about 35% of the time because of high school kids and people calling in. Staff G said there are also times when only two people are scheduled from 2:00 p.m. to 6:00 p.m. because they cannot get anyone to work. The CNA spoke of Mulberry Hall having six people that needed to be transferred by Hoyer lifts. According to the CNA, if someone supervised Resident #6 all the time, there would only be two CNAs left on the floor. The CNA continued by saying if someone that required a Hoyer needed help, nobody except the nurses and CMAs would be left, and some of them are not as good about helping as others. Staff G said she thought the facility would retaliate against her for saying so, but she would rather protect Resident #6 than herself. An interview on 7/18/17 at 3:30 p.m. with Staff A revealed his observations of Resident #6 after h/she awakened on 7/9/17. According to the RN, he could immediately tell the resident would probably have a bad day because h/she demonstrated jerky motions h/she sometimes makes that causes him/her to be unsteady. Staff A said it wasn't a matter of if h/she would fall, but a matter of when h/she would fall. The RN said because he anticipated it happening he told the CNA's he needed to get his charting and treatments done in preparation for when Resident #6 fell . According to Staff A, shortly after saying that, the housekeeper informed him that she attempted to lower Resident #6 to the floor as h/she fell . Staff A said he and the CNA's went to check his/her vital signs. The RN said Resident #6 seemed as cognizant as h/she normally would be and his/her vital signs were within normal limits (WNL). Staff A said they got the resident back up on his/her feet and put him/her into a wheelchair. The RN stated that did not last long because Resident #6 got up and tried pushing the wheelchair. He said he intervened by taking the wheelchair away to prevent another fall. Staff A said from that point on Resident #6 strolled around the facility like h/she normally did. According to the RN, while he processed the paperwork and notified the doctor. and family at the nurses' station, he heard another holler from a CNA in the lounge requesting a nurse's help because Resident #6 had fallen again. Staff A said he went to where the resident had fallen the second time and everything checked out alright. The RN said they stood the resident back on his/her feet and h/she started wandering around the facility again like usual. According to the RN, he proceeded to process the paperwork and make the appropriate notifications for the 2nd fall when the Service Aid informed him he found Resident #6 bleeding while lying on the floor of his/her room. Staff A said he went to the resident's room to complete an assessment. According to the RN, a CNA applied pressure to the laceration on the back of his/her head using some wash cloths. Staff A said neurological checks and vital signs were initiated and checked out fine. Staff A said at that point he told a CNA I know we don't have enough staff, but you're going to have to sit with Resident #6. The RN said he checked the resident's wound. He said the wound measured about 3 cm long. He also said it remained approximated which made it hard to tell where h/she was actually bleeding from. The RN said Resident #6 had been trying to get up, so he realized h/she had full range of motion (ROM). According to the RN, he left Resident #6 with the CNA's while he went to do paperwork for the third incident. Staff A said he left a message for the DON and the Assistant Director of Nursing (ADON). According to the RN, he called and spoke to Resident #6's physician right after the third fall. He said he obtained telephone orders to send Resident #6 to the ER by ambulance for a CT or X-ray of the head and sutures as needed. The RN said he suspected Resident #6 was going to fall from the minute he/she got up based on his observations of his/her disposition and unsteadiness. The RN said the resident has what he described as ticks; movements that cause the resident's knees to give out. He said some days his/her ticks are worse than other days, and based on the number of ticks h/she had that day, he considered it a bad day. According to Staff A, he would have assigned someone for one to one supervision of Resident #6 that day, but they were not staffed well enough to do that. According to Staff A, he did not think they are adequately staffed, however the problem is compounded by people calling in frequently. He said that once those issues are factored into the equation, they were almost always short staffed. The RN said he thought someone called in almost daily, or about 90% of the time. Staff A expressed his frustration over nothing being done about it and the problem just continued to happen. According to the RN, having someone walking side by side or trailing Resident #6 caused him/her to become anxious or nervous. Staff A spoke of the importance of being close enough to make observations of potential falls, but not so close to contribute to them. Staff A said Resident #6 seemed more receptive to some people than others. He also described it as a balance between safety and causing the resident to be agitated. According to the RN, Administration would have to make more staff available to them in order to monitor the resident well enough to prevent the preventable falls. Staff A said he believed some of his/her falls could be could be attributed to being short staffed. An interview on 7/19/17 at 9:20 a.m. with Staff F, LPN revealed she reported for her shift at about 6:00 p.m. on 7/9/17. According to Staff F, Staff A reported Resident #6 had fallen three times and gashed his/her head on the third fall. Staff F said the off-going nurse told her he had assigned someone to Resident #6 for one on one supervision. Staff F thought Resident #6 had been in her room at the time she reported for work, but h/she got up soon after which caused the wound to slightly bleed again. Another nurse on duty addressed the bleeding. According to the LPN, Staff A told her he had notified the doctor of all 3 falls via fax. The LPN said since the bleeding started again, she told Staff A to call the doctor for orders. Staff F said Staff A called the doctor immediately and obtained an order to have Resident #6 sent to ER for CT and evaluation for treatment. Staff F said Resident #6 returned to the facility with three staples in the back of his/her head. According to Staff F, they are supposed to get ahold of the doctor anytime a resident gets injured, no matter how minor. The LPN said she got upset when she walked into work and realized Staff A had only faxed the doctor and not called him. Staff F said a fax would only be appropriate if a fall did not result in an injury. An interview on 7/19/17 at 12:45 p.m. with the Director of Nursing (DON) revealed that although she had mixed feelings about assigning staff one to one with Resident #6, she agreed that it would be necessary in order to determine if any of the resident's falls were preventable. The DON concurred that if nobody was present to witness the falls, they would not know if they could have been prevented. An interview on 7/19/17 at 3:30 p.m. with Staff D, Service Aid, revealed his account of the fall that caused a head laceration to Resident #6 on 7/9/17 at about 4:15 p.m. According to Staff D, Resident #6 either spent his/her time walking around the facility or taking naps. He said h/she did a kind of lurching/stumbling thing as if his/her foot caught the floor. He said it resembled falling forward. The Aid said they told him he should shadow Resident #6 when he came to work at 4:00 p.m. because of Resident #6's tendency of wandering into other residents' room, not because of being at risk for falling. The Service Aid said he could not actually help the resident walk, but if h/she stumbled he could intervene and help steady him/her. According to the Aid, he usually walked a little bit behind and to the side of the resident. Staff D said the resident randomly talked to him and smiled, but never became agitated or anxious as he shadowed him/her. The Aid said Resident #6 almost seemed amused with him sometimes. Staff D said he could not locate the resident for a little while. He described his primary responsibility as passing ice water and snacks, but had had been instructed to walk with Resident #6 too. The Aid said he usually passed ice water and/or snacks to a couple of rooms and then checked on Resident #6 to keep a close eye on him/her. Staff D said he checked in Resident #6's room about 4:15 p.m. and found him/her alone lying on the floor (on 7/9/17). The Service Aid said he noted a little bit of blood on the floor, and on his/her hand and face. The Aid said he went to get Staff A. According to Staff D, nobody told him Resident #6 had fallen two other times that day. A subsequent interview on 7/24/17 at 9:50 a.m. with Staff A revealed his account of Resident #6's most recent fall on 7/23/17. According to the RN, Resident #6 had been strolling around all day. He said h/she seemed pretty steady and stable, but his/her pace seemed faster than he would have liked to seen him/her walk. Staff A said Resident #6 had been assigned to another nurse that day. The RN said he and the resident's nurse anticipated that Resident #6 may fall based on the pace he/she had been walking. Staff A said he did not think anyone witnessed the fall. He said an aide told him Resident #6 had fallen down by the Sunshine room at 4:30 p.m. According to Staff A, a couple CNA's were there assisting Resident #6 when he arrived. The RN said there were already bloody rags there when he got there, but he did not know who applied the pressure. He said the other nurse approached the site to do vital signs and an assessment right after he got there. Staff A said once the other nurse completed the assessment, they left Resident #6 with the CNA's while they went to the nurses' station where the other nurse called 911. According to Staff A, Resident #6 had blood on his/her forehead and in his/her mouth. Staff A said nobody had been walking with the resident, but there had been a lot of eyes on him/her. Staff A said they had been keeping a closer eye on the resident because it bothered him that h/she had been walking so fast. The RN mentioned that a helmet might be an appropriate intervention in light of the fact that Resident #6 sustained head injuries on multiple occasions. A subsequent interview on 7/24/17 at 12:40 p.m. with the DON revealed they had been doing hourly checks on Resident#6. According to the DON, she did not consider that as adequate so fifteen minute checks were implemented last Friday morning. According to the DON, they also had to record what Resident #6's activities were at the time of the check. She said Corporate recently agreed to provide one on one supervision for Resident #6 24 hours a day, seven days a week. The DON said Resident #6's daughter threw a fit about one to one supervision. According to the DON, whether or not Resident #6 got agitated by being so closely supervised depended on the person following him/her. When asked about staff to resident ratio, the DON said bath aids and restorative aids are counted amongst the numbers scheduled as direct care givers. According to the DON, RAs do not provide restorative therapy during meals so they were able to help feed and answer call lights. The DON said otherwise she scheduled one CNA to each of the three halls and one nurse or one certified medication assistant (CMA) to each hall. The DON agreed, some nurses and CMAs help CNAs more than others. The DON said there were ten to twelve residents that required the assistance of two staff members to transfer them with a Hoyer (mechanical lift) and one staff member to transfer 3 residents with EZ stands (mechanical lift). The DON said the CNAs have scheduled lunch breaks, and they are also supposed to take 15 minute breaks. The DON said nurses and CMAs cover their breaks and she insisted that they take them. A subsequent interview on 7/24/17 at 3:15 p.m. with Staff G said she worked on 7/23/17 when Resident #6 fell again and cut his/her head. According to Staff G, nobody witnessed the fall. She said the resident had been walking at a very fast pace and they kept encouraging him/her to slow down. Staff G said she was nearby and heard the thump and crying after Resident #6 fell . Staff G said they had been on top of the resident's fifteen minute checks, but it still happened. According to Staff G, it would absolutely take someone being with Resident #6 at all times to prevent any falls that might be preventable. An interview on 7/25/17 at 11:55 a.m. with Staff E, LPN, revealed what she knew of Resident #6's most recent fall on 7/23/17. According to Staff E, Resident #6 walked the halls quite a bit and had been down by the activity room when h/she fell . The LPN said a CNA reported the fall to her. Staff E said when she arrived, a CNA sat next to Resident #6 as h/she laid on the floor. According to Staff E, they had already placed a rag on the resident's forehead to stop the bleeding. Staff E said Resident #6's forehead appeared to have an indentation at the site of the laceration and his/her nose bled with swelling on the bridge of his/her nose. Staff E said Resident #6 had been crying. The LPN said she called 911 and then called the doctor who told her to call 911. The LPN relayed the information to a family member; telling them the injury seemed bad and the doctor also ordered a CT. According to Staff E, the fall occurred at about 4:30p.m. When asked about the resident's disposition prior to the fall, Staff E said h/she had been quiet, walking the halls and carrying his/her baby like usual. The LPN said she thought Resident #6 needed a dementia unit to address his/her needs. An interview on 7/26/17 at 9:50 a.m. with Staff H, Housekeeper revealed she worked 7/9/17 from 1:00 a.m. to 5:00 p.m. in activities. According to Staff H, she happened to be near Resident #6 as h/she stumbled and fell . The Housekeeper said she managed to soften the fall and prevented Resident #6 from hitting his/her head. Staff H said she did not notice any injuries, but immediately called for other staff to assist. According to Staff H, Resident #6 had been stumbling a lot that day, which caused him/her to be unsteady on his/her feet. The Housekeeper also said that Resident #6 goes when h/she wants to go, whether h/she is stumbling or not. There's no stopping him/her. Staff H said the resident needs placement in a dementia unit because h/she isn't safe here. 2. The MDS assessment dated [DATE] noted dementia, respiratory failure, [DIAGNOSES REDACTED](irregular heart rhythm), muscle weakness and unsteadiness on feet as [DIAGNOSES REDACTED]. The MDS also noted Resident #4 had been unsteady, could only stabilize with staff assistance and required limited assistance of one staff to transfer and toilet. The MDS documented Resident #4 had two or more falls since being admitted to the facility. The Care Plan noted on 2/3/17 Resident #4 began receiving diuretic (medication to induce urination) therapy, which may cause dizziness, fatigue and an increased risk of falling. The Care Plan also documented that Resident #4 required one staff to assist with toileting, transfers and ambulation, and had nine falls between 3/8/17 and 7/19/17 related to deconditioning. An observation on 7/6/17 at 8:00 a.m. revealed Staff B, Certified Nurses' Assistant (CNA) and Staff C, CNA as they assisted Resident #4 to stand from the bed and walk to the bathroom. As the resident sat on the side of the bed, Staff B put a new disposable brief on the resident and pulled it up to his/her knees, although Resident #4 was already wearing a brief. Staff B applied a gait belt and assisted Resident #4 to stand. Without pulling the new brief up any farther, Staff B assisted the resident to walk with a walker from the bed to the toilet (approximately 6 to 8 feet). After a few steps, Staff B realized the brief hindered Resident #4's ability to walk, so she pulled one side up just above the knee. As the resident shuffled towards the bathroom, the brief fell back down around his/her knee. It remained there until h/she completed the walk to the bathroom, at which time the resident's other brief was removed so he/she could sit down on the toilet. 3. The MDS assessment dated [DATE] noted anemia (deficiency of red blood cells or hemoglobin), schizophrenia, anxiety, depression, atrial fibrillation, weakness, lack of coordination, and the need for assistance with personal care as [DIAGNOSES REDACTED]. The MDS also noted Resident #5 had been unsteady, could only stabilize with staff assistance and required limited assistance of one staff to transfer and extensive assistance of one staff to toilet. The 7/22/14 Care Plan noted that Resident #5 had anemia and should be monitored for fatigue, dizziness and weakness. The Care Plan also noted that Resident #5 required assistance of one staff, a gait belt and walker to transfer. An observation on 7/6/17 at 8:15 a.m. of Staff A, RN assisting Resident #5 revealed the following. The RN borrowed a gait belt from a CNA in the room. As Resident #5 sat on the side of the bed, Staff A attempted to apply the gait belt to the resident. Staff A said to the CNA, your gait belt doesn't fit the resident. The gait belt would not buckle because of being too short to fit around the resident. Staff A grabbed Resident #5's shirt with the same hand that he held the two ends of the gait belt together with and used his other hand under Resident #5's arm to help the resident stand from the bed and transfer to the wheelchair. During the transfer, Resident #5 seemed very weak and struggled to stand even with assistance. When asked, the RN said he did not take the time to get a gait belt that fit. An interview on 7/26/17 at 11:10 a.m. with the DON revealed that though their corporation agreed to provide one to one supervision for Resident #6, they need to hire more staff in order to accomplish that. This surveyor observed Resident #6 walking around the facility alone on 7/26/17 at 9:45 a.m., which prompted the surveyor to ask the DON about her previous statement that one to one supervision would be provided. The DON said she would have to steal people from the floor to provide that kind of supervision, and they just do not have the manpower yet. When asked, the DON said she would have expected Staff A to use an appropriately sized gait belt to ensure Resident #5's safety when transferring him/her. The DON also said she would have expected Staff A to call the doctor immediately after a fall with injury per protocol instead of just faxing the SBAR. The DON said she would have expected Staff B to pull Resident #4's brief all the way up so as not to jeopardize his/her safety. On 7/26/17 at 11:45 a.m., the Corporate Nurse had been overheard saying the skills checklist provides guidance to staff, but a formal document titled Transfer Safety Policy does not exist in response to this surveyor asking the DON for a policy.

Based on record review and interviews, the facility failed to provide adequate supervision to protect one (1) of six (6) residents from hazards (Resident #3); and failed to update the resident's care plan. Interviews revealed Resident #3's inability to safely transfer and ambulate became apparent 2-3 months prior to his/her fall on 1/15/16, which resulted in lumbar fractures. Record review documented Resident #3 had been independent with ambulation and transfers at the time of his/her fall on 1/15/16. The Director of Nursing stated the resident refused to use his/her call light or ask for assistance. The facility reported a census of 49 residents. Findings include: 1. A Minimum Data Set (MDS) with an assessment reference date (ARD)of 11/18/15 revealed Resident #3 had [DIAGNOSES REDACTED]. The assessment indicated the resident had impairment on both sides of lower extremities. A Brief Interview for Mental Status (BIMS) revealed a score of 8 which indicated moderate cognitive impairment. A Care Plan with a focus area dated 12/16/14 identified a risk for injury/falls related to fibromyalgia, psychotropic medication use, a history of TIA's, a history of falls and chronic back pain use of narcotics. Interventions dated 8/6/13 to 1/12/16 specific to the focus area included: to encourage the resident to use a call light for assistance, ask for assistance with ambulating to the toilet and keep h/her walker out of reach. The care plan documented the resident had physical therapy (PT) evaluation on 11/5/15. The care plan identified the resident independent with transfers with the initiated date of 11/28/15; and to follow recommendations of PT. The resident ' s care plan with a focus area related to self care identified Resident #3 transfers and ambulates independently with walker with a revision date of 11/28/15. On 12/10/15 the care plan documented walker out of reach, calling for assistance. The care plan documented a fall on 1/12/16, with PT evaluation for stability and strengthening Clinical record revealed the resident sustained [REDACTED]. a). The fall incident description dated 11/3/15 at 9:54 a.m. indicated staff found the resident on the floor with his/her walker lying next to the resident. The resident had lost his/her balance after trying to reach for something on the floor. The resident sustained [REDACTED]. The Progress Notes dated 11/3/15 documented the resident had been taken to hospital for evaluation of pain in his/her neck and back. Staff documented they would encourage the resident to call for help when reaching for items or when leaning over. Progress notes dated 11/4/15 at 3:26 a.m. revealed the resident required the assist of one staff to assist with transfer and ambulation to and from bed to the toilet. Progress notes dated 11/5/15 at 1:43 p.m. revealed the resident complained of pain from the post fall of 11/3/15 and rated his/her pain at 10 out of 10 (a scale of 1-10, with 10 being the highest level of pain felt). b). Progress notes dated 12/9/15 at 3:27 p.m. indicated the resident had a short bout of shaking at dining time and stated he/she feels fine and didn't know why he/she was shaky. Progress notes continued indicating the resident's blood sugar at 299 milligrams/deciliter (mg/dl). The progress notes documented will continue to observe for further shaking issues. (The fall report dated 12/9/15 documented the resident fell approximately 15 minutes later in his/her room.) The fall incident description dated 12/9/15 at 3:49 p.m. identified the resident had fallen in his/her room. The resident reported he/she did not know what had happened, just got shaky and went down, without injuries. The resident had been assisted up (from the floor) by 3 staff (using a gait belt). Staff documented the resident had gait imbalance and weakness/fainted as predisposing physiological factors. c).The fall incident description dated 1/12/16 at 9:22 p.m. indicated the nurse had been passing medication and noticed the resident going down to his/her knees while walking to his/her room. Resident #3 fell to the floor landing on his/her knees. The incident report indicated the resident had his/her wheeled walker with the walker too far away from his/her body causing the resident to lean forward. A rehabilitation screen dated 1/13/16 revealed an evaluation determined physical therapy (PT) documented the reason for a referral was due to a witnessed fall walking back from meals. The resident had fallen forward on his/her knees with no injury. The resident thought his/her legs gave out from underneath him/her. The initial assessment indicated the resident able to maintain balance with handhold support and constant minimum assistance. The resident's current balance/fall risk increased to high risk for fall/s. The initial assessment noted Resident #3 had poor gait pattern as 4 wheeled walker is too far in front of him/her and he/she is unsafe with cadence (movement). (Cadence defined by medical dictionary mean number of steps per minute during normal gait.) Progress notes dated 1/14/16 at 12:03 a.m. revealed the resident needed assist of staff while walking to and from meals due to the resident moving the walker too far forward when he/she walks. d). An incident report dated 1/15/16 at 7:15 a.m. revealed staff found the resident on the floor in the bathroom face down with the walker in front of the resident. Staff assisted the resident up from the floor and positioned the resident on the side of the bed. The report indicated the resident very lethargic and unable to answer simple yes/no questions. The resident complained of right hip pain. Emergency personnel transported the resident to a hospital emergency room for evaluation. Hospital personnel reported the resident had been admitted for observation related to the fall and a urinary tract infection. A hospital discharge summary dated 1/26/16 at 3:21 p.m. revealed the resident had been admitted on [DATE] at 8:25 a.m. after sustaining a fall. Laboratory results indicated the resident had hyponatremia and a urinary tract infection. A computed tomography (CT) scan of the lumbar spine indicated secondary [DIAGNOSES REDACTED]. The resident had been seen by neurosurgery and they did not recommend any surgical intervention and instead recommend a brace. Regarding the resident ' s fall, he/she had been noted as bradycardia (abnormal slow heart action). During an interview dated 3/9/16 at 7:54 a.m. Staff D, a physical therapist assistant, reported a rehabilitation screen completed on 1/13/16 revealed the resident could not safely transfer independently. During an interview dated 3/9/16 at 8:03 a.m., Staff E, a registered nurse and Assistant Director of Nursing reported he provided direct care, including minimal assistance with transfer; assisting the resident up from the recliner. He stated at the time of the fall on 12/9/15 a change existed where the resident needed routine assistance with transfer and ambulation During an interview dated 3/9/16 at 6:30 a.m., Staff B a licensed practical nurse (LPN) reported the resident needed assistance for the last 2-3 months prior to his/her hospitalization (1/16/16) with transfer, incontinent care and dressing. The resident did not get up much, confused at times and received scheduled pain medication. During an interview dated 3/9/16 at 10:00 a.m., Staff F, a certified nursing assistant (CNA) reported the falls the resident sustained [REDACTED]. The resident's inability to transfer and ambulate safely occurred in November 2015. The resident did not see the call light, as he/she wanted to be independent. The resident had been over medicated and felt weak and dizzy. Staff F reported staff will assist the resident when they see him/her trying to transfer. During an interview dated 3/9/16 at 10:45 a.m., the resident's physician reported the resident did not use his/her call light and would attempt to transfer and ambulate independently. The resident had muscle weakness and dizzy and needed 1:1 care and needed assistance with transfer and ambulation prior to the hospitalization of 1/15/16. The spinal fractures noted in the hospital discharge summary were new and most likely from the fall of 1/15/16. During an interview dated 3/9/16 at 7:00 a.m. Staff C, LPN reported prior to the fall in February 2016, the resident alert and oriented to name and place most days. The resident slept throughout the day and would be confused after waking up. The resident would be shaky after meals and became dizzy. When this nurse would see the resident walking she would assist the resident. An incident report dated 2/14/16 at 8:25 p.m., documented Resident #3 had been found lying face down on the floor in front of his/her recliner. The incident description described the resident alert, very hard of hearing, hard to assess but oriented to name and place. The resident reported he/she did not know what he/she was trying to do. The resident ' s mental status listed oriented to person and no injuries observed. During an interview dated 3/9/16 at 10:30 a.m., the Director of Nursing services stated the resident had been independent with ambulation prior to incident of 1/15/16. The resident refused to use his/her call light and ask for assistance as the resident wanted to be independent. The resident had a right to refuse to use the call light and had a right to fall. The progress notes dated 1/26/16, 1/27/16, 1/28/16, 2/1/16 and 2/2/16 and 2/5/16, documented Resident #3 received the assistance of one staff for transfers and for Activities of Daily Living (ADLs).

Based on clinical record review observation, facility policy review, resident, family, and staff interviews, the facility failed to perform adequate assessments for 1 of 16 residents reviewed (Resident #4). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 5/20/15 documented a brief interview for mental status (BIMS) score of 15 that indicated cognition as intact. The MDS identified Resident #4 required, total dependence of two staff members for bed mobility, transfers and bathing, total dependence of one staff member for toileting and personal hygiene and extensive assistance of one staff member for dressing. The MDS documented Resident #4 as not steady but able to stabilize with assistant for surface to surface transfers. Resident #4 ' s MDS identified upper and lower extremity impairment in range of motion bilaterally. According to the MDS Resident #4 was always incontinent of bowel and included an indwelling urinary catheter. The MDS identified Resident #4 ' s [DIAGNOSES REDACTED]. The care plan initiated 1/28/15 failed to identify the Resident #4's need for assistance with transfer or required use of any device/s for transfer or ambulation. The care plan revised 4/21/15 identified Resident #4 exhibited a self-care performance deficit and directed two staff required for the performance of bed mobility. Resident #4 ' s care plan dated 3/3/15 identified impaired skin integrity issues that required a pressure reduction mattress, float heels in bed and observe for skin breakdown during cares. Review of the Daily Skilled Nurses Notes dated 4/25/15 at 10:50 a.m. completed by Staff B, registered nurse (RN) documented staff assisted Resident #4 up using a sit/stand lift and Resident #4 commented he/she felt a pop in the right arm. Resident #4 stated she/he thinks staff broke the arm. Staff B RN notified Resident #4's physician and obtained an order for [REDACTED].#4 sent to the hospital emergency room . The entry failed to contain any assessment of the Resident #4's arm or pain. The Prehospital Care Report dated 4/25/15 documented an ambulance departed the facility at 3:22 p.m. and arrived at the emergency room at 3:56 p.m. The Radiology Report for Resident #4 dated 4/25/15 at 4:22 p.m. documented an oblique, distal mid-shaft humerus fracture with mild dorsal and lateral displacement of the distal fracture fragment as well as advanced right glenohumeral [MEDICAL CONDITION] joint disease. During interview on 7/29/15 at 1:30 p.m. Resident #4 stated she/he suffered a broken right arm. Resident #4 stated staff transferred him/her using a lift stand, heard a noise during transfer and thought the lift had broken, but it was actually his/her right arm. Resident #4 stated it happened around 8:30 a.m. and the nurse on duty failed to check me out. During an interview at 4:10 p.m. Resident #4 stated she/he waited a long time to go to the hospital after his/her arm broke and experienced a lot of pain. Resident #4 stated she/he sat in the wheelchair from the time of the incident until around 2:00 p.m. when staff used a full body lift to transfer him/her to bed. Resident #4 requested ice for the arm and shoulder and received pain medication, but the nurse on duty never looked at his/her arm. During interview on 8/13/15 at 10:45 AM, Staff B RN stated he went to Resident #4's room while Resident #4 was still in the sit/stand lift. Resident #4 told him that she/he felt a pop and thought his/her arm was broken. Staff B RN stated staff finished transferring Resident #4 to the wheelchair and Resident #4 went to breakfast. Staff B RN stated he talked with Resident #4 after breakfast but did not remove any clothing to check the right arm and Resident #4 only complained of mild pain at that time. Staff B RN stated Resident #4 remained up in the wheelchair through lunchtime and thinks he administered pain medication to Resident #4. Staff B RN stated that he did apply ice to Resident #4's right arm and shoulder per nursing judgment as Resident #4 had pain. Staff B RN stated the Daily Skilled Nurses Notes he entered 4/25/15 starting at 10:50 a.m. is not accurate because he started the note at that time and kept adding to it as the shift went on and did not time each entry. Staff B RN stated he did not know what time Resident #4 actually went to the emergency room . Observation on 7/15/15 at 4:00 p.m. revealed Resident #4 in bed. Resident #4 stated she/he has some sores on his/her bottom and having pain in that area at this time. Observation revealed Resident #4 with an air overlay mattress on his/her bed that was not inflated as the pump not plugged in. Resident #4 requested the surveyor turn on his/her call light to summon staff to reposition him/her in bed because the sores hurt. Observation on 7/16/15 at 2:00 p.m. revealed Staff I certified nursing assistant (CNA) and Staff F CNA, transferred Resident #4 from the wheelchair to bed. Observation revealed Resident #4's air overlay mattress as not inflated and the pump remained unplugged from the wall. Staff F CNA then plugged the pump in before leaving Resident #4's room. Observation on 7/16/15 at 2:40 p.m. revealed Resident #4 in bed on his/her back with the air overlay mattress not inflated as the pump not plugged into the wall outlet. During interview on 7/29/15 at 1:30 p.m., Resident #4 stated she/he had several sores on his/her bottom that occurred after Resident #4 suffered a fractured right arm in April, 2015. During an interview on 8/6/15 at 10:20 a.m. the Director of Nursing (DON) observed the open areas but failed to fill out a skin sheet or contact the physician for treatment orders. The DON stated she did not notify Resident #4's responsible party. During observation on 8/5/15 at 7:58 a.m. Staff M CNA, and Staff N CNA, assisted Resident #4 with catheter cares. Staff N cleansed the genital area and the catheter tubing. When Staff N cleansed the genital area and around the catheter insertion site, the washcloth had a red color indicative of bloody discharge. On 8/6/15 at 9:19 a.m. Resident #4 stated he/she had bleeding from the genital area for 3 to 4 days. Resident #4 stated she/he can see the washcloths as the aides clean his/her genital area and the washcloth appeared red tinged or bloody. Resident #4 stated he/she told the nurse Staff L RN. During an interview on 8/6/15 at 10:40 a.m. Staff L stated staff failed to report Resident #4 was bleeding around the genital area. Staff L RN stated Resident #4 reported the bleeding and Staff L RN had attempted to call the physician and sent a facsimile (fax). Staff L RN stated she changed Resident #4 ' s catheter and visualized blood tinged urine and blood clots but stated unable to locate the source of the bleeding. During an interview on 8/6/15 at 11:50 a.m. Staff N CNA stated she noticed the washcloth appeared bloody when she cleansed Resident #4's perineal area but failed to report it to the nurse. A fax sent to Resident #4's physician dated 6/17/15 informed the physician Resident #4 exhibited red areas under the abdominal folds, groin area, and under the chest area. The physician ordered to apply an anti-fungal powder to the areas twice a day. A fax sent to Resident #4's physician dated 6/26/15 ordered to use a house barrier cream on the perineal area twice a day. A fax to Resident #4's physician dated 6/30/15 informed the physician Resident #4 exhibited two friction areas under the left abdomen. The physician ordered an island dressing to the areas to be changed every other day until healed. During observation on 8/5/15 at 7:58 a.m. Staff M CNA, and Staff N CNA, assisted Resident #4 with personal cares. While rolled on the right side, Staff N CNA cleansed Resident #4 ' s buttocks. Resident #4 appeared to have 3 small linear open areas to the right inner buttock. Staff N CNA sprayed with cleanser to cleanse under Resident #4's abdominal fold. Resident #4 had areas of excoriation under the right and left abdominal fold. A dressing covered an area under the right abdominal fold. The left abdomen skin excoriation lacked a dressing. Staff N CNA applied baby powder under the abdominal folds and the area to the top of the right buttock. Resident #4 complained of pain to the buttocks and requested cream to be applied. Staff N CNA applied an antifungal cream to the buttocks instead of the house barrier ordered by physician. During an interview on 8/6/15 at 10:20 a.m. the DON acknowledged staff failed to complete a skin sheet for the areas under the abdomen to monitor the areas for improvement or worsening. Interview on 8/25/15 at 11:40 a.m. with Resident #4 ' s spouse revealed concerns the facility failed to follow up and perform a thorough evaluation of the right arm after the incident involving the transfer and subsequent [MEDICAL CONDITION] are along with concerns the facility failed to adequately assess and review the open areas to the buttock and abdomen for healing. The Oakland Manor Nursing Home General Wand and Skin Care Guidelines revised in 12/10 directed the following: 13. Document weekly on the appropriate skin progress form for all pressure and non-pressure areas. If additional space is needed for documentation, write see nurses notes for any additional comments needed to support the progress of decline in the wound management. The facility's Wound Care Policy dated 1/1/14 instructed staff upon identification of the development of a pressure ulcer, staff fill out an Initial Wound Assessment Form and staff must update the care plan to assure appropriate interventions to manage the development of a pressure sore.

Based on clinical record review, staff and physician interviews, the facility failed to complete thorough assessments and follow physician's orders when one of four residents sustained a significant change in their condition resulting in hospitalization for dehydration (Resident #1). The facility reported a census of 40 residents. Findings include: A Hospital Discharge Summary dated [DATE] revealed Resident #1 had a history of [REDACTED]. The resident had been admitted on [DATE] to the hospital for progressive weakness and hypokalemia, UTI (urinary tract infection) and nephrolithiasis (process of forming kidney stones). The resident's final [DIAGNOSES REDACTED]. The discharge instructions noted the resident should continue to take milk of magnesia (as needed) and [MEDICATION NAME] to treat chronic constipation. According to the Admission Record form, Resident #1 had been admitted to the nursing home on [DATE]. A physician admission orders [REDACTED]. On [DATE] the physician renewed the continuation of [MEDICATION NAME] 100 mg two times a day (BID). Review of a Physical Therapy Plan of Care for Resident #1 found in this resident's clinical file, dated [DATE] noted Resident #1 desired to return home. The resident's medical history relating to diagnosis/condition included [MEDICAL CONDITIONS], dementia, arthritis, [MEDICAL CONDITION] hearing loss, and a current medical history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] included the following information: a. a cognitive score of 15 out of 15. b. the resident rejected care 1 to 3 days out of the seven day assessment period. c. totally dependent on staff for bed mobility, transfers, and toilet use. d. required extensive assistance for walking, dressing and bathing. e. had bilateral limited range of motion of both upper and lower extremities. f. frequently incontinent of bladder and occasionally incontinent of bowel. g. weighed at 132 pounds. This resident's Plan of Care dated [DATE] noted the resident's problems included risk for falls related to weakness, chronic pain related to arthritis, potential for altered nutrition, constipation and impaired decision making skills related to dementia. The plan of care goals included the resident would have no complaints of constipation. The plan of care approaches included: administer medications per physician order and evaluate effectiveness and encourage fluids and administer bowel promoting medications per physician's order. A Dietary Progress Note dated [DATE] documented this resident weighed 131.7 pounds. A Dietary Progress Note dated [DATE] noted this resident weighed 118.8 pounds showing a significant weight loss. A physician's order dated [DATE] at 4: 35 p.m., revealed [MEDICATION NAME] 100 mg BID would be discontinued. (The order also noted to discontinue 4 other medications.) A nurse's notes dated [DATE] at 4:30 p.m., revealed new order's from the physician to discontinue the [MEDICATION NAME] and 4 other medications. When staff informed the Resident and his/her spouse, the resident requested to stay on his/her current medications. A physician's order dated [DATE] at 7:15 p.m. noted the [MEDICATION NAME] at 100 mg twice a day would continue (along with the other 4 medications). Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. A communication sheet faxed to this resident's physician dated [DATE] informed the physician the resident was having loose stools for quite some time. The resident received [MEDICATION NAME] twice a day. The nurse asked the physician if it would be okay to decrease the physician's order to once daily. The physician gave a new order to discontinue the [MEDICATION NAME]. Review of the Nurse's Notes revealed the nurses failed to document any assessment of this resident's loose stools. Review of the Nurse's Notes revealed one entry [DATE] the resident refused his/her bath, the entry lacked any documentation of an assessment to show why resident refused bath. The next entry dated [DATE] noted consulted with physician regarding medications and therapies with no new orders. The entry lacked explanation of why physician was consulted or which medications were discussed and why. The next entry was dated [DATE] that documented laboratory results reported to physician with no new order received. The next entry was [DATE] which read new order received and family and pharmacy notified. The entry lacks information about the order and/or the resident. Review of the facility "BM" (bowel movement) record for [DATE] revealed this resident typically had one or two small or medium bowel movements per day up until [DATE] at which time the resident had an extra extra large, a small, a second small and a large all in one day. On [DATE] the resident had an extra large, a large, a medium and a large BM. [DATE] three larges and a medium. [DATE] two larges and two mediums. On [DATE] the resident had diarrhea on the day shift and on the evening shift. A Physician's Progress Notes dated [DATE] read, "Diarrhea" "Weight Loss" New orders included: discontinue [MEDICATION NAME]. The Nurse's Note for [DATE] at 4:00 p.m. noted the physician saw this resident while on rounds. Several medications were discontinued and pharmacy was aware. (The nurse failed to address the physician's documentation of diarrhea and failed to assess Resident #1 and his/her diarrhea.) A physician's order dated [DATE] noted multiple new telephone orders including a stool (BM) culture and an order for [REDACTED]. The Nurse's Notes dated [DATE] at 8:00 a.m. noted the nurse, Staff C received new orders for Resident #1. The Laboratory, pharmacy and family notified. The nurse failed to identify what the new orders were and failed to assess Resident #1 and/or the resident's continued diarrhea. When interviewed on [DATE] at 2:25 p.m. the licensed practical nurse, Staff C stated she took the order from this resident's physician on [DATE]. The physician called the facility and informed her of his concerns regarding this resident's loose stools and gave new orders to obtain a stool culture, to give this resident a liquid diet until the diarrhea stopped and to give Immodium, two tablets after each stool. The nurse stated she did not document the physician's concern about the diarrhea. She stated she did not go down and talk to the resident. She did not go down and assess the resident and she did not instruct the staff to inform her or the charge nurse each time this resident had a loose stool. Staff C stated she informed this resident's spouse of the new orders and the spouse also stated he/she also knew of this resident's diarrhea. When interviewed on [DATE] at 2:50 p.m. ,the resident's physician stated he called the facility and talked to the nurse about his concern with this resident's diarrhea. He gave the order to obtain a stool specimen and to give the Immodium after each stool. The physician stated he expected the staff to do an assessment of this resident and of his/her continued diarrhea and to follow his orders. Review of the BM Record for June of 2013 revealed this resident's increased stools and diarrhea continued. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The record showed the nurses failed to give this resident any Immodium in [DATE]. The Nurse's Notes from [DATE] through [DATE] revealed the professional nurse's failed to address this resident's diarrhea and failed to document an assessment of this resident's declining condition. A Transfer Form dated [DATE] noted reason for transfer: foul smelling, watery stool for several days. Will not eat or drink. Very weak. Involuntary Bowels The as needed (PRN) MAR indicated [REDACTED] A Nurse's Note dated [DATE] at 2:00 p.m. noted resident complained of being very sick and stated, "I have diarrhea so bad. It is like water pouring out of me!" Resident had 2 large foul smelling watery stools. Resident not eating, and hydration is very poor. Resident medicated with [MEDICATION NAME] (Immodium) two caps times two with no effect. Family notified of resident's change in status. Physician ordered staff to send the resident to the hospital. The nurse documented this resident's temperature of 97, pulse at 54, blood pressure of ,[DATE]. A Cardiology Consultation report dated [DATE] read, "...presented to the hospital with acute [MEDICAL CONDITION], decreased appetite, diarrhea and nausea. The Hospital History and Physical dated [DATE] noted the [AGE] year-old resident from the nursing home presented to the hospital with severe diarrhea for the last five days, hypokalemia, and acute [MEDICAL CONDITION]. The hospital assessment included: acute [MEDICAL CONDITION], dehydration, perfuse diarrhea, generalized weakness, hypokalemia and [MEDICAL CONDITION]. The Hospital Discharge Summary dated [DATE] documented Primary Diagnosis: [REDACTED]. [MEDICAL CONDITION], 3. [MEDICAL CONDITION], 4. Persistent diarrhea, 5. Advanced age with debility. Biopsy revealed lymphocytic [MEDICAL CONDITION] which was felt to be the etiology of the persistent nausea and diarrhea symptoms. The patient died [DATE]. The resident had been admitted to the hospital with [REDACTED]. On presentation, Resident #1 was significantly dehydrated. When interviewed on [DATE] at 3:50 p.m. a registered nurse, Staff G stated she had no knowledge of Resident #1 having any diarrhea or loose stools. Staff G stated the nursing assistants were good at informing the nurses when residents had loose stools. She stated the evening nurses check the BM (bowel movement) charts every day to check which residents need MOM (laxative) and the night nurses check the BM records every night to check which residents require a suppository. Staff G was then shown a Fax (communication sheet) sent to this resident's physician on [DATE]. This Fax informed this resident's physician Resident #1 was having loose stools for quite some time. The nurse asked the physician if they could decrease this resident's stool softener [MEDICATION NAME] from twice a day to once a day. The physician discontinued the [MEDICATION NAME]. Staff G then verified she wrote this Fax. She stated she did not assess Resident #1. She did not go down and ask the resident about his/her bowels. She did not go and check the BM records. She did not assess the resident to attempt to determine the cause of the loose stools, for potential causal factors such as flu, impaction, etc. She stated she sent the physician the Fax and asked the physician to change his orders based solely on what one nursing assistant told her. At this time, Staff G verified the nursing assistants documented the resident's bowel movements on [DATE] as extra extra large, and small and small loose, and on [DATE] as extra large loose and medium loose. Review of the nurse's progress noted revealed this nurse failed to document her concerns regarding Resident #1 ' s loose stools. A physician's progress note dated [DATE] the physician documented "Diarrhea" and weight loss. He gave an order to discontinue [MEDICATION NAME]. When interviewed on [DATE] at 2:50 p.m. the resident's physician stated he/she was first made aware of this resident's diarrhea by the resident's spouse. The physician called the facility and informed them of the resident's diarrhea. The physician was also concerned about the resident's nausea. The physician stated he/she had attempted to adjust the resident's potassium due to potassium can cause nausea and diarrhea, however the resident's blood potassium levels dropped and he/she had to reinstate the oral potassium supplements. The physician stated he/she was surprised to learn the facility failed to assess Resident #1 and failed to implement his/her orders and failed to give the anti-diarrhea medication. The physician also stated he/she ordered a liquid diet due to regular food could make the diarrhea worse. The physician stated the resident was admitted to the hospital for dehydration. A Physician's Order dated [DATE] instructed the staff to obtain a stood culture and to give this resident a liquid diet until loose stool subsides and to give an antidiarrhea medication two tablets after each stool, not to exceed six tablets a day. When interviewed on [DATE] at 2:25 p.m. a licensed practical nurse, Staff C stated she works as a nurse every other weekend and she does the MDS (minimum data set) assessments for the facility. She stated she received a phone call from Resident #1 ' s physician on [DATE]. She stated the physician called due to he/she was concerned about this resident's diarrhea. The physician called and informed Staff C the resident was having loose stools and informed her of what he/she wanted done including obtain a stool culture, give this resident liquid diet until the loose stools ceased and to give an anti-diarrhea medication after each loose stools and laboratory work. This nurse stated she did not document the physician's concern about the loose stools, she did not go down and talk to the resident, she did not assess the resident and she did not tell the nursing assistants to let the nurse know each time this resident had a bowel movement so they could give the resident, the physician ordered anti-diarrhea medication. The nurse stated she informed this resident's spouse of the physician's new orders, at which time the spouse informed this nurse he/she was aware of the resident's diarrhea. When interviewed on [DATE] at 9:20 a.m. a licensed practical nurse, Staff H stated she had been a nurse for [AGE] years. Staff H described Resident #1 as a very frail, sickly kind of man/woman. Staff H stated Resident #1 began to decline and had diarrhea for four or five days. The resident was also not eating. Staff H stated she would ask Resident #1 if he/she was having diarrhea and some days the resident would say yes and some days he/she would say no. When asked if she, Staff H ever assessed Resident #1 due to the diarrhea, Staff H stated, "No, I did not do any kind of assessment on (him/her), diarrhea is diarrhea." Staff H stated Resident #1 had been given a general diet and was only given a liquid diet when the resident complained of nausea. Staff H stated she did work and care for Resident #1 on [DATE]. She stated she failed to check the BM document and failed to identify and treat Resident #1 ' s continued diarrhea on [DATE]. Staff H stated, "I guess I failed (him/her). "I didn't check it." Staff H verified although she documented this resident had diarrhea and was sent to the hospital on [DATE] she actually sent the resident to the hospital on [DATE]. Review of the Transfer Form dated [DATE] Staff H documented the reason for this resident's transfer to the hospital was foul smelling watery stool for several days, will not eat or drink and very weak. Resident involuntary bowels. Staff H denied assessing this resident's hydration status and denied listening to this resident's bowel sounds to check for blockage and denied doing a digital rectal check to check for impaction. When asked what type of assessment she did on this resident, the nurse stated, "I took his/her temperature." When interviewed on [DATE] at 8:50 a.m. a certified nursing assistant (C.N.A.) Staff I stated Resident #1 was a great person who when he/she asked you how you were, he/she really cared about your answer. Staff I stated this resident's stools were just like water. It was just straight diarrhea. It was not normal. Resident #1 used to have regular bowel movements, and then they changed to straight diarrhea. Staff I stated she had informed the nurses of this resident's diarrhea. This resident was continent of his/her bowels prior to the diarrhea, but then became incontinent when the diarrhea began. The resident became very upset when incontinent of bowels. No one ever informed Staff I they had an anti-diarrhea medication for this resident and she was never asked or instructed to tell the nurse whenever this resident had a BM. The resident loved to drink Ginger Ale and they always offered the resident a regular diet. Review of the dietary records the facility offered this resident a regular diet for each meal from [DATE] through [DATE] with the exception of the evening meal on [DATE]. When interviewed on [DATE] at 8:20 a.m. the Director of Nursing stated Resident #1 passed away in the hospital and she did an investigation of the events leading up to this resident's hospitalization /death. She found there were conflicting reports weather or not this resident was having diarrhea. She determined the C.N.A.s were documenting this resident was having continued diarrhea in the BM records. The staff failed to report this resident's diarrhea in a timely manner. The professional nurses did not know this resident was having diarrhea. The nurses only gave this resident the physician ordered anti-diarrheal medication on [DATE], the day he/she was sent to the hospital for dehydration. The resident's family and the nursing assistants all stated this resident was having diarrhea, but the nurses were not treating the diarrhea. The resident ate and drank very little. The resident was at risk for dehydration. The resident always felt ill. The Director of Nursing stated the facility just rehashed this resident yesterday due to the family had called the facility and wanted some kind of answers as to what had occurred. The Director of Nursing stated no one gave this resident any anti-diarrheal medication due to they were not aware of the diarrhea. The staff nurses informed the Director of Nursing that they would not go to the BM records to check for diarrhea, they expected the nursing assistants to report any diarrhea.

Based on clinical record review and interviews, the facility failed to ensure physician's orders for medication administration were followed for 1 of 5 residents reviewed for significant medication errors (Resident #1). The facility reported a census of 52 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 required extensive assistance of one for bed mobility, transfers, walking, dressing, hygiene and using the toilet. The MDS revealed the resident occasionally incontinent of bladder, with pertinent [DIAGNOSES REDACTED]. The medical center Discharge Summary dated 5/23/11 for Resident #1 revealed pertinent [DIAGNOSES REDACTED]. The Interim Plan of Care dated 5/27/11 revealed the resident alert and oriented. The Medication Error Report dated 5/28/11 at 8:15 a.m., documented the resident had been given 160 mg (milligrams) of [MEDICATION NAME] CR- with the physician ' s order ' s to monitor the resident. The Incident/Accident Report dated 5/28/11 at 8:30 A.M. documented the resident received incorrect medication. Staff documented an immediate call to the resident's physician, the physician not in, but would call the on-call physician. Staff initiated neurological assessments for the resident. The Neurological assessment flowsheet dated 5/28/11 documented Resident #1 level of consciousness as alert from 8:30 a.m. to 9:30 a.m. and then drowsy from 10 a.m. to 1 p.m. The resident's pulse reading increased from 72 to 120 between 8:30 a.m. to 8:45 a.m. and then fluctuated between from 80 to 120 until 2 p.m. The staff described the resident as drowsy- sleepy between 10 a.m. to 1 p.m. The nurse's notes dated 5/28/11 at 8:15 a.m. documented the medication error. The note documented the PA-C (physician ' s assistant) at facility at noon and discussed the sign and symptoms. The PA reassured the nurse the vitals were stable and drowsiness normal, and requested staff continue to check on resident. The daily skilled notes for 5/28/11 at 4 p.m., documented the resident very sleepy, but arouse easily. The resident ' s family had been at his/her bedside. The resident ' s Oxygen (O2) Stat read 84% with 2 liters of O2. The O2 was increased to 2.5 liters; and the resident took a bite of food and had small emesis and remained sleepy. At 6:45 p.m., the resident ' s physician was called And informed of symptoms and ordered the resident be sent to the emergency room . The Transfer form dated 5/18/11 revealed the resident received [MEDICATION NAME] 160 mg in error in am and had been very sleepy all day. The form documented the resident now had two small-moderate emesis of undigested food and had not eaten, drank little today and not voided since early in the morning. The emergency room progress notes dated 5/28/11 documented Resident #1 given 2 mg of [MEDICATION NAME] IM for [MEDICATION NAME] overdose. The progress note described the resident as somnolent(drowsy/sleepy), slurred speech and looking gray in color. The progress note also mentioned the resident had [MEDICAL CONDITION] and was sensitive from respiratory standpoint anyway. During interview on 7/5/11 at 10:32 A.M. the on-call physician on duty the evening of 5/28 stated he remembered Resident #1 very well. He stated s/he came in with respiratory distress due to [MEDICATION NAME] overdose. He stated s/he was very sick and he stated it was a major injury. He stated he is doing great now. He further stated when asked, the resident had not been sick with pneumonia. During interview on 6/15/11 at approximately 10:00 A.M. Staff A, Licensed Practical Nurse (LPN) stated just prior to the Memorial Day weekend, they had two new residents admitted . One resident (Resident #2) had pain due [MEDICAL CONDITION] and she wanted to address the resident's pain right away when out of report. She stated she obtained the morning medications for Resident #2, entered the resident's room and administered them, and found out as the resident had been taking the medications, she had given Resident #2's medication plus a narcotic to Resident #1 by mistake. She stated he/she had only taken 2 tablets and found it to be the [MEDICATION NAME] for Resident #2. Staff C, Certified Nursing Assistant, (C.N.A.) walked in and told Staff A, she gave Resident #1, Resident #2's medications and that Resident #2 moved into the room next door. Staff A immediately interrupted the resident taking the medications before they had all been taken. Staff A instructed Staff C to stay with the resident while she notified the physician. The primary care physician for Resident #1 was out of the office and she spoke to the physician's nurse. Staff A stated the office nurse agreed to notify the on-call physician and request he notify Staff A ASAP. When Staff A had not received a call from the physician on call, she called the facility's Medical Director and spoke to the Physician's Assistant (PA) and received orders to monitor and do vitals every 15 minutes through her shift. She stated she called the resident's family and they came to the facility to sit with the resident. She stated the two new residents admitted within 24 hours of each other looked a lot alike, same coloring, same stature and their rooms close in proximity. She stated the resident's name plates had not been placed by the door yet and now they are making a paper label with the resident's name on it on admission. She stated Resident #1 had been alert and cognizant, must have been sleepy maybe because she called him/her by the wrong name 3 times when Staff C came into the room and made the correction. Staff A stated Resident #1 came back from the hospital and found to be stable until he/she got sick with pneumonia and had to be readmitted to the hospital again. She stated because of his/her young age and his/her list of medical problems, the family chose to move him/her closer to their primary care physician. She stated Resident #2 was admitted into Hospice care and passed away shortly after the incident. She stated she apologized to the resident's daughters and stated this had been her first medication error and she had been worried about the resident's pancreatic pain and should have been more certain of the identification of the two residents, since both were new admits. During interview on 6/16/11 at 12:10 P.M. Staff C, C.N.A. stated she was in the hall outside the 2 new residents' rooms and heard Staff A call Resident #1 the first name of Resident #2. She stated she corrected her and Staff A looked at Resident #1 and requested the medications she had just given him/her; the resident had them in hand. Staff C overheard Staff A explain to Resident #1 that she gave him/her the wrong pills. Resident #1 found to be alert and able to make own decisions. Staff A immediately checked Resident #1 out while explaining and requested that Staff C remain with the resident. Staff A immediately went to the station and started making calls. She stated Staff A said what she needed to do is notify the physician for orders and keep a close eye on the resident. During interview on 6/15/11 at 4 P.M. the Director of Nursing stated she received a phone call at home from the facility with a report that Staff A gave Resident #1, Resident #2's medications and she stated the pills taken were [MEDICATION NAME]. She instructed Staff A to call their Medical Director since she had not heard from the on-call physician. She stated the nurses are expected to call the Medical Director when ever another physician hasn't called back soon enough. She stated the Medical Director's Physician Assistant (PA) got involved and gave orders and also completed an evaluation of Resident #1 at the facility. During interview on 6/15/11 at 3:15 P.M. Staff B, Registered Nurse (RN) stated she worked when Resident #1 had the wrong medicine that morning. She stated she evaluated him/her at around 4 P.M. and found the resident to be stable with oxygen on and his/her daughter sitting next to the bed. She stated she noted the resident as drowsy, lungs clear with no abdominal distension and a strawberry health shake had been offered and taken. She stated the daughter remained at bedside. She stated at 6:30 P.M. the resident's oxygen saturation went down to 84% and staff turned the up at that time to 2.5 liters/nasal cannula. She stated the resident took a few bites of supper and had a small emesis of undigested food. The resident's daughter stated to Staff B the resident had not eaten or drank much and had not voided all day. The resident remained sleepy and had a second emesis. Staff B called the physician on-call and received orders to send him/her to the emergency room . She stated the daughter asked if she could drive the resident and since vital signs were within normal limits and s/he had no signs of respiratory distress, she allowed the daughter to drive him/her to the emergency room , further stating the resident preferred it. During interview on 6/27/11 at approximately 10:30 A.M. the resident's primary care physician stated she hadn't seen Resident #1 when s/he received the wrong medication. She stated another physician within their clinic was on call and evaluated the resident in the emergency room . She stated the resident is doing very well now and has his/her own apartment close by. The facility's Resident Medication Error report dated 5/28/11 documented that on admission, residents names are not placed outside of their rooms until a permanent name plate arrives. It also identified that all residents have a picture taken on admission. Unfortunately, the facility had a printer problem and could not get the printer to print the picture. Resident #1 ' s physician's orders dated 5/27/11 directed staff to administer [MEDICATION NAME] 5/325 milligrams (mg) by mouth (po) every 6 hours as needed (PRN). Resident #1 ' s physician ' s orders lacked any order to administer [MEDICATION NAME] 80 mg (milligrams) 2 tabs (160 mg) every twelve hours. According to CAMH (Centre for Addition and Mental Health) web search at: http://www.camh.net the difference between [MEDICATION NAME] and [MEDICATION NAME] are: " Both [MEDICATION NAME] and [MEDICATION NAME] relieve pain, but while [MEDICATION NAME] gives relief for about five hours, the effects of [MEDICATION NAME] last for about 12 hours. [MEDICATION NAME] contains five milligrams of [MEDICATION NAME], which is all released when the pill is taken. [MEDICATION NAME] doesn ' t contain [MEDICATION NAME]. It is pure [MEDICATION NAME] in amounts much larger than in [MEDICATION NAME]. Just one [MEDICATION NAME] pill can have the same amount of [MEDICATION NAME] as 16 [MEDICATION NAME] pills. "