Every finding on record at Park View Rehabilitation Center

Based on record review and staff interviews, the facility failed to ensure that only licensed staff administered medications. Additionally, the facility failed to ensure that narcotics were counted only by qualified personnel authorized to manage controlled substances, and that licensed nursing staff completed the shift-to-shift narcotic count together. These failures allowed an unlicensed staff member (CNA) to attempt medication administration and perform narcotic counts, both beyond their scope of practice. The facility reported a census of 42 residents. Findings include: 1. During an interview on 6/10/26 at 10:23 AM, Staff B, CNA, stated that agency nurse Staff C, Licensed Practical Nurse (LPN), asked if she attended nursing school. Staff B confirmed she had and would graduate if she passed her final test in May. Later, Staff C informed Staff B that Resident #3 would not take her medications. Staff B reported that Staff C stood in the doorway and pressured her to help administer the medications to Resident #3. Staff B stated, I hate confrontation. Staff C handed me her med cup, he put it in my hand and said 'here.' When Staff B asked, Are you sure? after realizing the request was wrong, Staff C replied, Ya, I couldn't get her to take them. Staff B stated, I don't argue with the nurses, I was always taught not to. The nurses are the boss. When asked if she administered the medications to Resident #3, Staff B replied, I went and tried, with Staff C in the door way, I tried but she wouldn't take them. When asked if she used a spoon, Staff B stated, Yes, with a spoon. When asked if the medications were crushed, Staff B stated, they were not. I told Staff C that Resident #3 is not taking them. Staff B noted that Staff C then asked her to crush the medications; Staff B replied, I guess. Staff B recounted, But then Staff C put the medications in the crusher, crushed them and gave them to me and walked away. Staff B did not attempt to administer the medication again, noting Resident #3 was actively passing. Staff B returned the medications to Staff C, informed him Resident #3 refused them, and walked away. Staff B stated that Staff E, CNA, was also present in the room. Staff C reported she received disciplinary action that included suspension without pay. During an interview on 6/10/26 at 11:33 AM, Staff E, CNA, reported that Staff C, LPN, entered Resident #3's room and asked, 'Do you guys know this resident?' Staff E replied that the resident had slept most of the day and refused medications for the shift. Staff C asked if Staff B, CNA was a nurse; both Staff B and Staff E replied she was not. Staff C, LPN told Staff B, CNA 'You give this,' and watched from the doorway as Staff C attempted to administer the medications; however, Resident #3 refused. When asked whether staff crushed the medications, Staff E stated, 'I don't remember the details. I think so, I do know that Resident #3 wouldn't take them.' 2. During an interview on 6/10/26 at 9:02 AM, Staff A, Certified Medication Aide (CMA), stated on 4/21/26 she received a report from Staff B, CNA that two nurses, Staff C, LPN, and Staff D, LPN were not getting along. Staff A observed Staff B, CNA performing a narcotic medication count with Staff C. When asked if she observed Staff B performing a narcotic count, Staff A replied, I did see that Staff B, CNA and Staff C were doing the narc count; they even asked me a question about it, but I don't remember what the question was. Staff A immediately contacted the Assistant Director of Nursing (ADON) and asked, Is Staff B a med aide? Because she's doing narc count. The ADON responded, No. When asked if they discussed anything else, Staff A stated, Nothing; we hung up. During an interview on 6/10/26 at 10:23 AM, Staff B, CNA stated that, at the end of the shift on 4/21/26, Staff C, LPN did not answer the call light or walkie. Staff B then observed Staff D, LPN exchanging a loud conversation with Staff C near the [NAME] 3 Hall, which caused staff to run from the hall to ensure none of the residents fell. Staff C demanded that Staff B count narcotics with him, claiming the ADON directed him to do so. Staff B stated, I said what the heck, I said no and he said that the ADON said that I had to. I said that I didn't have a license and that I couldn't. She added, I know it was wrong but he said I had to. Staff B reported that after she completed a narcotic medication count with Staff C, she completed a separate count with Staff D. She confirmed the nurses did not complete the count together as the ADON had directed. Staff B stated, I said that I didn't have a license and that I couldn't count. I know it was wrong but Staff C, LPN said I had to. Then I counted with him then with Staff D, LPN and she said that I was doing it all wrong. The CNA's were caught in the middle. I counted with each of them but not together. When asked if she documented completing the narcotic count, Staff B replied, Yes, Staff C said I had to sign the sheet. During an interview on 6/10/26 at 2:03 PM, Staff D, LPN, reported on 4/21/26 she witnessed Staff B, CNA perform a narcotic medication count and received a resident nurse report from Staff C, LPN. Staff D reported that Staff B holds neither a medication aide certification nor a nursing license. Staff D stated, Staff B should have never been put in a position to count narcotics, receive a nurse report and be left with the cart keys. The Narcotic and Controlled Substance form dated April 2026 showed Staff B, CNA signed her initials on 4/21/26. During an interview on 6/10/26 at 1:49 PM, The DON reported that a CNA must never work beyond their scope of practice. The DON reported that no CNA should perform a narcotic count or administer medication. The DON reported the CNA received education and disciplinary action. During an interview on 6/10/26 at 2:46 PM, the Administrator reported that only nurses are permitted to administer medications. The Administrator also reported that she remained unaware the nurses failed to complete the narcotic medication count together. The Administrator stated that nurses must count the narcotics together at the end of every shift. The Administrator reported the facility lacked a specific policy and instead followed the Iowa code for scope of practice.

Based on staff interviews, the facility failed to ensure that medication cart keys were secured and handled exclusively by qualified personnel, allowing a Certified Nursing Assistant (CNA), who is unauthorized to manage controlled substances, to possess the keys and conduct narcotic counts. The facility reported a census of 42 residents. Findings Include: During an interview on 6/10/26 at 10:23 AM, Staff B, CNA, admitted she performed narcotic counts with Staff C, Licensed Practical Nurse (LPN), and Staff D, LPN, separately, rather than together as directed by the Assistant Director of Nursing (ADON). Although Staff B stated she lacked the licensure to conduct counts, she claimed Staff C, LPN, insisted she participate and sign the documentation. Staff B noted she performed counts with each nurse individually, remarking that the CNAs were caught in the middle. During an interview on 6/10/26 at 2:03 PM, Staff D, LPN, reported that on 4/21/26, she witnessed Staff B, CNA, perform a narcotic medication count and receive a resident nurse report from Staff C, LPN. Staff D reported that Staff B holds neither a medication aide certification nor a nursing license. Staff D stated, Staff B should have never been put in a position to count narcotics, receive a nurse report and be left with the cart keys. During a follow-up interview on 6/10/26 at 2:10 PM, Staff B confirmed that Staff C, LPN, left the medication cart keys in her possession upon exiting the facility. Staff B noted she was given no choice in the matter and held the keys for an undetermined period before transferring them to Staff D, LPN, following the completion of the count. During an interview on 6/10/26 at 2:19 PM, the Director of Nursing (DON) stated that a CNA must never work beyond their scope of practice and that no CNA should possess medication cart keys. The DON reported that the CNA received educational and disciplinary action. During an interview on 6/10/26 at 2:46 PM, the Administrator acknowledged being unaware that the CNA had possession of the medication cart keys. The Administrator confirmed the facility lacked a policy regarding the safe handling of medication cart keys, despite adhering to CMS and pharmacy standards.

Based on record review and staff interviews, the facility failed to ensure that the resident's physician and responsible party were notified regarding the failure to administer prescribed, scheduled medications including a high-risk medications for 2 of 3 residents reviewed (Resident #1 and #2). The facility reported a census of 42 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of malignant neoplasm of anal canal, renal insufficiency and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #1 showed the Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were not administered on 4/21/26:Clonidine for hypertensionMetoprolol for hypertensionSertraline for depressionCefuroxine Axetil for abnormal findings in the lung fieldKlor-Con for low potassium 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of blood clot, depression, and dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #2 showed the Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were not administered on 4/21/26:Trazodone for depressionEliquis for history of blood clot in lungMemantine for Alzheimer's DiseaseRisperidone for behavioral disturbances Tylenol for generalized pain During an interview on 6/4/26 at 4:15 PM, the DON confirmed that Resident #1 and Resident #2 missed their scheduled evening medications on 4/21/26. Although the DON acknowledged Eliquis is a high-risk medication, the physician and the residents' families were not notified of the missed doses, which the DON admitted should have occurred. The DON stated, we usually do but it didn't happen this time. Review of the facility policy concerning notification of change in condition revealed the document failed to provide necessary guidance for personnel regarding the failure to administer prescribed medications, particularly those categorized as high-risk. During an interview on 6/10/26 at 2:46 PM, the Administrator admitted that notification to the physician should have occurred and indicated they would search for a corresponding facility policy.

Based on staff and resident interviews and record review, the facility failed to ensure residents remained free from significant medication errors. On 4/21/26, staff failed to administer scheduled evening medications for 2 of 3 resident reviewed (Resident #1 and #2). Instead, the medications were found in envelopes stapled to the residents' respective medication bubble packs. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of malignant neoplasm of anal canal, renal insufficiency and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #1 showed the Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were not administered on 4/21/26:Clonidine for hypertensionMetoprolol for hypertensionSertraline for depressionCefuroxine Axetil for abnormal findings in the lung fieldKlor-Con for low potassium During an interview on 6/10/26 at 1:04 PM, Resident #1 reported that she did not receive any of her medications on a night in April. When asked to remember the nurse, Resident #1 replied, it was a gentleman. Resident #1 could not recall his name and answered, I never did know it but he was an agency nurse. Resident #1 stated that someone spoke to her about the incident the next morning. When asked if she had any complications related to the missing medication pass, the resident stated, 'No, I don't believe so.' 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of blood clot, depression, and dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #2 showed the Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were not administered on 4/21/26:Trazodone for depressionEliquis for history of blood clot in lungMemantine for Alzheimer's DiseaseRisperidone for behavioral disturbances Tylenol for generalized pain During an interview on 6/10/26 at 9:02 AM, Staff A, Certified Medication Aide (CMA), stated, Staff D, Licensed Practical Nurse (LPN) showed me bubble packs that had the envelopes used for crushing meds stapled to the bubble pack. It looked like a full med pass was in there. Staff A identified the medications as belonging to Resident #1 and Resident #2. During an interview on 6/10/26 at 10:23 AM, Staff B, Certified Nursing Assistant (CNA), reported that when Staff D, LPN reviewed the medication cart for Staff C, LPN Staff D found bubble packs with envelopes with medications taped to the bubble packs. Staff B further stated, Staff D showed me, maybe there were 3 but I don't know which residents they were for. During an interview on 6/10/26 at 2:03 PM, Staff D, LPN corroborated that Resident #1 and #2 missed their medication pass on the evening of 4/21/26. Staff D noted that although the medications were indicated as administered by Staff C, LPN, she discovered an envelope containing medications stapled to the medication bubble cards for both residents. During an interview on 6/4/26 at 4:15 PM, the Director of Nursing (DON) reported that staff alerted her to medications found in envelopes (the clear medication envelopes used for crushing medications) attached to medication bubble cards. The DON's investigation determined that on 4/21/26, two residents missed the evening medication pass, and she found the medications stapled to a medication bubble pack for each of the two residents. The DON noted the medications were signed off as administered on the Medication Administration Record (MAR). The DON identified the residents as Resident #1 and Resident #2. The DON and the Assistant Director of Nursing (ADON) reviewed the medications, compared the medication, and confirmed the scheduled evening medications were present within the envelopes. The DON noted that the practice of stapling medication envelopes to bubble packs had never occurred prior to that night. The DON reported staff is expected to leave medications in the bubble packs unless administered. If medications cannot be administered once removed from the bubble packs, the medications should be destroyed. When the DON followed up with the agency nurse, Staff C, LPN reported that he felt flustered during the shift due to the events that occurred and never returned to passing the medications. When asked if the investigation showed complications related to the missed medication pass for either resident, the DON stated, no. When asked if the physician was notified, the DON stated, no. When asked if she considered any of the medication to be a high risk medication, the DON acknowledged Eliquis as a high risk medication. When asked if the provider and family should have been notified, the DON stated, yes, we usually do but it didn't happen this time. During an interview on 6/10/26 at 2:46 PM, the Administrator stated her expectation that facility personnel adhere to the six rights of medication administration. Upon requesting the pertinent policy, the Administrator indicated the facility utilizes the National Standard as their guiding protocol for the six rights of medication administration.

Based on the record review and interviews with facility staff, the facility failed to maintain accurate documentation of medication administration as not administered on 4/21/26 for 2 of 3 residents reviewed (Residents #1 and #2). The facility reported a census of 42 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of malignant neoplasm of anal canal, renal insufficiency and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #1 showed the following medications as administered. The Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were confirmed as not administered on 4/21/26:Clonidine for hypertensionMetoprolol for hypertensionSertraline for depressionCefuroxine Axetil for abnormal findings in the lung fieldKlor-Con for low potassium 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of blood clot, depression, and dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Review of the April 2026 Medication Administration Record (MAR) for Resident #2 showed the following medications as administered. The Director of Nursing (DON) indicated by documentation on the MAR the following evening mediations were confirmed as not administered on 4/21/26:Trazodone for depressionEliquis for history of blood clot in lungMemantine for Alzheimer's DiseaseRisperidone for behavioral disturbances Tylenol for generalized pain During an interview on 6/10/26 at 9:02 AM, Staff A reported, Staff D, Licensed Practical Nurse (LPN) showed me bubble packs that had the envelopes used for crushing meds stapled to the bubble pack. Staff A indicated the medications belonged to Resident #1 and Resident #2. Staff A stated It looked like a full med pass was in there. Staff A reported although the medications were not administered, Staff C, Licensed Practical Nurse signed the medication as administered on the MAR. During an interview on 6/10/26 at 2:03 PM, Staff D, LPN corroborated that Resident #1 and #2 missed their medication pass on the evening of 4/21/26. Staff D noted that although the medications were indicated as administered by Staff C, LPN, she discovered an envelope containing medications stapled to the medication bubble cards for both residents.During an interview on 6/4/26 at 4:15 PM, the Director of Nursing (DON) stated she was notified by facility staff regarding medications discovered in clear crushing envelopes which remained attached to bubble cards. The DON reported her subsequent investigation revealed that Resident #1 and Resident #2 did not receive their evening medication pass on 4/21/26. The DON confirmed finding medications stapled to a bubble pack for each resident, despite the Medication Administration Record (MAR) showing the medications as administered. The DON and the Assistant Director of Nursing (ADON) conducted a comparison of the drugs and confirmed that the envelopes contained the scheduled evening medications. The DON reported staff is expected to leave medications in the bubble packs unless administered. If medications cannot be administered once removed from the bubble packs, the medications should be destroyed. During an interview on 6/10/26 at 2:46 PM, the Administrator stated her expectation that facility personnel adhere to the six rights of medication administration. Upon requesting the pertinent policy, the Administrator indicated the facility utilizes the National Standard as their guiding protocol for the six rights of medication administration.

Based on resident council meetings, Electronic Health Record (EHR)review, document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed (Resident #27, #53, #11 and #15). The facility reported a census of 45 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #27 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS also documented Resident #27 was dependent on staff for toileting hygiene, lower body dressing, and taking off footwear. On 3/9/26 at 12:28 PM Resident #27 stated he has had to wait up to 45 minutes in the last week or two for his call light to be answered. Review of Resident #27's EHR documented Resident #27 resided in room [ROOM NUMBER]. Review of facility provided call light log for Resident #27 in room [ROOM NUMBER] from 3/4/26 - 3/11/26 revealed call lights that had longer than a 15 minute response time on: 3/5/26 at 5:04 AM 19 minutes and 53 seconds. 3/5/26 at 6:57 PM 22 minutes and 24 seconds. 3/8/26 at 6:49 AM 38 minutes and 26 seconds. 3/10/26 at 5:36 AM 19 minutes and 40 seconds. 3/10/26 at 3:35 PM 30 minutes and 56 seconds. 3/10/26 at 7:42 PM 26 minutes and 8 seconds. 2. The MDS for Resident #53 had not had a completed cognitive section for the MDS because Resident #53 had entered the facility on 3/6/26. Review of Resident #53's EHR documented an admission date of 3/6/26. On 3/9/26 at 1:31 PM Resident #53 stated he had not stayed at the facility long, just 2 or 3 days. Resident #53 explained it had taken up to an hour to have his call light answered. Resident #53 stated at one time he wanted a bed pan and was incontinent of stool because he had to wait so long. Resident #53 explained he had to wait while sitting on a bed pan for 45 minutes. Resident #53 explained he had sores on his buttocks but the sores originated from the hospital. Resident #53 stated it was embarrassing to be incontinent of stool because he had to wait and he was continent of his bowels. Review of EHR dated 3/9/26 at 1:37 PM titled, Progress Notes documented Resident #53 was alert to person, place, time and staff names and faces. Review of Resident #53's EHR documented Resident #53 resided in room [ROOM NUMBER]. Review of facility provided call light log for Resident #53 in room [ROOM NUMBER] from 3/6/26 - 3/11/26 revealed call lights that had longer than a 15 minute response time on: 3/7/26 at 10:47 AM 29 minutes and 25 seconds. 3/7/26 at 12:42 PM 25 minutes 16 seconds. 3/7/26 at 5:56 PM 16 minutes and 57 seconds. 3/8/26 at 3:30 AM 32 minutes and 56 seconds. 3/8/26 at 6:10 AM 1 hour, 1 minute and 38 seconds. 3/8/26 at 8:16 AM 15 minutes and 5 seconds. 3/8/26 at 9:38 AM 25 minutes and 16 seconds. 3/8/26 at 10:17 AM 24 minutes and 49 seconds. 3/8/26 at 12:59 PM 40 minutes and 6 seconds. 3/8/26 at 2:11 PM 26 minutes and 8 seconds. 3/8/26 at 3:02 PM 18 minutes and 42 seconds. 3/8/26 at 5:35 PM 30 minutes and 15 seconds. 3/8/26 at 8:00 PM 26 minutes and 46 seconds. 3/9/26 at 4:47 AM 18 minutes and 55 seconds. 3/9/26 at 5:34 AM 19 minutes and 30 seconds. 3/9/26 at 6:06 AM 18 minutes and 25 seconds. 3/9/26 at 9:42 PM 16 minutes and 49 seconds. 3/10/26 at 12:18 AM 25 minutes and 16 seconds 3/10/26 at 7:38 AM 17 minutes and 27 seconds. 3/10/26 at 8:55 AM 24 minutes and 4 seconds. 3/10/26 at 11:04 AM 16 minutes and 17 seconds. 3/10/26 at 4:22 PM 18 minutes and 23 seconds. 3/10/26 at 5:19 PM 17 minutes and 45 seconds. 3/10/26 at 7:45 PM 23 minutes and 31 seconds. 3/11/26 at 4:37 AM 32 minutes and 20 seconds. 3/11/26 at 1:19 PM 16 minutes and 19 seconds. 3/11/26 at 4:49 PM 22 minutes and 49 seconds. On 3/11/26 at 3:50 PM Staff I, CNA stated she had noticed call lights had taken longer than 15 minutes to be responded to. Staff I explained that usually several call lights were on at once and it took longer than 10 minutes to put the initial resident to bed. Staff I explained that staff filled slips out to explain the reason there are call lights longer than 15 minutes. 3. Review of Resident #11's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognitive functioning. The MDS further revealed Resident #11 required two plus physical assistance with sitting to standing, chair/bed-to chair transfers, and transferring to the toilet. Interview on 3/10/26 at 8:39 AM with Resident #11 revealed that call lights take forever, and are up to 30 minutes sometimes. Resident #11 further revealed that she watches the clock and can tell how long it takes. 4. Review of Resident #15's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognitive functioning. The MDS further revealed Resident #15 required two plus physical assistance with sitting to standing, chair/bed-to chair transfers, and transferring to the toilet. Interview on 3/10/26 at 9:18 AM with Resident #15 revealed that call lights often take longer than 15 minutes to be answered, and at times she has waited almost 30 minutes to be helped. Resident #15 revealed that she watches the clock. Interview on 3/11/26 at 1:02 PM with Staff C Registered Nurse (RN) revealed residents wear a pendant and when pushed go to tablets and pagers that CNA's carry around. Staff C then revealed that the call lights above the doors do not actually light up. Staff C further revealed that he feels the teams are pretty good, and answer call lights pretty quickly. Staff C disclosed that he is unaware of any call light audits being completed. Interview on 3/11/26 at 1:08 PM with Staff D CNA revealed that the call lights above the doors for residents' rooms do not go on when a call light is turned on. Staff D revealed the residents have pendants. Staff D further disclosed staff are supposed to fill out a paper if they realize call lights are on longer than 15 minutes. Interview on 3/11/26 at 1:11 PM with Staff F CNA revealed that she carries a pager that shows when call lights are on, and how long that they are on for. Staff F then revealed that call lights do go longer than 15 minutes on occasion. Staff F then disclosed that she notices it more when agency staff are at the facility, as they do not get the pager at the beginning of their shift. Staff F revealed that if call lights go longer than 15 minutes the staff are to fill out a paper as to why the call light took longer than 15 minutes to answer. Interview on 3/11/26 at 1:22 PM with Staff E CNA revealed that call lights above the doors do not function, and that the residents' have pendants on necklaces. Staff E then revealed that she carries a pager system that she picks up when her shift starts, and this will be alerted as to when a call light is on and how long a resident has been waiting. Staff E then disclosed that call lights have taken longer than 15 minutes to answer. Staff E revealed that in the main nurses hub there is a big screen that has all the call lights, and it also notifies staff as to what call lights are on and how long they have been on as well or if there are low batteries in the pendants. Interview on 3/12/26 at 8:25 AM with the Director of Nursing (DON) revealed that she has heard that call lights have lasted longer than 15 minutes ,and staff fill out slips. The DON further revealed that she has heard of agency staff not picking up the pagers for the call light system. The DON further revealed that call lights should be answered in 15 minutes or less. The DON then disclosed that call lights are a concern. Review of facility provided documents titled, Past Calls 3/4/36-3/11/26 revealed call light logs with several call lights lasting longer than 15 minutes. Upon review of the documents there were several instances of times ranging from 16 minutes up to 1 hour and 8 minutes. Review of a facility provided document titled, Call Light Policy with a revised dated of 9/2023 revealed: a. Facility shall answer call lights in a timely manner.

Based on observation, staff interview and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination, not dating open food items and not disposing of expired food items. The facility reported a census of 45 residents.Findings include:Observation on 3/9/26 at 10:10 AM of a 2 door refrigerator revealed these food items open and undated 16 oz. container of parmesan cheese and a bag of diced chicken.Observation on 3/9/26 at 10:14 AM of a 2 door freezer revealed a large bag of bacon bits and a large bag of chicken cordon bleu both open and undated.Observation on 3/9/26 at 10:16 AM of a 3 door freezer revealed a plastic container containing about 10 biscuits and a large bag of cinnamon rolls open and undated. A box of pre-cooked hamburgers with bag open and box top cut away with food items on the shelf above and a box of pre-cooked omelets with the bag open and box top cut away with the hamburger box on the shelf above. Observation on 3/9/26 at 10:20 AM of dry storage revealed 3 cans of chili beans with an best by date of 1/25, 1 can of butter beans with a best by date of 6/25, 1 can of tomato paste with a best buy date of 9/25 and a glass jar of pizza sauce with a best by date of 9/25.On 3/9/26 at 11:17 AM Staff N, Certified Dietary Manager (CDM) stated she would expect the food items that were open to have an open date. The CDM stated she would expect the food items that would have a best by date that was prior to today's date would have been discarded and not served to residents. An observation during the lunch meal service revealed Staff N obtained container of butter, obtained loaf of bread, obtained bag of sliced meat from the refrigerator, applied gloves to both hands, opened bread bag with both hands, removed a slice of bread from inside the bag with right hand, placed slice of bread on the plate, left hand used to hold bread in place, right hand used to hold the knife and butter the slice of bread, right hand used to open sealed bag of deli sliced meat, left hand held bag of meat, right hand reached in to remove several slices of meat, some slices of removed meat placed on bread, a couple slices of meat placed back in the bag of sliced meat, knife used to cut the slice of bread in half, each slice of bread with meat picked up and folded together into a sandwich, gloves removed and plated sandwich taken to dining room. Review of a facility provided policy revised 10/23 titled, Food Handling documented the purpose of the policy was to adhere to the food safety standards described in the local Food Code and as per CMS food safety standards for long-term care. Employees must perform hand hygiene prior to handling food and maintain safe food handling practices. All foods prepared in operation must be covered and labeled with date of preparation prior to storage in refrigerators and freezers. A use-by date should be specified. Upon receiving, check products for condition, possible contamination, and temperature. Reject any product that is questionable or damaged. Store refrigerated and frozen foods first and date products to ensure first in-first out process.

Based on record review, staff interview, and policy review the facility failed to have the necessary required members attend quarterly quality assurance meetings. The facility reported a census of 45 residents.Findings include:Review of facility provided documents titled, Quality Assurance and Performance Improvement Committee Attendance Record for the months of August 2025 through February 2026 revealed there was no Infection Preventionist (IP) that attended the Quality Assurance (QA) meetings. Interview on 3/12/26 at 8:51 AM with the Administrator revealed that the facility did not have an IP until the new Director of Nursing (DON) came to the facility to work. Follow up interview on 3/12/26 11:13 AM with the Administrator confirmed the IP was not present at the meetings from August of last year to February of this year. The Administrator then revealed her expectation would be to have an IP at the meetings per expectations.Review of a facility provided document titled, QAPI Policy with a revision date 10/2023 revealed:a. The members of the QAPI committee must meet at least quarterly.

Based on Electronic Health Records (EHR) review, Medication Administration Records - Treatment Administration Records (MAR-TAR), resident interviews, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower and failed to apply edema wear as ordered by the physician to 3 of 3 residents reviewed (Resident #4, #27 and #11). The facility reported a census of 45 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS also documented Resident #4 required partial / moderate assistance to shower/bathe self with staff doing less than half the effort. On 3/10/26 at 9:28 AM Resident #4 said she was supposed to receive baths on Tuesdays and Thursdays. Resident #4 explained she would like a shower twice a week. Resident #4 said she was supposed to wear edema socks but has not had them in a couple of months. On 3/10/26 at 9:44 AM an observation in Resident #4's bathroom revealed no compression socks present. Resident #4 wearing thick black socks just over the ankle. On 3/11/26 at 10:14 AM an observation in Resident #4's bathroom revealed no compression socks present. Resident #4 wearing thick black socks just over the ankle. Review of Resident #4's EHR titled, Orders documented a physician's order with a start date of 12/9/25 to apply edema wear in the morning and remove in the evening. Review of Resident #4's MAR-TAR documented a physician's order with a start date of 12/9/25 to apply edema wear in the morning and remove in the evening. Review of Resident #4's EHR titled, Baths for the last 30 days revealed a bath was given on 2/11, 2/17, 2/19, 2/24, 3/4, 3/5, 3/10. No refusals had been documented. Review of Resident #4's EHR titled, Tasks documented Resident #4 prefers a shower 3 times a week and as needed. Review of Resident #4's EHR titled, Care Plan documented an intervention to assist Resident #4 with shower/bathing per schedule. On 3/11/26 at 3:50 PM Staff I, Certified Nurse Assistant (CNA) stated she does work with Resident #4 and was currently working with Resident #4 that morning. Staff I explained Resident #4 was fairly independent. Staff I explained she had never taken edema wear off of Resident #4 and it was never passed on to her by anyone at the facility that Resident #4 required edema wear. On 3/11/26 at 4:03 PM Staff J, Registered Nurse (RN) acknowledged she worked with Resident #4 frequently. Staff J stated she had taken Resident #4's edema wear off and had taken them off this week. Staff J explained that she had taken the edema wear off the night of 3/10/26 or 3/9/26. On 3/11/26 at 3:54 PM Staff K, CNA acknowledged she had been working on Resident #4's hall for the last month. Staff K stated had periodically checked on Resident #4 to ensure she was safe. Staff K explained Resident #4 was fairly independent. Staff K stated Resident #4 had not had edema socks that she was aware of. On 3/11/26 at 4:23 PM the Director of Nursing (DON) stated she expected the nurse would document if they put the edema wear on and would make an observation that the edema wear is in place. The DON also stated she expected a nurse would ensure the edema wear was removed in the evening in accordance with the physician's orders. 2. The MDS dated [DATE] documented Resident #27 had a BIMS of 13 indicating no cognitive impairment. The MDS also documented Resident #27 was dependent on staff for toileting hygiene, lower body dressing, and taking off footwear. On 3/9/26 at 12:28 PM Resident #27 explained he was supposed to get 2 showers a week but only usually received one. Resident #27 stated he was supposed to receive showers on Monday and Thursday each week but mostly got them only on Thursday. Review of Resident #27 EHR titled, Tasks documented baths were given on 2/12, 2/16, 2/19, 2/23, 3/2, 3/9. Bath missed on 3/2 and 2/26. No refusals documented. On 3/11/26 at 9:07 AM Staff D, Certified Nurse Assistant (CNA) / Certified Medication Assistant (CMA) / Bathaide stated someone will fill in when she is not at the facility. Staff D acknowledged residents did not receive baths as they are supposed to a minimum of twice a week. Staff D explained she was pulled to the floor frequently and unable to complete the baths appropriately. On 3/11/26 9:17 AM Staff L, CNA and Restorative Aide explained she would complete baths when Staff D was not at the facility or was pulled to the floor. Staff L stated it had been rough lately and she got pulled to the floor quite a bit. Staff L stated in the past 3 weeks one either Staff D or herself are pulled daily. 3. Review of Resident #11's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognitive functioning. The MDS further revealed Resident #11 required two plus physical assistance with sitting to standing, chair/bed-to chair transfers, transferring to the toilet, and transferring to the bath/shower. Interview 3/10/26 at 8:44 AM Resident #11 revealed that she has only been receiving one shower a week, and it should be twice a week. Resident #11 further revealed that the facility is short of staff, and constantly pulls the bath aide to the floor and baths/showers aren't getting completed. Review of Resident #11's Care plan with a revision with a date of 2/14/26 revealed an intervention to assist Resident #11 with shower/bathing per schedule. Review of a document titled, Documentation Survey Report with a date of February 2026 revealed Resident #11 had a shower on the 4th, 18th, and 25th. Review of the Documentation Survey Report for the month of March 2026 revealed Resident #11 had refused 1 time with no other showers documented. Interview on 3/11/26 at 8:15 AM with Staff D CNA disclosed residents get baths 2-3 times a week. Staff D then revealed the bathtub had been broken for about a year and parts had been ordered. Staff D then revealed the facility did order a part, but it was too small and had to be sent back. Staff D revealed if residents refuse a bath then it is charted in the electronic health record. Staff D further disclosed that she has been pulled a lot to the floor. Staff D then confirmed bathing is not being completed twice a week. Interview on 3/11/26 at 9:47 AM with the Director of Nursing (DON) revealed baths should be completed twice a week, and if there are refusals then they should be documented. The DON stated bed baths should be offered, and if they do not get a bath/shower it should be moved to the next day. Interview on 3/11/26 at 10:05 AM with the Administrator revealed that she would expect baths/showers to be given at the appropriate times, and according to the resident's requests. Review of a facility document titled, Hygiene-Bathing/Shower with a revision date of 3/24 indicated staff need to document in the Electronic Healthcare Record (EHR) when baths/showers are completed.

Based on Electronic Health Record (EHR) review, resident interview, staff interview, 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 2 of 3 residents reviewed (Resident #4 and #9). The facility reported a census of 45.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. The MDS also documented Resident #4 required partial / moderate assistance to shower/bathe self with staff doing less than half the effort.On 3/10/26 at 9:39 AM Resident #4 stated when she came in she had therapy and then it stopped. Resident #4 stated she could walk down the hall with a walker and did not need a wheelchair when she was in therapy. Resident #4 explained she used a walker now. Resident #4 stated she would like to have some therapy and had spoken to someone about therapy. Resident #4 stated she did not know who she had spoken with but thought they would get back to her about therapy. Review of Resident #4's EHR titled, Task documented restorative 3 times a week, nu-step for 10 minutes, seat 9, arms 11, laying down exercises lower left extremity and right lower extremity for 15 reps each, ball under the knee then kick up foot, heel slides, hip abduct and adduct, straight leg raise 3 times a week. Review of Task documented Resident #4 had no refusals. Task documented Resident #4 had utilized nu-step 4 times for 15 minutes. Review of Resident #4's EHR titled, Survey Report V2 for month of February documented Resident #4 completed restorative on 2/25 and 2/27.Review of Resident #4's EHR titled, Survey Report V2 for month of March documented Resident #4 completed restorative on 3/2, 3/4 and 3/9.2. The MDS dated [DATE] documented Resident #9 had a BIMS of 14 indicating no cognitive impairment. The MDS also documented Resident #9 was dependent on staff for toileting hygiene, shower/bathe, lower body dressing and taking off footwear.On 3/10/26 at 8:49 AM Resident #9 stated when there was someone available they were pulled to the floor frequently. Review of Resident #9's EHR titled, Task documented under the restorative task manual resist leg press for 10 - 15 reps each leg. Nu-step 5 - 10 minutes as tolerated. The restorative task documented Resident #9 refused 2/24 and 2/27. The restorative task documented Resident #9 did not refuse 2/11, 2/12, 2/13, 2/16, 2/17, 2/18, 2/19, 2/23, 2/25, 2/26, 3/2, 3/3, 3/4, 3/5, 3/6, 3/9, 3/10 and 3/11. The restorative task documented 0 on 2/11, 2/17, 2/19, 2/23, 2/26, 3/3,3/6, 3/9 and 3/10.Review of Resident #9's EHR titled, Care Plan documented an intervention that Resident #9 was in a restorative nursing program to help achieve and maintain optimal physical, mental, and psychosocial skills. Care Plan also documented as an intervention to educate Resident #9 of restorative program needs and participation schedule, encourage Resident #9 to participate in restorative programs and follow therapy recommendations as applicable.On 3/11/26 at 9:07 AM Staff D, Certified Nurse Assistant (CNA) / Certified Medication Assistant (CMA) / Bath aide stated she would fill in for Staff L when she was off. Staff D acknowledged she was unable to complete restorative with the residents appropriately because she would be pulled to work as a CNA frequently.On 3/11/26 at 9:17 AM Staff L, CNA / Restorative Aide stated she had been in restorative since September or October. Staff L explained it had been rough lately because she was pulled to the floor quite a bit to work as a CNA. Staff L explained in the past 3 weeks either Staff D or herself are pulled daily. Staff L explained when she documented 0 on the restorative task that indicated she was pulled to work as a CNA and was unable to complete the restorative task for the resident. Staff L acknowledged that restorative task for Resident #4 and #9 did not have the restorative task completed as it was written.On 3/11/2026 1:12 PM Staff M, Regional Director of Operations (RDO)/Physical Therapist Assistant (PTA) stated Staff L got pulled to the floor at times. Staff M explained the restorative task documentation did not appear to have been charted that it was completed according to how the restorative task was written.On 3/11/26 at 2:51 PM the Director of Nursing (DON) acknowledged the Bath Aide and Restorative Aide get pulled frequently but not both together a lot. The DON acknowledged after review of restorative task for Resident #4 and #9 the restorative was not charted as completed appropriately. The DON stated she expected the restorative program would be followed as written. Review of policy revised 5/25 titled, Nursing Rehabilitation / Restorative Care documented upon the completion of a comprehensive assessment of a resident, the facility should attempt to incorporate restorative programs that will assist a resident to maintain or improve their physical functioning. It is recognized that this will not be possible in all cases. Residents who are candidates for restorative nursing care shall be appropriately assessed, care planned and evaluated for progress. The need for rehabilitation/restorative care will be determined through a comprehensive assessment and/or skilled evaluation. The rehabilitation/restorative plan will be determined through nursing assessment with therapy intervention if deemed appropriate. The care plan should include goals, interventions, special instructions & frequency of the restorative program. This information is to be communicated to the caregivers responsible for carrying out the tasks as outlined by the plan of care, documented in the task and available on the Kardex. The Restorative program Evaluation Quarterly will be documented with the following criteria: Review of the current plan of care for implementation, appropriateness of goals & interventions and tolerance/intolerance to current program.

Based on observation, clinical record review, and staff interview, the facility failed to implement appropriate infection prevention and control practices to prevent the spread of infection. Specifically, the facility failed to clean equipment between resident use for 1 of 5 residents reviewed (Resident #15). The facility also failed to follow Transmission-Based Precautions (TBP) when delivering a meal tray to a resident with COVID-19 for 1 of 2 residents reviewed (Resident #37). Additionally, the facility failed to follow current Centers for Disease Control and Prevention (CDC) guidelines by not implementing Enhanced Barrier Precautions (EBP) during a wound care dressing change to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 3 residents reviewed (Resident #11). The facility reported a census of 45 residents.Findings Include: 1. Observation on 3/9/26 at 12:12 PM showed Staff A, Dietary Aide, failed to don personal protective equipment (PPE) prior to entering Resident #37's room while the resident was on Transmission-Based Precautions. Staff A entered the room, placed the meal tray on the bedside table within reach of the resident, exited the room, and then used hand sanitizer. Staff A did not don PPE prior to entering the resident's room. During an interview on 3/9/26 at 12:26 PM, the Director of Nursing (DON) reported that Resident #37 tested positive for COVID-19 on 2/28/26 and would remain on Transmission-Based Precautions until 3/10/26. During an interview on 3/11/26 at 10:14 AM, the Administrator reported all staff should wear PPE when entering a room where a resident is COVID-19 positive. The Administrator further reported Staff A had been off work prior to the resident testing positive for COVID-19 and had missed the PPE refresher training provided to staff. The Administrator reported she would follow up with dietary staff to ensure Transmission-Based Precautions were followed. 2. Observation on 3/09/26 at 12:05 PM noted Staff B came out of covid positive Resident #15's room, and brought out the sit to stand mechanical lift. Staff B Certified Nursing Assistant (CNA) was observed not cleaning the lift after use, and took the lift to the end of south hall and placed the lift in the living area. On 3/11/26 at 9:47 AM interview with the DON confirmed that mechanical lifts should be cleaned after use in a room requiring PPE. Interview on 3/11/26 at 10:05 AM with the Administrator revealed that mechanical lifts should be cleansed after use in rooms requiring PPE. 3. The Minimum Data Set (MDS) dated [DATE] for Resident #11 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS also documented an active diagnosis of Multidrug-Resistant Organism (MDRO). MDS also documented Resident #11 an infection of the foot and other open lesion(s) on the foot. Review of Resident #11's Electronic Health Record (EHR) titled, Orders documented a physician's order with a start date of 2/17/26 for a dressing change to right ankle and right lower shin to cleanse with normal saline, apply aquacel ag and cover with mepilex border 3 times per week until healed. Review of Resident #11's EHR titled, Medication Administration Record - Treatment Administration Records (MAR-TAR) documented a physician's order with a start date of 2/17/26 for a dressing change to right ankle and right lower shin to cleanse with normal saline, apply aquacel ag and cover with mepilex border 3 times per week until healed. On 3/11/26 at 9:35 AM an observation of Resident #11's wounds provided by the Assistant Director of Nursing (ADON) revealed the ADON knocked on the door, entered the room, completed hand hygiene, applied gloves, did not apply gown, explained to Resident #11 procedure, pulled right sock down, right lateral outside aspect of right lower extremity had a 1.5 inch by about 3/4 of an inch wound with pink wound bed, no active drainage of bleeding, ADON pulled right leg pant leg up over knee, revealed a dark brown / black scab 1.5 inches x about 1 inch, no redness noted around the area, removed gloves, completed hand hygiene. On 3/11/26 at 9:40 AM the ADON stated had Resident #11 had both wounds since admission to the facility. On 3/11/26 at 9:32 AM an observation outside of Resident #11's room revealed no Enhanced Barrier Precautions (EBP) sign posted outside the door. Review of Resident #11's EHR titled, Care Plan documented no focus, goal and interventions for EBP. On 3/11/26 at 2:51 PM the Director of Nursing (DON) / Infection Preventionist (IP) acknowledged Resident #11 was not currently on EBP. The DON stated typically the EBP is only in place with residents who have a wound that had an infection and/or a MRDO. The DON stated if the wound did not have an infection present or a history of an infection then EBP was not required. The DON stated she uses her knowledge of infections to determine what residents required EBP. The DON stated if she had any other questions she would reach out to Staff G, Regional Nurse Consultant (RNC) with any questions but does not refer to the CDC for guidance. On 3/11/26 at 2:51 PM Staff G acknowledged Resident #11 should have EBP in place related to her wounds. Review of the facility's Infection Control Manual dated September 2023 indicated staff are required to don appropriate PPE prior to entering the room of a resident on Transmission-Based Precautions. Review of a facility provided policy titled, Infection Control Manual Surveillance with a revision date of September 2023 indicated staff are to perform terminal cleaning and disinfection of patient's/resident's room and reusable medical equipment. Review of facility provided policy revised 3/24 titled, Enhanced Barrier Precautions documented the purpose of the policy was to minimize risk of transmission of novel or targeted Muli-Drug Resistant Organisms (MDROs) during high contact resident care activities for residents requiring enhanced barrier precautions (EBP). EBP will be used in conjunction with standard precautions for residents with any of the following (if/when Contact Precaution requirements are not in place): Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply and wounds and/or indwelling medical devices (even if the resident is not known to be infected or colonized with a targeted MDRO). For residents whom EBP are indicated; gowns and gloves should be used during high contact resident care activities that provide opportunity for MDROs to be transferred to staff hands and clothing. High contact resident care activities include: Wounds care: any skin opening requiring a dressing and dressing.

Based on record review, staff and family interview, the facility failed to allow a resident representative/Power of Attorney (POA) assist a cognitively impaired resident with decision making for 1 resident reviewed (Resident #4). The facility reported a census of 47 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Diagnoses included atrial fibrillation, cirrhosis, arthritis, and repeated falls.The Progress Noes dated 9/14/25 at 12:29 p.m. documented Resident #4 was alert to person, and to place. The resident was confused.The Progress Notes dated 9/15/25 at 10:32 a.m. documented the resident was alert to person. The resident was confused and forgetful.The Progress Notes dated 9/16/25 at 1:10 p.m. documented the resident was alert to person. The resident was confused and forgetful.The Progress Notes dated 9/17/25 at 1:48 p.m. documented the resident was alert to person. The resident was confused and forgetful.The Progress Notes dated 9/17/25 at 10:20 a.m. documented the Social Services Director (SSD) spent some time with the resident this morning going over the Medicaid application. He was knowledgeable about the information and what each insurance company was for. Reviewed with the resident's family member for accuracy.An undated and unsigned note in the resident's EHR read life insurance policy for the resident $15,000. Would need to call company at time of death with the policy number and phone number. Would need a copy of the death certificate sent to the company.An email dated 9/29/25 at 3:46 p.m. documented the SSD wanted to email the POA so it was in writing and a visual for her. The SSD had been working on gathering all of the resident's items for the Medicaid application with him. The things they discovered included a final expense policy with a cash value of an estimated $3,277.81, and a face value of $15,000 (would likely need to be cashed out to get him below resources). The SSD waited on documents including the life insurance. Once she had them she should be able submit the Medicaid application. The resident was okay with cashing out the final expense plan, if the POA was as well. It would take a little bit of time for the transaction to be completed.The POA responded asking what the SSD meant cashing out his policy, as she needed to do this.In an email from the SSD to the resident's POA regarding a Medicaid application update on 9/30/25 at 10 a.m. the SSD wrote the resident must be below $2,000 in assets in order to submit. The SSD could assist the resident with it, just wanted the POA aware. The POA thought it was a supplemental policy. When they called it was a final expense policy.An insurance company Request for Cash Surrender Value of Policy contained the resident's signature, and the SSD signature for the witness dated 10/15/25.The clinical record lacked documentation of the resident's cognitive status when he signed the cash surrender policy.On 1/7/25 at 12:23 p.m. the SSD stated she had contact with the resident's daughter via email and in person about the resident's life insurance policy. She thought when they talked, the POA was okay with him cashing out the insurance policy. The resident was ok with it. They needed to spend down if he wanted to get on Medicaid. She said the resident's BIMS was in the moderately impaired category, but in the upper end. She said when his daughter came in she was very upset with her about doing this. The SSD said she had no documentation of how she proceeded. She did not document dates or times when she talked to the resident's POA. On 1/8/25 at 10:05 a.m. the resident's POA stated the resident did not want to cancel his life insurance policy. The POA said when the SSD said they needed to do this, she told her to wait until she could get in touch with the insurance company to see what they could do. She said the insurance company would not give her the information until they had the POA papers. She faxed them, then she had to send them via certified mail. She said she found out the insurance was cancelled from the company. She was very upset. There were other options. She said the resident's mental status had declined and he was not in a condition to make that decision. She said if the resident had understood what it meant, he would not have signed the paper.On 1/8/25 at 12:50 p.m. the corporate Medicaid Service Coordinator stated when spending assets down to under $2,000 they had to look at everything. She said there were several options for life insurance; cashing out the policy, buyout of the policy with a different owner, and an irrevocable burial fund. It was her understanding the resident had a high enough BIMS and was able to make this decision himself.On 1/8/25 at 2:30 p.m. during the exit conference the SSD stated not being aware of the buyout option. She said the POA had applied a CD to the burial fund.

Based on record review and staff interview, the facility failed ensure an As Needed (PRN) psychotropic medication was only continued after 14 days with a provider written rationale and end date for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 47 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Diagnoses included atrial fibrillation, cirrhosis, arthritis, and repeated falls. A New Prescription Summary dated 9/25/25 documented an order for Lorazepam/Ativan 0.25 mg by mouth every 4 hours PRN for anxiety.An order dated 10/2/25 changed the Lorazepam 0.25 mg, from every 4 hours PRN, to every 2 hours PRN with no rationale for continuing and no end date.The Medication Administration Record for October showed the PRN Lorazepam 0.25 mg administered 19 times through the 28th, and 11 of those times were ineffective.On 1/7/25 at 8:46 a.m. the Director of Nursing (DON) said family didn't want the resident on the psych meds. She said they tried all the non-pharmacological interventions before administering meds because that was what the family wanted. The DON stated she did not think they gave a rationale or end date to continue the PRN Lorazepam.The facility policy, Usage for Psychotropic Medications Guidance, revised 3/25, documented PRN use of psychotropics (excluding antipsychotics) to 14 days unless extended by the attending physician with a documented rationale.

Based on record review, staff interview, and policy review, the facility failed to ensure interventions were in place to prevent falls, and failed to ensure the completion of neuro assessments after falls for 1 of 3 resident's reviewed (Resident #4). The facility reported a census of 47 residents.Findings include:1.According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required partial/moderate assist with oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, sit to stand, and chair/bed-to-chair transfer. Diagnoses included atrial fibrillation, cirrhosis, arthritis, and repeated falls. The Care Plan with a goal target date of 1/4/26 identified the resident at risk for falls related to impaired cognition and recent falls. The resident's goal to minimize the risk for falls. Interventions included the resident to wear gripper socks in bed.The Progress Notes dated 10/16/25 at 8:05 p.m. documented Resident #4 was in bed with the bed in lowest position. Resident with grippy socks on and was noted as staff walked by laying on the floor between the bed and the wall. The resident gripped the curtains. The resident answered simple questions of yes or no, but not able to verbalize what he attempted to do. Relevant interventions in place at the time of the incident included the resident had on grippy socks on. The Progress Notes dated 10/19/25 at 1:55 a.m. documented the nurse was called into the room. The resident in the room by his dresser, on the floor leaning on his left arm, holding himself up. The resident stated he did not hit his head, but his left arm hurt. The nurse noted a skin tear on his left arm near his elbow 4x3 cm. It took 3 staff to get the resident up with a gait belt into the wheelchair. Education given to staff, that the resident needed to wear proper footwear, grippy socks or shoes at all times, even in bed. 2. The Progress Notes dated 10/16/25 at 8:05 p.m. documented Resident #4 laid on the floor between the bed and the wall. The resident gripped the curtains. The resident answered simple questions of yes or no, but not able to verbalize what he attempted to do. A Neurological Evaluation Flow Sheet (Double Sided) initiated 10/16/25 at 8 p.m. documented results of the post fall assessments for Resident #4. The flowsheet lacked completed assessments on 10/17/25 at 12 a.m., 1 a.m. 4 a.m., and 5 a.m. indicating the resident sleeping. An entry for 10/17/25 2-10, and 10-6 documented sleeping but included vital signs, and the 2-10 column included pupil size and reaction while the resident slept.The Progress Notes dated 11/19/25 at 6:45 p.m. documented the ADON summoned the nurse. Upon approaching, observed the resident sitting on his buttocks on the floor, facing the med room door. The resident's bilateral lower extremities (BLE) flexed out in front of him and bilateral upper extremities (BUE) flexed at his sides. The resident's wheel chair sat behind him. A Neurological Evaluation Flow Sheet initiated 11/19/25 at 6:45 p.m. documented results of the post fall assessments for Resident #4. The flow sheet lacked completed assessments on 11/21/25 at 12:45 a.m., and 11/22/25 at 12:45 a.m. indicating the resident sleeping. On 1/7/25 at 1:32 p.m. the Director of Nursing (DON) stated the neuro sheets needed to be filled out completely. At times hospice may ask a resident be allowed to sleep through the neuros, but they did not do that for this resident that they she knew of. The facility Fall Occurrence policy revised 2/2024 documented the procedure included an incident would be completed each time a resident had a fall. Neurological assessments would be initiated for unwitnessed falls and/or falls that were witnessed and the resident hit their head (neuros completed as directed on neuro flowsheet). Documentation and monitoring to be completed for 72 hours post fall. Complete neurological evaluation with vital signs initially, then every 30 minutes X 4, then every hour X 4, then every 8 hours X 9 (72 hours). More frequent evaluations may be necessary. Complete episodic charting for at least 72 hours including any pertinent evaluation findings related to the neurological evaluation. Review the most recent evaluation on the medical record and notify the Physician of any changes from the previous evaluation.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 resident's reviewed (Resident #1). The facility reported a census of 43 residents. Resident #1 had wounds that were deteriorating. The resident was seen in the wound center. The facility sent the assessment of the wound in a fax to the PCP on 8/21/25 and wrote the resident would be seen in the wound center 8/22/25. The PCP replied okay. The PCP was not the wound center provider. The resident did not have an appointment on 8/22/25. The facility did not follow up until 8/27/25 with an assessment. The fax notified the wound center physician that the wound deteriorated and had a foul odor. The physician ordered a different treatment until seen on 8/29/25. The nurse who did the assessment had hoped he would want to see her sooner, but did not convey that in the fax. The resident admitted to the hospital 8/28/25 in respiratory distress, with fever and a large buttock ulcer, which likely caused her symptoms. The resident became septic (a life threatening complication of an infection). Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. The resident had diagnoses including a stroke with hemiplegia (paralysis of 1 side of the body) of the right dominant side.The Care Plan identified the resident at risk for alteration in skin integrity related to immobility, right sided weakness Status Post (S/P) stroke, anticoagulant and antiplatelet usage. On 7/30 pressure ulcer R buttock, and 8/15 pressure ulcer L buttock. Interventions included: Administering medications as ordered, administering treatment per physician orders, barrier cream to peri area/buttocks as needed, educating the resident and/or family/caregiver as to causes of skin breakdown, including transfers/positioning requirements, encouraging good nutrition and hydration in order to promote healthier skin, encouraging to reposition, following facility policies/protocols for the prevention/treatment of skin breakdown, observing skin condition with care, pressure reducing device on bed, pressure reducing device on chair, providing preventative skin care, using pillows/positioning devices as needed.The Progress Notes documented the following: a. On 7/31/25 at 9:32 a.m. a reddish-purplish colored area remained on the resident's left upper buttock due to Moisture Associated Skin Damage (MASD). The skin was peeling over this area with yellowish colored drainage and the Mepilex saturated. They used a Mepilex dressing to this area for protection on bath days. They questioned changing the Mepilex dressing daily to this area, start Vitamin C 500 mg, Zinc 50 mg daily, and 4 oz of supplement 2 times a day, to promote wound healing. b. On 7/31/25 at 4:01 p.m. a fax received from the Primary Care Provider (PCP) regarding the compromised area on the left upper buttock. New orders included changing the Mepilex dressing daily to the area, and starting Vitamin C, Zinc, and supplement. c. On 8/4/25 at 10:51 a.m. the open area to the resident's left buttock was purple, with blisters, appearing to turn into a pressure area. A moderate amount of drainage to the area, and the Mepilex saturated this a.m. The resident had pain when touched the area. Asked for an order to have the resident seen at the wound clinic. d. On 8/4/25 at 3:46 p.m. the fax returned regarding an order for the resident to be seen at the wound clinic for the open area to her buttock. The physician responded yes. e. On 8/7/25 at 11:33 a.m. a weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock. The skin was peeling over the area with serous drainage. The area had deteriorated and measured 8.2 cm x 8 cm. They used a Mepilex dressing to the area daily. She also had a red 1.2 cm x 1.3 cm blanchable area on her left buttock with intact skin. Moisture barrier cream applied to the area. She would be seen in the wound clinic the next day. They would continue to monitor the area. f. On 8/7/25 at 9:19 p.m. received a fax regarding the resident's weekly skin assessment. The physician responded agree. g. On 8/8/25 at 11:25 a.m. the resident returned from the wound care appointment with a new order for Santyl ointment to the right buttock wound and cover with Mepilex 3 times per week. h. On 8/14/25 at 9:01 a.m. the weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock with the skin peeling, serous drainage, and some yellow slough. The area remained the same and measured 8.2 cm x 8 cm. She also has a reddish-purple 2.2 cm x 2.2 cm area that had deteriorated on her left buttock with intact skin. Moisture barrier cream applied to the area. She would be seen in the wound clinic the following day. They would continue to monitor the area. i. On 8/15/25 at 12:36 p.m. the resident went to the wound clinic with orders for Santyl & Mepilex to the right buttock and sacrum 3 times a week and as needed (prn). Aquacel AG/small Mepilex border to the left buttock 3 times a week and prn. Follow up appointment 8/29/25 at 9:30 a.m. Family notified and planned to go with the resident to the appointment. j. On 8/18/25 at 6:27 p.m. a communication with the physician, changed the resident's left upper buttock dressing due to soiling. The area measured 3.3 cm x 2 cm, the wound edges were reddened, the wound bed had eschar, exudate moderate/purulent with foul odor. Area cleaned and patted dry, and Aquacel ag, and Mepilex border applied. Asked if had any other suggestions.Changed dressing to right upper buttock due to soiling. The area measured 8.7 cm x 10.7 cm with a moderate amount of purulent exudate with a foul odor, wound edges reddened and wound bed had eschar. Cleaned the area patted dry and Santyl and a Mepilex border applied. Asked if had any other suggestions, k. On 8/19/25 at 6:33 p.m. received a fax regarding dressing change and findings. The physician replied with he would continue the same dressing change, and prn when soiled until Friday (8/22/25). The fax returned by the wound center physician on 8/19/25 included follow up on Friday (8/22/25). l. On 8/21/25 at 3:54 p.m. the weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock with some yellow slough and measured 2.7 cm x 2 cm. She also had an open area that measured 8 cm x 10.5 cm that had deteriorated on her right buttock with yellow slough around the edges and brown discolored skin in the center. She would be seen in the wound clinic the following day. They would continue to monitor. The fax with the above information returned by the Primary Care Provider on 8/22/25 read okay. The clinical record lacked documentation the resident had an appointment at the wound center on 8/22/25, or follow up on the wound status. The clinical record lacked documentation the facility notified the wound center physician of the deteriorating wound. m. On 8/27/25 at 7:18 a.m. a weekly skin assessment documented an open area remained on the resident's left upper buttock with yellow slough around the edges and a brown colored center. The area measured 2.7 cm x 2 cm. She also had an open area that measured 8 cm x 9.9 cm with a depth of 1 cm, that had deteriorated on her right buttock with yellow slough around the edges and brown discolored skin in the center, and the areas were lifting around the edges and had a very foul odor. They would continue to monitor the area. n. On 8/27/25 at 12:53 p.m. received a new order for the wound to the resident's left buttock. The fax returned by the wound center physician on 8/27/25 read okay, would see her Friday, and use a dressing with Dakin's solution daily. o. On 8/28/25 at 2:25 p.m. the resident had labored breath sounds, with wheezing heard bilaterally. The head of the bed elevated to prevent shortness of breath. A Foley catheter remained in place. Bowel sounds present in all 4 quadrants. Abdomen soft and non- tender. The resident alert and oriented to self only. Speech and respirations labored. The resident denied pain or shortness of breath when asked. Call placed to PCP and received the okay to send the resident to the emergency room (ER) by ambulance. Call received from ER notifying the resident admitted through the weekend for intravenous (IV) antibiotics. p. On 8/28/25 at 3:08 p.m. the transfer to the hospital summary included the resident's vitals were temperature 103.5 (norm 97-99), pulse 114 (norm 60-100), respirations 28 (norm 12-18), blood pressure 166/108 (high), and pulse oximetry 95% on room air. Breathing was labored and lung sounds with course crackles bilaterally.The Hospitalization report dated 8/29/25 at 3:55 p.m. documented the resident admitted with respiratory distress, fever and a large right buttock ulcer. The resident had urine, blood and wound cultures done in the ER before starting IV antibiotics. The resident had gradually developed a large right buttock ulcer after having a stroke, causing right hemiparesis and expressive aphasia (loss of ability to produce language). She was on oral antibiotics based on her last wound culture results before coming to the hospital. At the hospital they started the resident on Rocephin 1 gm every 12 hours and Vancomycin 1500 mg daily. Albumen 25 mg was added to her medications due to poor nutritional status and hypoalbuminemia. The resident's family preferred a larger hospital for her care where she could have advanced wound care for her large buttock ulcer which likely caused her symptoms. Prior to her transfer the resident had an episode of atrial fibrillation with rapid ventricular response requiring IV medication for heart rate control, IV Lasix, morphine and oxygen with a mask for her respiratory distress. She also had a dose of IV Tylenol for the fever. Her heart rate and blood pressure stabilized by the time she transferred. Prior to the resident's transfer, her blood cultures became positive. The principal diagnosis on discharge was sepsis with acute respiratory failure, and the active problems included open wound of right buttock with complication.On 9/3/25 at 9:07 a.m. Staff A Licensed Practical Nurse (LPN) stated the day she sent Resident #1 out she thought she was having respiratory issues. She had vitals that were high, her blood pressure pulse and respirations. After she sent the resident, out she received a return call later from a Registered Nurse (RN) at the hospital stating they were keeping for her bottom, and she would be on IV antibiotics. Staff A stated the day she sent her out she hadn't looked at her bottom because she was quite concerned about the condition she found her in. She said she had never done the dressing to the resident's bottom because she had just recently oriented to a nursing position. She said she had worked at the facility for years and just recently became an LPN. She said she did see the dressing change when orienting but she did not know the date that she saw it. She said the wound appeared to be large and appeared to have purulent drainage. She said the resident did not express pain during the treatment change. She was not sure which buttock that would have been on.On 9/3/25 at 11:30 a.m. Staff B LPN stated when she looked at the wound and did the dressing change on 8/27 the smaller one seemed the same. The other one appeared deeper and the edges were starting to come off and she was draining serous drainage although it was hard to tell if it was actually drainage or some of what they were putting in the wound.On 9/3/25 at 12:20 p.m. Staff C LPN Stated she was doing the wound assessment every week since the MDS coordinator left for vacation, and then decided not to come back. She said she did this normally on Thursdays and then she would fax the doctors with the results. She said the resident's wounds had been deteriorating and she had done the assessments on a Wednesday prior to 8/29/25 and the wound stunk. She sent a fax to the doctor and he returned with using Dakin's solution until he saw her on the 29th. She had hoped that he would want to see her before that. Regarding whether the resident had an appointment on the 22nd, she said she wasn't sure. She said it's possible she looked at the wrong week and that's why she thought there was one, but she couldn't say for sure.On 9/3/25 12:47 p.m. Staff D LPN stated between the last two times she had seen the resident's bottom, it had gotten much worse. She said it had opened up and it was deeper. She said between the two times it had gone from being changed twice a week to daily. She doesn't remember odor but she had drainage. In the last two days she worked there was a lot more drainage. She said she had to call the resident's family member to let her know about a new order regarding her potassium and she talked to her at that time about the wound, and the family member was going to her next appointment with her. On 94/25 at 9:10 a.m. the Provisional Administrator confirmed the resident did not have an appointment on 8/22/25 at the wound center.The facility undated Skin Management policy documented the potential ongoing management strategies may include risk factor management interventions including management of acute changes in the resident's condition.

Based on observation, record review, and staff interview, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #2). Resident #1 fell on 7/10/25 fracturing his right elbow that would require surgical repair, and a laceration near his right eye requiring 7 sutures. The resident had a pressure alarm that did not sound to alert staff the resident was getting up without assistance. Staff failed to determine why the alarm did not sound. On 7/11/25 the resident fell again fracturing his left elbow, also requiring surgical repair. The resident's pressure alarm again failed to sound to alert staff the resident was getting up. The facility reported a census of 43 residents. Findings include:The Care Plan documented Resident #2 admitted to the facility on [DATE]. The Care Plan identified the resident had impaired cognitive function, and at risk for falls, on 7/10/25 at 10:30 a.m. fall with no injury, on 7/10/25 at 2:07 p.m. fall with right eyebrow laceration, fracture right elbow, on 7/11/25 at 6:10 a.m. fall with left elbow fracture, left eyebrow laceration, pain in left wrist. On 7/10/25 door alarm initiated and moved to a closer room to the nurse's station.The Progress Notes documented the following: a. On 7/10/25 at 10:30 a.m. the aides summoned the nurse when the resident was found in a sitting position in the opposite room. The resident went to the emergency room for evaluation. b. On 7/10/25 at 2:07 p.m. the resident was found in a sitting position in the room across the hall. The resident was unable to move his right upper extremity. The resident's eye lid on the right side (swelling hemorrhaging). Certified Nursing Assistants (CNA's) held a cold washcloth to the site of his face. Relevant interventions in place at the time of the incident: included a bed alarm.Preliminary Recommendations, if any, for consideration as further preventative measures was a door alarm. c. On 7/10/25 at 2:59 p.m. received a call from hospital. The nurse reported resident had a laceration to his right eyebrow that was sutured. The resident had 7 sutures needing removal in one week. Suture care instructions being sent back with resident. Nurse also reports the resident broke his right elbow in multiple locations and would need surgery. Prior to surgery, the resident needed cardiac clearance. Appointment set up with cardiology for July 16th at 8:45 a.m. They called to schedule a surgery appointment on July 17th. The nurse at the hospital reported the resident had splint and sling in place, the elbow would need to be kept at 90 degrees. The resident could continue same medications, and able to return to the facility at that time. d. On 7/10/25 at 3:13 p.m. received paperwork upon resident's return. Suture instructions: keep wound clean and dry, use hydrogen peroxide and water soaked gauze to wipe clean every day. The goal of each cleaning was to get it back to just stitches and skin, not letting a scab form. They should dress the laceration with antibiotic ointment, and cover with bandages if it could get dirty. No prolonged soaks until healed, quick showers were okay, patting dry afterwards. Stitches out in 7 days, monitor for infection. Tylenol if needed for temp or discomfort. No instructions for splint care. e. On 7/11/25 at 8:03 a.m. the nurse was called into the resident's room at 6:10 a.m.by the CNAs while they were doing physical rounds and saw the resident on the floor face down. No alarm sounded. The fall was not witnessed. It took 2 staff with a gait belt to assist the resident up and into his recliner with a walker. The resident had a slow, unsteady gait. The resident wore his gripper socks. It appeared the resident used his walker at the time of the incident. The floor was dry other than the blood that came from the resident's injures after the fall. The resident was last checked at 4 a.m. and was not incontinent of bowel and the catheter emptied. The resident stated he tried to hold himself up when asked what he was attempting to do. The resident bled from the previous injury to his right eye brow and a new injury to the left eyebrow. The nurse had previously laid eyes on the resident at 5:50 a.m. and he rested in bed. The resident had full range of motion (ROM) to his extremities other than his right arm that had a previous injury to his elbow. He did not complain of discomfort while having resident do ROM other than slight discomfort in his left wrist. Neuros initiated and pupils sluggish. The resident complained of pain in his nose, lower back, and left wrist. The resident got a laceration to his left eyebrow. Made resident comfortable and cleaned blood off. The resident had a pressure alarm under him while in bed. This alarm did not sound. The resident had a history of turning his alarms off and/or moving them. Preliminary Recommendations, if any, for consideration as further preventative measures was a bed alarm that attached to the resident and sounded when the resident tried to get up. f. On 7/11/25 at 11:15 a.m. called the hospital to check the status of the resident. The ER nurse informed the resident had fractured his left elbow. g. On 7/11/25 at 5:55 p.m. a hospital nurse called and stated the resident admitted with possible return 7/12 or 7/13/25. h. On 7/13/25 at 10:30a.m. the resident returned to the facility. Both arms were in splints with ace wrap form his hands to the upper arm bilat. The resident could move his shoulders and legs. He did not reach with his arms. Fingernails were slightly pale but had + capillary refill (quick medical assessment that measured how quickly blood returned to the capillaries (tiny blood vessels) in the skin, used to evaluate circulation). A hospital after visit summary dated 7/10/25 documented the resident seen for right elbow fracture and right eyebrow laceration. The resident had a right eyebrow laceration repair. Return to care facility instructions included: Sutures out in 7 days, right elbow with posterior splint and sling for support, loosen and reapply if too restrictive. The resident's chart needed labeled a fall risk. An x-ray of the right elbow on 7/10/25 at 9:50 a.m. showed a fracture traversing the base of the olecranon process. There was posterior and proximal migration of the proximal fracture fragment with separation of fragments by at least 2.6 cm. Discussed the case with orthopedics. The resident would need surgical intervention on this. He would need cardiac clearance first. Appointment set up 7/16/25 at 8:45 a.m. A hospital report dated 7/11/25 at 7:05 a.m. documented the resident presented to the ER via ambulance from the care facility secondary to a fall. The resident had been well at morning rounds and a few minutes later he apparently decided to get up and fell in his room. He apparently had a piled enough stuff on his bed alarm so it did not go off. He had a small laceration by the left eyebrow and swelling to the left elbow.An x-ray of the left elbow on 7/11/25 at 8:34 a.m. showed an acute mildly displaced intra-articular fracture of the olecranon. There was prominent dorsal soft tissue swelling. Discussed with the orthopedist and the resident would be scheduled for surgery on his left elbow in conjunction with the prior arranged surgery to the right elbow. These were nearly identical fractures sustained on consecutive days. Resident at significant risk for fall secondary to events of the last 2 days. The resident admitted to the hospital.On 9/3/25 at 9:38 a.m. Staff E Registered Nurse (RN) stated the resident fell on 7/10 around 9 a.m. He had been in bed prior to the fall. He did have an alarm on his bed but, he did not know if the alarm sounded at the time of the fall. He said he just charted it a little bit in the morning and then did a much more in depth documentation that afternoon. On 9/3/25 at 12:12 p.m. Staff F Certified Nursing Assistant (CNA) stated all she knew was that when they went to get the resident to take him to breakfast he wasn't there. They let them know that they needed to look for him and so they started a search, but it didn't take very long for them to find him he was just across the hall in another room. On 9/3/25 at 1:43 p.m. Staff G CNA stated she was the full-time bath aid but she had been called to work on the floor for a couple hours that day. Someone called over the walkie that the resident needed to come out for breakfast. She went to his room and he wasn't in there, and he wasn't in the bathroom, and she said well he's not in his room. They decided they needed to search for him which didn't take very long because he was across the hall. She didn't even know he could walk. She said his alarm did not sound that morning. Staff G said she didn't know why the alarm didn't go off that morning she never found out. On 9/3/25 at 1:51 p.m. Staff H CNA stated she did not hear the alarm sound, and she did not know why it did not.On 9/4/25 at 9:29 a.m. Staff G Licensed Practical Nurse (LPN) stated the resident had the alarm in place on 7/11/25 but it did not sound. She said either they did not turn it on the night before or the resident had turned it off himself. She said she thought he had learned how to turn it off. She said he now had another alarm hooked to him that sounded if he pulled away from it. She said the alarm was in place so when he was getting up they would know, and respond.The undated facility Fall Occurrence policy documented the purpose to ensure residents were evaluated for fall risks and implemented interventions to minimize the risk for falls and/or the risk for injury from falls.

Based record review and staff interview, the facility failed to notify the resident's representative of a change in condition for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 43 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. The resident had diagnoses including a stroke with hemiplegia of the right dominant side.The Care Plan identified the resident at risk for alteration in skin integrity related to immobility, right sided weakness Status Post (S/P) stroke, anticoagulant and antiplatelet usage. On 7/30/25 pressure ulcer right buttock, and 8/15/25 pressure ulcer left buttock. A Concern Form dated 8/29/25 documented Resident #1's family member gave a verbal in person report. She felt the facility had not notified her of the resident's wound worsening.The Progress Notes dated 8/21/25 at 3:54 p.m. documented the weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock with some yellow slough and measured 2.7 cm x 2 cm. She also had an open area measuring 8 cm x 10.5 cm that had deteriorated on her right buttock, with yellow slough around the edges and brown discolored skin in the center. The fax with the above information returned by the Primary Care Provider on 8/22/25 showed physician notification. The clinical record lacked documentation the resident representative received notification of the change in the wound.On 9/3/25 at 12:20 p.m. Staff C Licensed Practical Nurse (LPN) stated she normally did wound assessments on Thursdays and then she would fax the doctors with the results. She said the resident's wounds had been deteriorating.The facility Notification for Change of Condition policy revised 6/2023 identified the facility would provide care to residents and provide notification of resident change in status. The facility must immediately inform the resident; consult with the resident's physician, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status.

Based on observation, resident and staff interviews, clinical record review, and policy review, the facility failed to develop and implement a Comprehensive Care Plan for 4 of 12 residents reviewed (Resident #4, #15, #16, #22). The Care Plans failed to identify target behaviors related to the use of psychotropic, antianxiety, and antidepressant medications, and non-pharmalogical interventions. The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 12/13/24 identified a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The MDS included diagnoses of anxiety, depression, and Non-Alzheimer's Dementia. The document identified little interest or pleasure in doing things 2-6 days in the reporting period, rarely lonely or isolated from those around. The MDS identified Resident #4 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #4's Electronic Medical Record (EMR) Physician Orders dated 3/6/25 identified the resident was prescribed; a.) Quetiapine Fumarate 25 mg - .5 tablet once daily for dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbance, b.) Lexapro 5 mg - 2.5 mg once daily for depression unspecified. The Physician Orders did not identify target behaviors related to the medications prescribed. An EMR Progress Note dated 7/17/24 identified refusal of care. Resident #4's Care Plan initiated 9/14/23 identified a focus area related to utilization of a psychotropic medication in the category of antipsychotic and antidepressant. The document identified interventions including side effects, monitor behaviors per facility protocol, monitor for changes in cognition, mood and behaviors. The Care Plan failed to identify target behaviors related to the use of psychotropic medications, non-pharmalogical interventions, and the side effects of medications. The Care Plan failed to have a focus area with goal(s), and interventions related to the diagnosis of dementia. 2. The MDS for Resident #15 dated 1/22/25 identified a BIMS score of 15/15 indicating normal cognition. The MDS included diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The document identified no signs/symptoms of feeling down, depressed or hopeless, social isolation, delusions, hallucinations, rejection of care or wandering. The MDS identified Resident #15 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #15's EMR Physician Orders dated 3/5/25 identified the resident was prescribed; a.) Buspirone HCI 10 mg 1 time/day for anxiety disorder, unspecified and major depressive disorder, single episode unspecified, b.) Buspirone HCI 15 mg 3 times/day for anxiety, c.) Lexapro 30 mg 1 time/day for major depressive disorder, single episode unspecified, d.) Bupropion HCI ER (XL) 24 hour 300 mg 1 time/day for depression, e.) Trazodone HCI 50 mg .5 tablet 1 time/day for major depressive disorder, single episode unspecified, f.) Abilify 1 mg 1 time/day for major depressive disorder, single episode unspecified, The Physician Orders did not identify target behaviors related to the medications prescribed. The EMR Progress Notes dated 5/1/24 to 3/5/25 revealed Resident #15 displayed behaviors of complaints of not getting what she wants related to smoking, ignoring staff when attempting to assist, history of frequent complaints and anger with staff, refusal of assessment, and yelling at staff. Resident #15's Care Plan identified the use of a psychotropic medication in the category of antipsychotic/ antidepressant, and anti-anxiety related to anxiety and depression diagnoses. Interventions for staff to follow revealed medications as ordered, side effects and complications, ensuring the diagnosis corresponds with medication prescribed, non-pharmalogical interventions, monitor behaviors per facility protocol, cognition, mood, and behavior. The Care Plan failed to identify the target behaviors related to the use of antipsychotic medications and anxiety. 3. The MDS for Resident #16 dated 1/22/25 identified a BIMS score of 15/15 indicating normal cognition. The MDS included diagnoses of anxiety disorder, depression, schizophrenia, and post traumatic stress disorder. The document identified the resident feeling down, depressed or hopeless during the previous 7-11 days, poor appetite or overeating 7-11 days, feeling bad about oneself 2-6 days, sometimes feeling lonely or isolated from others. The document revealed no behaviors, rejection of care or wandering. The MDS identified Resident #16 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of Resident #16's EMR Physician Orders dated 3/5/25 identified Resident #16 was prescribed a.) Sertraline 50 mg 1 tablet day related to major depressive disorder, b.) Lamotrigine 200 mg 1 tablet day related to schizoaffective disorder, bipolar type, c.) Invega Oral Tablet Extended Release 24 hour 6 mg 1 tablet day related to schizoaffective disorder, bipolar type The Physician Orders did not identify target behaviors related to the medications prescribed. The EMR Progress Notes dated 1/25/25 to 3/5/25 revealed Resident #16 displayed no behaviors. Resident #16's Care Plan revealed the utilization of psychotropic medication in the category of antipsychotic/antidepressant related to schizoaffective disorder, depression. The Care Plan revealed interventions for staff included side effects, use of non-pharmalogical interventions, and monitoring behaviors per facility protocol. The facility failed to identify target behaviors related to the use of psychotropic medications and schizoaffective and depression diagnoses in the Care Plan. 4. The MDS for Resident #22 dated 12/20/24 identified a BIMS score of 13/15 indicating normal cognition. The MDS included diagnoses of anxiety, depression, bipolar, and psychotic disorder. The document identified no signs/symptoms of feeling down, depressed or hopeless, social isolation, delusions, hallucinations, rejection of care or wandering. The MDS identified Resident #22 took antipsychotic and antidepressant medications during the last 7 days of the assessment period. Review of the EMR Physician Orders dated 3/5/25 identified Resident #22 was prescribed; a.) Seroquel 25 mg 1 tab at bedtime for generalized anxiety disorder, delusional disorder, b.) Amitriptyline HCI 50 mg one time day for depression, c.) Duloxetine HCI 60 mg one time/day for depression. The Physician Orders did not identify target behaviors related to the medications prescribed. The EMR Progress Notes dated 5/1/24 to 3/5/25 revealed Resident #22 had 2 episodes of depression without the symptoms of depression. The Progress Notes did not identify target behaviors. Resident #22's Care Plan revealed the utilization of psychotropic medication in the category of antipsychotic/antidepressant related to depression and anxiety. The Care Plan revealed the interventions for staff included side effects, monitoring behaviors per facility protocol, and monitoring for changes in mood, cognition, and behavior. The facility failed to identify target behaviors related to the use of psychotropic medications with anxiety and depression diagnoses in the Care Plan. On 3/6/25 at 8:07 AM the Administrator and the Director of Nursing (DON) stated some residents have Behavior Management Plans that were developed by the Social Worker with the assistance of the psych provider if necessary. The Administrator stated however not every resident had a Behavior Management Plan. The Administrator stated the plans were located in the Narc Book on the medication carts. The Administrator stated those individuals with a Behavior Management Plan also had a sheet that staff mark what behaviors happened during the day. The DON and Administrator acknowledged neither target behaviors nor non-pharmalogical interventions were identified on all the Care Plans. On 3/6/25 at 11:36 AM the Administrator was unable to provide details regarding the statement monitor behaviors per facility protocol identified on the Care Plans. On 3/6/25 at 12:00 PM the Regional Nurse Consultant stated the monitor behaviors per facility protocol was a general statement used by the previous corporation, and the facility was in the process of updating Care Plans to provide more individualized focus areas, goals and interventions. The facility policy, Baseline Care Plan Guidelines V2, Rev 121018, revealed the Care Plan should provide the information needed to safely care for a new resident. The document revealed the interventions needed to match the resident's current needs. The facility policy, Antipsychotic Drug Use, Revised 10/99, revealed the facility would identify the symptoms of the diagnosis requiring antipsychotic,antidepressant drug intervention. The document revealed the Care Plan should be reviewed and updated for interventions related to identified behaviors or symptoms of the diagnosis.

Based on observations, staff interviews, clinical record reviews, and policy reviews the facility failed to review and revise the Care Plan interventions for 2 of 12 residents reviewed (#4, #17). The facility failed to revise Care Plan interventions for a resident who had a change in oxygen use and changed from weight gain to weight loss, and a resident who had a new intervention for fall prevention. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 12/13/24 identified a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The MDS included diagnoses of anxiety, depression, Non-Alzheimer's Dementia, and congestive heart failure (CHF). The MDS identified Resident #4 took antipsychotic and antidepressant medications. The document revealed the resident did not have a weight loss or gain of 5% or more in the past month or loss or gain of 10% or more in the last 6 months. The document revealed the resident did utilize oxygen (O2). a.) The Electronic Medical Record (EMR) Progress Notes 5/1/24 to 3/5/25 revealed on 2/19/25 the Dietitian noted the resident weighed 162.4# triggering for a loss of 19# (10%) since 1/19 weight of 183#, and from 8/23/24 weight of 183#. The entry questioned the accuracy of the 1/19 weight as weights before and after were in the 169-173# range. However the 180 day (6 month) look back revealed a significant weight loss. The entry further revealed notification to the primary care provider (PCP), the resident's BMI was 27 indicating overweight, and the resident had been ill. An entry on 7/23/24 identified a weight warning for weight gain with the resident retaining fluid and requesting small servings during meals. Additionally the resident was triggered for a weight gain on 5/15/24 with the initiation of a diuretic related to CHF. The EMR Weights revealed Resident #4 had daily weights until 2/24 then weights decreased gradually to monthly or twice monthly. The EMR Clinical Physician Orders revealed an order for daily weight for one time a day for edema initiated on 10/10/23 and discontinued on 2/1/24. Resident #4's Care Plan revealed a focus area identifying unplanned/unexpected weight gain related to CHF, bilateral lower extremity (BLE) edema with a creation date of 9/20/23 and revision date of 11/20/24. An intervention for staff to follow included weight daily per PCP order created on 12/20/23 and revised on 11/20/24. The facility failed to update the Care Plan to reflect Resident #4's change from unexpected weight gain to weight loss, and discontinuation of daily weights on 2/1/24. On 3/6/25 at 8:12 AM the Administrator and Director of Nursing (DON) acknowledged the resident's Care Plan neither reflected the current interventions for weighing the resident nor the documentation by the Dietitian in the Progress Notes of the resident having a significant weight loss rather than a weight gain. b.) The EMR Progress Notes 5/1/24 to 3/5/25 revealed Resident #4's use of O2. An entry on 10/23/24 revealed O2 at 2-4 liters(L) per nasal cannula (NC) every shift for titrated O2 to keep sats equal to or greater than 90%. Entry dated 6/22/24 revealed communication with the PCP to increase O2 use to 2-4 L per NC. The EMR Clinical Physician Orders dated 3/6/25 revealed an order for O2 at 2L-4L per NC every shift for titrate O2 to keep saturations equal to or greater than 90% confirmed on 6/22/24. Resident #4's Care Plan revealed a focus area related to CHF with an intervention of continuous humidified O2 on at 2L/NC. The facility failed to update the Care Plan to reflect Resident #4's change of O2 use from continuous 2L to O2 at 2L-4L every shift for titrate to keep saturations equal to or greater than 90%. Observation on 3/3/25 revealed Resident #4 with humidified O2 via NC at 3L while seated in her recliner. Observation on 3/4/25 revealed Resident #4 at the beauty salon with humidified O2 via NC at 3L. On 3/4/25 at 1:08 PM Staff B, Certified Nursing Assistant (CNA)/Bath Aide, stated Resident #4 utilized O2 at all times and staff could turn the concentrator off and on to transport the resident. On 3/4/25 at 1:51 PM Staff C, Registered Nurse (RN), stated the resident used oxygen at all times. However when the staff confirmed with the Clinical Physician Orders, the staff stated the orders reflected titrated oxygen not continuous to keep sats above 90%. On 3/6/25 at 8:15 AM the DON stated the order allowed the nurses to raise the oxygen if necessary to 4L to keep the resident's saturations above 90%. The DON acknowledged the Care Plan did not reflect the order for titration to 4L. 2. The MDS for Resident #17 dated 1/24/25 identified a BIMS score of 4/15 indicating severe cognitive impairment. The MDS included diagnoses of hypertension (high blood pressure) anxiety, Non-Alzheimer's Dementia, and history of falling. The MDS identified Resident #4 took antipsychotic and antiplatelet medications. The document revealed the resident had 1 fall with no injury and 1 fall with injury (except major) since the prior assessment. The document revealed the resident utilized a bed alarm and chair alarm both used daily. On 3/3/25 at 12:32 PM observed Resident #17 in a low bed with a bed pad alarm and bed rails; w/c alarm present on w/c. On 3/4/25 at 1:01 PM observed Resident #17 in a low bed with a bed pad alarm, bed rails, and call light within reach. Resident #17's Care Plan dated 12/2/20 identified a focus area related to not thinking clearly related to back pain with an intervention of an alarm at all times due to attempts to self transfer. The document revealed a focus area related to fall at home sustaining a closed compression fracture and risk for falls related to weakness and restless leg syndrome. Interventions for this focus area included appropriate footwear, self propelling wheelchair (w/c) with leg rests out of way, Dycem to recliner. The document revealed a focus area related to use of grab bars on the bed with the intervention of use of grab bars for impaired mobility and transfer ability. The facility failed to revise the Care Plan to reflect the use of a low bed as a fall intervention. On 3/4/25 at 1:08 PM Staff B stated when the resident goes to bed, it is moved to the low position. The staff were told to lower the bed by nurses, and it was on the Communications Board, part of the EMR. Staff B stated the resident had been utilizing the low bed for awhile. On 3/4/25 at 1:51 PM Staff C stated she would look at the Care Plan for all of Resident #17's fall interventions. When the staff was reviewing the Care Plan, she stated the resident required a low bed for some time, but acknowledged it was not on the Care Plan. Staff C updated the Care Plan during the interview. On 3/4/25 at 3:37 PM Staff D stated fall interventions for Resident #17 included a pressure pad alarm, w/c alarm, and the bed lowered to the floor. On 3/6/25 at 8:17 AM the DON stated Care Plan focus areas and interventions should be added to the Care Plan as they are needed to reflect the resident's current needs and level of care. The DON expected if a new fall intervention was put into place it would be added to the Care Plan at that time. On 3/6/25 at 8:20 AM the Administrator stated she expected the Care Plans to provide interventions that reflected the residents' needs. The Administrator acknowledged that some Care Plans might need updates as there had been a change in staffing and the DON had been covering multiple areas. The facility did not have a policy related to Care Plan revisions. The Administrator indicated the facility followed the Resident Assessment Instrument (RAI) manual for Care Plan updates.

Based on observations, record review, staff interviews, the facility failed to have an emergency tracheostomy kit with obturator at bedside for 1 of 1 residents reviewed (Resident #24). The facility reported a census of 38. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of coronary artery disease, acute respiratory distress, depression, and pneumonia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #24 had a tracheostomy (surgical opening in neck to provide for obstruction of breathing) and required oxygen. Review of the Care Plan with a target date of 5/15/25 revealed Resident #24 has a tracheostomy in place related to malignant neoplasm of the larynx. The Care Plan revealed that the facility would maintain a spare trach at the bedside. The Care Plan failed to have documentation that Resident #24 would fiddle with the emergency trach kit while it was in the room. Review of the facility provided tracheostomy guidelines for Resident #24 that are kept in the narcotic binder at the nurses medication cart titled Tube Out Procedures revealed that the extra tracheostomy tube and obturator will be kept at bedside. Observations of the residents room on 3/3/25 at 1:00 PM and 3/6/25 at 12:05 PM revealed no emergency tracheostomy set with an obturator kept in the room. Interview on 3/6/25 at 12:05 PM, Staff A, License Practical Nurse (LPN) stated the facility keeps the extra tracheostomy set up at the nurses station. When asked about the agency nurses and how they would know where to locate it if there was an emergency, Staff A responded that she would report where it was kept during nurse to nurse report. Interview on 3/6/25 at 12:15 PM with the DON, acknowledged they don't keep the emergency trach kit in the room because Resident #24 is independent with ambulation and is able to get up and fiddles with items throughout his room and it wouldn't stay clean. Interview on 3/5/25 at 11:20 AM with the Administrator stated the facility does not have a tracheostomy policy.

Based on observation, record review, and staff interview, the facility failed to assure adequate pressure reduction interventions and complete a dietary assessment related to the new onset of pressure ulcers for 1 of 4 residents reviewed (Resident #12). The facility reported a census of 46 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #12 demonstrated long and short term memory problems and moderately impaired skills for daily decision making. The resident required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. The resident's [DIAGNOSES REDACTED]. The resident had no pressure ulcers but had the risk for developing pressure ulcers. The MDS described pressure sores as the following: Stage I is an 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. (MONTH) 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. (MONTH) include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable: known but not stageable due to coverage of wound bed by slough and/or eschar. The Progress Notes dated 8/23/18 at 10:36 a.m. documented the resident transferred to the hospital. At 2:45 p.m. the facility inquired about the resident and found he admitted for observation. A Plan of Care from the resident's hospital stay dated 8/23/18 at 3:44 p.m. documented the resident's heels were scaly and purple in color. The resident repositioned every 2 hours and heels elevated/floated on a pillow. A Progress Note dated 8/25/18 and faxed 8/25/18 notified the physician the resident returned from the hospital with a blister like stage 2 area of the left heel measuring 3.5 by 3 cm. The resident had an open area of the scrotum and the coccyx with 1 by 1 and 1 by 0.5 cm purple areas that were suspected deep tissue injury. They would encourage the resident to float heel when in bed. A Braden Scale For Predicting Pressure Ulcer Risk dated 8/25/18 scored the resident at 13 indicating moderate risk. The assessment included the resident had very limited mobility, making occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, and had a problem with friction and shear. The undated Care Plan with a goal target date of 8/31/18 identified the resident with the potential for pressure ulcer with interventions including to attempt to float heels with a pillow when in bed as allowed, cushion in wheelchair, and pressure relieving mattress on the bed. The care plan included the intervention for supplement for weight maintenance and skin healing (interventions in place prior to the new pressure ulcer development). During an interview on 10/2/18 at 2:03 p.m. Staff B Registered Nurse (RN ) stated the resident had a standard pressure reduction mattress on return from the hospital. The Care Plan lacked any new interventions for pressure reduction related to the new pressure ulcers, or interventions for protecting the heels when not in bed. The clinical record lacked documentation of whether they were able to float the resident's heels, or of a turning or repositioning program. A Progress Note dated 9/12/17, communication with the physician at 2:42 p.m. documented the resident's left heel, stage 2 pressure area had opened up, and a large skin flap came off. There was a new area on the resident's right heel, a stage 1, skin intact over the site, non blanchable area 2 by 1.8 cm and a new area over the outer aspect of the right foot, measuring 2 by 1 cm, dark purple, also a stage 1. A Weekly Pressure Ulcer Progress Report dated 9/12/18 documented the right heel measured 2 by 1.8 cm, dark purple, stage 1. The report defined suspected deep tissue injury: purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear. The Progress Note dated 9/12/17 included in a facsimile (fax) on 9/17/18 notified the physician of the 9/12/18 documentation and questioned if he would like to continue the treatment, and the right foot was open to air. The note documented blue boots would be utilized at all times to decrease pressure with a foot cradle on the bed. An Edit Intervention document showed the blue boots on at all times, initiated 9/12/18 (the date the pressure ulcer of the right heel discovered). A Nursing Home visit dated 9/25/18 documented the resident seen for follow up of ulcers of both heels. Both heels had necrotic (dead) tissue, with the plan to have a wound care consult for the heel ulcers. A Progress Note dated 9/28/18 at 2:22 p.m. documented the resident out of the facility to the wound clinic at 11:40 and returned at 1:10 p.m. The resident returned with orders for a pressure relief mattress to bed, heel lift boots at all times, and keep pressure off areas at all times. The physician also wrote treatment orders and new orders for Zinc, vitamin C and [MEDICATION NAME] daily (supplements for wound healing). A Wound Clinic History and Physical dated 9/28/18 documented the resident's principle problem a stage 3 pressure area of the right heel, with active problems of unstageable pressure ulcers of the right and left heels. During the visit the ulcers were debrided to excise the eschar (necrotic tissue) and exudate from the ulcer surface. Complete removal of the material required extension into and including removing underlying subcutaneous tissue. The depth increased over 0.2 cm with the debridement. The physician recommended continuing the blue boots to help avoid pressure on the area, and also recommended zinc, vitamin C and [MEDICATION NAME] daily to promote healing. The facility clinical record lacked a dietary assessment to determine the resident's nutritional needs related to the development of the pressure ulcers. Discharge Instructions dated 9/28/18 included to keep pressure off areas at all times, and please provide the resident with an air mattress. During an interview on 10/2/18 at 2:03 p.m. Staff B Registered Nurse (RN ) stated they were trying to float the resident's heels when he returned from the hospital (8/25/18) and then they got the heel boots 9/12/18 (when the new ulcer to the right heel identified). During an interview on 10/2/18 at 2:57 p.m. the Corporate Nurse stated the air mattress was initiated 9/28/18 after the physician recommendation. They didn't have specific documentation on the floating of the heels, except what was in the progress notes. She did not think he was on a specific repositioning program. During an observation on 10/3/18 at 8:10 a.m. Staff C Licensed Practical Nurse (LPN), and Staff D Certified Nursing Assistant (CNA) assisted with the dressing change to the resident's heels. The resident laid in bed slightly to the right with a pillow under his legs, and his knees bent. Staff removed the heel boots, and with them off, the resident's heels pressed on the mattress (with the pillow in place under the legs). The left heel ulcer had a black necrotic area surrounded by pink open skin. Staff C confirmed the necrotic tissue. Staff C completed the dressing change using clean technique. Staff C did the same treatment to the lateral right heel ulcer. The ulcer had black necrotic tissue at the upper ridge of the ulcer with the remaining tissue of the ulcer pink. During an interview on 10/3/18 at 8:55 a.m. Staff D stated working at the facility for about 2 years. She stated prior to the heel boots the resident usually had a pillow under his legs, but he also often had his knees bent the way they were this morning. She said if he was on his side his heels were off the mattress. During an interview on 10/3/18 at 1:44 p.m. Staff E CNA stated (prior to the blue boots) they would put a pillow under the resident's legs in bed, but he was stiff and bent his legs so his heels would be on the mattress. It was difficult to float them. During an interview on 10/3/18 at 12:22 p.m. the Director of Nursing (DON) stated the dietician had not assessed the resident in regards to the new pressure ulcers. She stated they usually had the dietician assess a resident with a pressure sore when noted. Review of a Pressure Ulcer Risk Assessment and Documentation policy and Procedure updated (MONTH) 2011, identified the following: Residents will be assessed upon admission and re-admission for potential risk factors that may contribute to pressure ulcer development and interventions will be implemented to reduce that risk. The assigned nurse will complete the Admission and Readmission Pressure Ulcer Risk assessment tool on new admission and readmissions. Determine the factors/conditions that place the resident at risk for developing pressure ulcers. List any additional risk factors/conditions. Determine interventions in conjunction with each risk factor that has potential to reduce both the likelihood of pressure ulcer development and/or improve the clinical condition of the resident. Review the risk factors and interventions with the resident and /or responsible party. The following interventions may be incorporated as deemed pertinent to the resident's condition: Assist with repositioning immobile residents a minimum of approximately every two hours. Positioning devices such as pillows or foam wedges may be used to keep bony prominence from direct contact with each other. May use pillows under the calves of the residents who are immobile to relieve pressure on the heels or suspend heels off the foot of the bed. May use mechanical lifting devices, draw sheets or pads to move residents in bed who cannot assist during transfers and position changes to reduce friction/shearing. Assess nutrition and hydration needs quarterly/significant change to maintain skin integrity; encourage foods/fluids. May use pressure reduction mattress to bed and pressure reduction device to chair. Assess any new pressure ulcer as soon as discovered and document. Notify the dietary manager manager and she will be responsible to initiate dietary interventions. Update the care plan to reflect new interventions to aid in the healing process.

Based on observation, record review, staff and resident interviews and review of the policy and procedures, the facility failed to assure residents at risk for skin breakdown received care to prevent the development of pressure sores (Residents#6, #10). Upon admission to the facility, both Resident #6 and #10, entered without a pressure sore and upon admission, both residents required extensive assistance from staff with activities of daily Living such as bed mobility and transfer. Even though Resident #6's care plan included interventions for staff to follow in order to prevent pressure sore development, Resident #6 did develop a left heel pressure sore. Resident #10's Care Plan lacked approaches to prevent the development of a pressure sore and the resident's heels were not off loaded. The sample consisted of 3 residents with pressure sores (as identified by the facility) and the facility reported a census of 50 residents. Findings include: 1. Resident #10 had an admission MDS assessment dated [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. The resident scored 13 on the Brief Interview for Mental Status (BIMS). The score of 13 represented the resident had no cognitive problems. The MDS indicated the resident required extensive assistance from 2 staff members for bed mobility, bathing and toileting. The resident required extensive assistance of one staff with transfer and dressing. The MDS documented the resident did not walk in room or the corridor during the assessment period. The MDS identified the resident as not at risk for the development of pressure ulcers and had no pressure ulcers. The MDS identified the facility did not implement a repositioning program. A Braden Scale For Predicting Pressure Sore Risk form dated 5/24/17 indicated the resident scored 18. A score of 18 indicated the resident at risk for pressure ulcer development. The Braden Scale identified the resident had a problem with moderate to maximum assistance with moving. Complete lifting without sliding against sheets is impossible which can lead to sheer or friction on the skin. The Review of an admission/readmission nursing assessment dated [DATE] revealed no abnormal skin conditions documented upon admission to the facility. The Care Plan identified a focus area that the resident needed assistance with activities of daily living related to limited mobility, weakness and the right [MEDICAL CONDITION] (undated). The intervention included to please check skin for redness, open areas, scratches, cuts, bruises. The Care Plan identified another focus area. The resident has a suspected deep tissue injury ulcer on the right heel and a potential for pressure ulcer development regards to immobility. (Not dated). The goal for the focus area dated 7/27/17 indicated the pressure ulcer will show signs of healing and remain free from infection. The interventions included to off load feet when in bed. Use ROHO cushion in wheelchair and a pressure relieving device on the bed and educate the resident the importance of repositioning and how this would help the pressure ulcer heel since prefers not to reposition. Review of an interdisciplinary progress note dated 6/7/17 at 2020 (8:20 PM) identified a staff member called a nurse to the resident's room. The note documented the right heel as red and mushy, but with the skin intact. The resident denied pain or discomfort. The note documented the area as 1.2 by 1.4 centimeters (cm) and blue boots (soft foam boots) initiated. The progress note documented the nurse notified the physician and the son. An interdisciplinary progress note dated 6/8/17 at 1750 (5:50 PM) documented the facility received a facsimile with a physician order [REDACTED]. Review of a weekly pressure ulcer progress report revealed the following information regarding the right heel ulcer identified on 6/7/17: 6/7/17- Right heel measured 1.2 x (by) 1.4 cm with reddened and intact skin. The form failed to stage the wound. 6/13/17- Right heel measured 1.2 x 1.0 cm with no drainage, no odor, and described the heel as a reddened soft deep tissue injury. The report documented the interventions of a Roho cushion (pressure relieving cushion), elevated heels, and a Hormel brand Health supplement. 6/21/17- Right heel measured 1.4 x 1.0 cm with no drainage or odor and described the wound as a flat blister soft deep tissue injury. The report document the interventions as the elevated heels and Hormel brand Health supplement. 6/27/17- Right heel measured 1.4 x 1.0 cm with no drainage or odor. The report documented the blister dried up and left a firm area. The report document the interventions as the elevated heels and Hormel brand Health supplement. 7/3/17- Right heel measured 1.4 x 1.0 cm with no drainage or odor with a brown and dry color. The report document the interventions as the elevated heels and Hormel brand Health supplement. 7/12/17- Right heel measured 1.6 x 1.0 cm with no drainage or odor with a brown and dry firm area. Review of a Medication Administration Record [REDACTED]. Review of a treatment administration record (TAR) dated 6/1/17-6/30/17 revealed skin prep applied twice daily to the right heel until healed initiated on 6/8/17. Review of a fax to the physician on 6/23/17 indicated an update on the right heel ulcer and described the ulcer as a flat blister measuring 1.4 x 1.0 cm. The fax listed the current interventions as a supplement, pressure reducing cushion, heels up in bed and used skin prep twice daily. Review of a fax to the physician dated 6/7/17 indicated a notification of the back of the resident's right heel as red and mushy. The resident denied pain or discomfort. The facility applied blue boots and the area measured 1.2 x 1.4 cm. The physician approved a request to apply skin prep twice daily until healed. Review of a fax dated 7/12/17 indicated a decline in the right heel ulcer measuring 1.6 x 1.0 cm describing the ulcer as brown, dry and firm. The fax listed the current interventions a supplement, pressure reducing cushion, pressure reducing mattress, heels up in bed, repositioning at least every 2 hours and using skin prep twice daily. Observation on 7/12/17 at 8:10 AM indicated the resident rested supine in bed with a pillow under his/her calves. Observation identified the resident wore black stockings. Staff B, (licensed practical nurse) removed the resident's stockings and exposed the small hard dark colored callused on the right heel. Staff B applied a skin prep wipe to the callused area, allowed it to dry and then assisted the resident with dressing. Review of a Pressure Ulcer Risk Assessment and Documentation policy and Procedure updated as January 2011, identified the following: Residents will be assessed upon admission and re-admission for potential risk factors that may contribute to pressure ulcer development and interventions will be implemented to reduce that risk. 1). The assigned nurse will complete the Admission and Readmission Pressure Ulcer Risk assessment tool on new admission and readmissions. Determine the factors/conditions that place the resident at risk for developing pressure ulcers. List any additional risk factors/conditions on page 2 of the form. Determine interventions in conjunction with each risk factor that has potential to reduce both the likelihood of pressure ulcer development and/or improve the clinical condition of the resident. Review the risk factors and interventions with the resident and /or responsible party. Include the signature and date of the nurse who completed the assessment and reviews with the resident at the bottom of page 2. 2). The assigned nurse will complete the Admission Nursing Assessment which includes factors/conditions that may place a resident at risk for pressure ulcer development. 3). Communicate interventions to the appropriate staff. 4). The Admission and Readmission Pressure Ulcer Risk Assessment tool can be used in conjunction with the Resident Status Sheet as a partial working care plan until the full care plan is completed per the Resident Assessment Instrument guidelines. 5). Update the care plan and interventions as risk factors change. 6). Preventions: The following interventions, although not inclusive, may be incorporated as deemed pertinent to the resident's condition: -Clean skin gently to minimize the use of force and friction after incontinent episodes. May apply topical barrier agents. -May apply moisturizers to dry skin. -Assist with repositioning immobile residents a minimum of approximately every two hours. -Positioning devices such as pillows or foam wedges may be used to keep bony prominence from direct contact with each other. -Keep head of the head at the lowest degree of elevation consistent with the resident's medical condition and other restrictions. -May use pillows under the calves of the residents who are immobile to relieve pressure on the heels or suspend heels off the foot of the bed. -May use mechanical lifting devices, draw sheets or pads to move residents in bed who cannot assist during transfers and position changes to reduce friction/shearing. -Observe skin when dressing/undressing. -Remove stockings or support stockings to assess skin. -Observe proper placement of tubing to reduce pressure risk. -Assess nutrition and hydration needs quarterly/significant change to maintain skin integrity; encourage foods/fluids. -May use pressure reduction mattress to bed and pressure reduction device to chair. -Assist with range of motion for those residents who have mobility deficits. -May utilize physical therapy/occupational therapy services. -The use of excessive layers of linens should be avoided when pressure reduction devices are used on the bed or in a chair. -If appropriate, offer toileting to minimize incontinent episodes and excessive exposure to moisture. -Check the inside of the resident's shoes for rough areas that may rub on the foot and check shoes for appropriate fit. On 7/12/17 at 10:05 AM, Resident #10 was interviewed and stated the staff did not start elevating his/her heels until after the blister developed on the heel. 2. According to a [DIAGNOSES REDACTED].#6's [DIAGNOSES REDACTED]. Resident #6 had a MDS (Minimum Data Set) assessment with a reference date of 8/22/2016. The MDS indicated the resident required extensive assistance from 2 staff with bed mobility and transfers, documented the resident had not walked during the 2 week assessment period and had impaired range of motion in both lower extremities. The MDS identified the resident at risk for pressure ulcer development and had no pressure ulcers at the time of the MDS assessment. The MDS identified the resident's admission to the facility as 8/15/16. A Care Area Assessment (CAA) with an assessment reference date of 8/22/16, identified Resident #6 as a potential risk for the development of a pressure ulcer due to being admitted with 2 surgical incisions related to a left [MEDICAL CONDITION] and repair, various bruising on the resident's extremities, occasionally incontinent of urine and 2 plus [MEDICAL CONDITION] in both lower legs. A Braden Scale for Predicting Pressure Sore Risk form dated 8/15/16 identified the resident as at risk for pressure sore development with a score of 16. The scoring guide on the same form identified a score 15-18, placed a resident at risk for pressure sore development. A Care Plan, not dated but identified by Staff B, Licensed Practical Nurse(LPN)/Care Coordinator as the resident's initial care plan; included a focus for the potential for pressure ulcer development related to immobility of his/her left hip, decreased mobility and occasional urinary incontinence. The care plan included a goal for no pressure ulcer development and included the following interventions: apply lotion to the resident's skin when dry, use a pressure reducing mattress on my bed and cushion in my wheelchair, off load my feet when in bed (suspend heels or elevate the heels to ensure no pressure from a mattress, chair etc. rests, on the heels), report any skin concerns to a nurse According to a facsimile (fax) sent to a Physician on 11/19/16, staff advised the physician of a new open blister with pressure area (Stage 2 pressure ulcer, discovered on 11/18/16) on the resident's left heel. The heel measured 1.4 centimeters (cm) by 2.0 cm and a depth of 0.1 cm with drainage noted. The physician ordered skin prep (liquid film forming dressing) to the resident's left heel daily. Review of Resident #6's Weekly Pressure Ulcer Progress Report forms indicated staff assessed the left heel ulcer as follows: On 11/18/16: 1.4 cm by 2.0 cm and depth of 0.1 cm with serosanguinous (serum and blood drainage) and no odor. Staff identified the pressure ulcer as Stage 2 (partial thickness loss of the dermis, presenting as a shallow open ulcer. May also present as an open or ruptured serum filled blister. The skin is made up of 3 layers of tissue: 1st layer- epidermis, 2nd layer dermis and 3rd layer subcutaneous). On the same date as staff noted the development of the resident's heel ulcer, staff documented the implementation of the use of heels up device (a medical device made out of material such as foam to suspend or float heels while a person lies in bed). 11/23/16: 1.5 cm by 2.0 cm, no drainage. 11/30/16: 1.5 cm by 2.0 cm, no drainage. 12/5/16: 1.4 by 2.0 cm, no drainage. 12/13/16: 1.4 cm by 2.0 cm, no drainage. 12/21/16: 1.4 cm by 2.0 cm. Staff documented an odor noted and no drainage. Review of a fax to the physician dated 12/21/16, revealed staff advised the physician of the change in the resident's left heel pressure ulcer. Staff included the measurement of 1.4 cm by 2.0 cm and documented dried drainage on the resident's bedding with a foul odor. Further review of the fax indicated the Physician responded with the following orders: Discontinue the skin prep to the heel and dress heel daily with a [MEDICATION NAME] dressing. Begin [MEDICATION NAME] (protein and vitamin based supplement to aid in skin healing) two times a day Refer to the wound clinic. A Wound Clinic History and Physical note dated 12/20/16 indicated the physician documented the resident as less mobile since his/her [MEDICAL CONDITION], the heel ulcer likely started from pressure and described the ulcer as unstageable. The physician's plan included debridement (removal of necrotic tissue to promote healing) into the subcutaneous tissue of the left heel ulcer, continue with daily dressing changes and the use of [MEDICATION NAME] AG. Review further Wound Clinic History and Physical notes revealed the resident saw a Physician, continued to describe the left heel ulcer as unstageable and continued to complete debridement into the subcutaneous tissue of his/her left pressure ulcer on the following dates: 1/6/17, 1/20/17, 1/27/17, 1/30/17, 2/3/17, 2/10/17, 2/17/17, 3/317, 3/17/17, 3/24/17, 3/31/17. Review of ongoing Wound Clinic History and Physician notes indicated the resident continued to be seen in the wound clinic, the Physician described the left heel ulcer as Stage III and continued to debride into the subcutaneous tissue of the ulcer on the following dates: 4/7/17, 4/14/17, 4/21/17, 5/5/17, 5/12/17, 5/31/17, 5/26/17, 6/2/17, 6/9/17, 6/16/17, 6/30/17 and 7/7/17. The following is ongoing assessments as documented on Weekly Pressure Ulcer Progress Reports by nursing staff: (Note: even though a physician at the wound clinic initially assessed the resident's left heel ulcer as unstageable between the dates of 12/20/16 - 3/31/17 and then described the left heel ulcer as Stage III between the dates of 4/7/17 and 7/7/17, nursing staff initially and continued to describe the resident's left heel ulcer as Stage II throughout the following assessments) 12/29/16: 1.8 cm by 1.9 cm, no drainage. 1/2/17: 1 cm by 1.1 cm with a small amount of brown colored drainage. 1/10/17: 1.6 cm by 1.5 cm by .1 cm in depth and a small amount of brown colored drainage. 1/18/17: 1.5 cm by 1.5 cm by 0.3 cm in depth, brown drainage. 1/24/17: 1 cm by 1.5 cm by 0.3 cm in depth, brown drainage. 2/1/17: 0.9 cm by 0.8 cm, 0.3 deep, brown drainage. 2/7/17: 0.9 cm by 0.8 cm, 0.3 cm deep, brown drainage. 2/15/17: 0.9 cm by 0.7 cm, 0.2 cm deep, brown drainage noted on dressing. 2/22/17: -.9 cm by 0.7 cm, 0.2 cm deep, brown drainage. 3/1/17: 0.9 cm by 0.7 cm, 0.2 cm deep. 3/6/17: 1 cm by 1 cm, 0.1 cm deep with scan serosanguinous (serosang) drainage. Staff documented the resident's left heel ulcer remained the same size at 1 cm by 1 cm, 0,1 cm deep, with serosang. Drainage on 3/13/17, 3/21/17, 3/27/17, 4/3/17, 4/10/17, 4/17/17, 4/24/17 and 5/3/17. 5/10/17: 2 cm by 1.1. cm, 0.1 cm deep and 0.3 cm by 0.2 cm dark center. Small amount of brown colored drainage. 5/16/17: 2 cm by 1.5 cm, 0.1 cm deep with small amount of brown colored drainage. 5/24/17: 1.5 cm by 1.5 cm, 0, 1 cm deep with serosang. Drainage on dressing. 5/30/17: 1.6 cm by 2 cm, 0.2 cm deep. 6/6/17: 1.6 cm by 1.5 cm, serosang. Drainage on dressing. 6/13/17: 2 cm by 1.7 cm. 6/20/17: 1.5 cm by 1.5 cm. 6/27/17: 1.5 cm by 1.5 cm. 7/5/17: 1.3 cm by 2.1 cm, 0.2 cm deep. 7/12/17: 1.2 cm by 2 cm, 0.1 cm deep. Record review revealed the resident's left heel wound was diagnosed via wound cultures with staphylococcus aureus infections and required oral antibiotics on: 1/13/17-[MEDICATION NAME] milligrams (mg) two times a day for 10 days. 5/9/17- [MEDICATION NAME] 875 mg, two times a day for 10 days. 5/29/17- [MEDICATION NAME] 875 mg, two times a day for 10 days. 8/13/17- Keflex 500 mg, three times a day for 10 days. Observation on 7/12/17 at 8:05 A.M., revealed Resident #6 lied in bed on his/her back with his/her left heel over a heels up device in bed. Staff A Registered Nurse/RN had previously removed the dressing from the resident's left heel and an area measured by Staff A as 2 cm by 1.2 cm and 0.1 cm deep in size. Observation revealed the compromised area round in size, dried skin around the perimeter of the wound with a pink wound bed. The resident continued to sustain the left heel pressure ulcer, approximately 8 months after the development of the ulcer on 11/18/16. 7/11/16 at 10:05 A.M., the facility Director of Nursing (DON) stated she could only speculate on how Resident #6 acquired a pressure ulcer after admission to the facility, when the resident's care plan called for interventions to prevent the development of a pressure sore. During interview on 7/11/17 at 10:08 A.M., Staff C confirmed she worked with Resident #6 at the time of his/her admission to the facility 8/2016. Staff C stated she could not remember if staff floated his/her heels to prevent a pressure sore. During interview on 7/12/17 at 1:20 P.M., Staff B stated the facility had not asked for or received Resident #6's wound clinic notes and had not known for certain what the Physician had documented in the notes. Staff B confirmed the facility had no knowledge the Physician staged the pressure sore at Stage III.

Based on observation, record review, staff interviews and review of policy/procedures, the facility failed to assess and manage pain for 1 of 6 residents reviewed (Resident # 2). The facility reported a census of 44 residents. Findings include: 1. Resident #2 had a MDS (Minimum Data Set) assessment with a reference date of 5/29/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS reflected the resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for personal hygiene and bathing and supervision and setup assistance for eating. The resident totally depended upon 2 staff for transfers, dressing, and toilet use. The resident did not walk during the 7-day MDS assessment period. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 3. A score of 3 identified the resident had a severe cognitive impairment. The MDS reflected the resident received scheduled pain medication, prn (as needed) and non-medication intervention for pain. During an observation on 7/7/15 at 8:30 a.m., Resident #2 laid in bed in a supine position (on back). When Staff C (Certified Nursing Assistant) raised the head of the resident's bed, the resident stated ouch and that she had a cramp. Staff C lowered the head of the bed. During an observation on 7/7/15 at 11:20 a.m. Staff A CNA and Staff C CNA assisted Resident # 2 to a standing position from the wheelchair. The resident took a couple of unsteady steps and sat on the toilet. During the transfer, the resident groaned and displayed facial grimacing. Staff A and Staff C attempted to reposition the resident on the toilet but the resident stated ouch, that hurts. While sitting on the toilet the resident continued to groan loudly and grimace. The resident stated oh, oh. During the transfer back to the wheelchair, the resident groaned and grimaced. During the transfer from the wheelchair to the recliner, the resident stated her legs were aching and oh, I hurt, oh, I need a nurse. Staff C stated she would tell the nurse about the resident's pain. After the resident sat down in the recliner, Staff D LPN (Licensed Practical Nurse) entered the room. Staff C stated to Staff D that the resident needed some pain medicine. Staff D administered medicine to the resident and identified it to be Tylenol. The facility lacked documentation of the pain medicine's effectiveness. Review of the July MAR (Medication Administration Record) for Resident #2 reflected the nurse ' s had not administered any prn (as needed) pain medication on 7/7/15. During an observation on 7/8/15 at 7:40 a.m., the resident sat in a recliner moaning and yelling that her legs were aching. The resident could be heard throughout the hallway. Review of the July MAR for Resident #2 reflected the staff administered [MEDICATION NAME] ([MEDICATION NAME]/anti-[MEDICAL CONDITION]) Tablet 400 mg (milligrams) on 7/8/15 at 8:15 a.m. for complaints of right leg pain. Review of the IPN (Interdisciplinary Progress Notes) reflected the staff evaluated the pain medication ' s effectiveness on 7/8/15 at 12:40 p.m. The facility lacked documentation of the medication effectiveness assessed earlier in the day. The resident ' s Walking Program record dated June 2015 reflected the following entries. On 6/25/15, the resident in so much pain and could not stand up to pivot transfer. On 6/28/15, the resident could not stand up, too much leg and hip pain. On 6/29/15, the resident complained of pain, wouldn't sit on edge of the bed for staff. Needed 2 assist this morning. On 6/29/15, the resident would not stand this afternoon. On 6/30/15, the resident having trouble bearing weight and would not walk. Review of the June 2015 MAR for Resident #2 identified the resident did not receive prn pain medication on 6/25/15, 6/28/15, 6/29/15, or 6/30/15. The facility lacked documentation of pain level assessments or evaluations for Resident #2 on 6/25/15, 6/28/15, and 6/30/15. There was one pain level assessment entry in the IPN at 10:30 a.m. on 6/29/15. The facility lacked further documentation of pain level assessments on that date. Review of the MAR for June 2015 reflected the resident did not receive prn cool packs for pain/swelling on 6/25/15, 6/28/15, 6/29/15, or 6/30/15. Review of Resident #2's Walking Program record dated July 2015 revealed the following entries: On 7/6/15, the resident in a lot of pain, resident in bed the whole shift screaming out in pain when repositioned. On 7/7/15, the resident in a lot of pain. Review of the IPN dated 7/6/15 at 10:15 a.m., documented the resident yelled out during two attempts to get the resident out of bed. Review of the July 2015 MAR for Resident #2 reflected the resident received 400 mg of prn [MEDICATION NAME] at 7:30 a.m. on 7/6/15. The medication is listed as effective in the prn section of the MAR but does not have a time listed for the evaluation. The MAR indicated [REDACTED]. The Care Plan for Resident #2 with a target date of 9/16/15 directed staff to provide pain medications as ordered and monitor effectiveness. Review of the Medication Review Report for Resident #2 dated 5/31/15 listed the following physician orders: Tylenol Extra Strength Tablet 500 mg. Give 1 tablet by mouth three times a day for pain related to closed fracture Tylenol Extra Strength 500 mg. Give 2 tablets every 8 hours as needed for elevated temperature and pain [MEDICATION NAME] Tablet 400 mg. Give 1 tablet by mouth every 6 hours as needed for pain Cool packs as needed for pain/swelling to left elbow and pelvis QID (four times a day for 20 minutes) The start date was identified as 5/25/15. During an interview on 7/8/15 at 1:00 p.m., Staff B CNA stated Resident #2 had been in a lot of pain since her fall in May. She stated that she can determine the resident is in pain because she grimaces and yells out. During an interview on 7/8/15 at 1:15 p.m., Staff A CNA stated the resident had been in a lot of pain during her shifts on 7/6/15 and 7/7/15. During an interview on 7/8/15 at 1:24 p.m., Staff C CNA stated the resident has had trouble walking recently due to her pain level. During an interview on 7/8/15 at 2:00 p.m., Staff E LPN, stated the resident would be sent to the hospital due to increased pain and inability to walk. During an interview on 7/9/15 at 7:26 a.m., the Director of Nursing (DON) stated if a resident was in pain, the staff would assess effectiveness of pain medications. The DON stated prn medications would be evaluated for effectiveness. During an interview on 7/9/15 at 7:30 a.m., the DON stated Resident #2 had a hip x-ray last night which was negative. She stated the resident is now back in the facility and has been ordered non-weight bearing until a scheduled appointment with an orthopedic specialist. She stated Resident #2's scheduled Tylenol increased to 1000 mg tid (three times per day). The hospital physician order [REDACTED]. The x-ray dated 7/8/15 identified the resident had an aggressive displacement of the left superior and inferior pubic ramus (pelvis) fractures. The right hip did not have a fracture. The IPN dated 7/9/15 at 12:00 p.m. identified the staff verified an appointment with the orthopedic physician on 8/12/15 at 9:00 a.m. The IPN note of 7/17/15 at 10:30 a.m. reflected the nurse sent a fax to the physician and requested the appointment sooner (than 8/12/15) due to the pain. The facility policy/procedure titled Pain Assessment & Management, dated 11/10, reflected if pain is noted, review the current admission orders [REDACTED]. If the resident does not receive a medication, then notify the physician. If a resident receives prn pain medication, have the resident (if able) rate the intensity of the pain. The policy identified 2 scales to use; Numeric Rating Scale and the Verbal Descriptor Scale. Approximately an hour after the pain medication has been administered, ask the resident again to rate the pain using the same scale. Documentation should be made for both the initial pain rating and the response to the medication on the prn flow sheet with each administration. For cognitively impaired residents who cannot effectively communicate pain, use a broad assessment approach including but not limited to: family member interviews, staff observations, documented medical diagnosis, pain history, or evidence of aggressive behaviors. Complaints of pain cannot be dismissed even if residents forget they have reported pain. All complaints of pain should be documented in the Interdisciplinary notes.

Based on observation, record review, staff and resident interviews, the facility failed to provide adequate supervision and implement care plan interventions identified to prevent accidents for 2 of 5 residents reviewed (Residents #1 & #3). Resident #1 slid off the side of the bed to the floor when one staff performed care. The care plan directed that 2 staff should provide the care. The resident fractured his/her right hip and left knee during the fall. Staff ambulated Resident #3 without the proper number of staff and staff lowered the resident to the ground with the assistance of a visitor. Resident #3's care sheet identified two staff should transfer the resident and the care plan identified one or two staff could transfer the resident and that two staff should ambulate the resident. The facility failed to ensure Resident #2 and Resident #4's enviroment remained as free of accident hazards as possible. Both Resident #2 and Resident #4 sustained skin injuries from staff finger nails and rings. The facility census was fifty-five (55) residents. Findings include: 1. A Minimum Data Set (MDS), dated [DATE], assessed Resident #1 with a brief interview for mental status (BIMS) score of "15" (no cognitive impairment). The resident required the assistance of two staff with bed mobility and toileting. The resident was nonambulatory. The resident had functional range of motion limitations of both upper and lower extremities. The resident had [DIAGNOSES REDACTED]. The resident had frequent pain rated "5" out of a possible 10 with 10 being the worst pain. The resident measured 59 inches tall and weighed 176 pounds. The resident had no history of falls. A therapy referral form dated 12/5/13, revealed staff requested an occupational therapy (OT) screen for decreased wheelchair posture/positioning and pain. The record lacked evidence this was carried out. On 2/18/14 at 2:35 p.m. the OT stated she had seen the resident often in the past but she cannot recall if she did a screen in response to the 12/5/13 request. She does not keep a copy of every screen but she does give the facility a copy if she completes a screening. When asked about the positioning portion of the screen request, she stated she would evaluate wheelchair positioning unless the facility specifically requested something different. She stated she did not recall evaluating the resident's bed positioning before but she does evaluate bed positioning if requested. A care plan, in place prior to the incident and dated 1/15/14, identified the resident required two staff for repositioning in bed. The nursing care plan identified Resident #1 required 2 staff with pericares after each bowel movement. The resident utilized an indwelling urinary catheter. The care plan identified that the resident used an air mattress on the bed. An incident report form dated 2/4/14 at 8:45 p.m. and documented by Staff N licensed practical nurse, revealed staff called Staff N to Resident #1's room. The resident laid on the floor with legs awkwardly turned. The resident complained of right hip discomfort and internal rotation of the right leg and knee. Staff A (nurse aide) voiced that she turned the resident on the right side for cares and misjudged the resident's position on the edge of the bed. The resident started to slide off the bed. The bed was in the high position approximately 4 feet from the floor. The resident stated his/her legs were on the floor and the resident could not hold on. Staff N contacted the emergency room (ER) and the resident transported to the ER via ambulance. The facility documented in the Interdisciplinary (ID) progress notes dated 2/4/14 at 10:40 p.m., revealed a hospital nurse phoned the facility and informed the facility the resident had a fractured right femur. ID notes dated 2/11/14 at 10:25 a.m. revealed the resident left the hospital via ambulance following surgical repair of the right hip fracture. The facility documented the resident also sustained a nondisplaced left hip fracture. The resident would wear immobilizers on both legs upon return. The resident arrived via ambulance at the facility on 2/11/14 at 12:30 p.m. The Hospitalist History and Physical dated 2/5/14 identified Resident #1's sustained a fall out of bed and started experiencing right hip pain which was initially severe in intensity and was aggravated upon even the slightest movement at the right hip joint. At baseline, the resident was bed bound. The document identified the x-rays revealed Resident #1 sustained a right proximal femur fracture. The hospital progress note dated 2/9/14 identified Resident #1 had surgery for [REDACTED]. The hospital final report of x-ray preformed on 2/5/14 revealed the resident had an evidence of comminuted fracture of the most distal left femur adjacent to/within/just above the femoral component of the left total knee replacement. The report documented the resident had left knee joint effusion indication hemarthrosis. The resident had diffuse swelling of soft tissues along the supeolateral and lateral aspects of the fracture site. The resident had profound osteopenia presumed osteoporosis and heavy alterial calcification noted. The hospital reports did not identify x-rays were completed for Resident #1's left hip or mention the resident sustained [REDACTED]. In a written statement, documented on 2/4/14 at 8:30ish, Staff A wrote she removed the bedpan following the resident having a bowel movement. She used wipes to clean the resident and informed the resident of the pad changing and that the resident would need to go over a big bump. At that time Staff A observed the resident's legs sliding off the bed. As Staff A reached for the resident, the resident went to the floor. Staff Interviews: On 2/13/14 at 12:50 p.m. Staff A (nurse aide) stated she had the assistance of Staff K (nurse aide) until the resident got off of the bedpan. Staff K then retrieved a bedpad for the resident and left the room after delivering it. Staff A needed to finish cleaning the resident and apply a new bed pad to the bed. Staff A stated the resident evidently was over further than she realized on an air mattress. Staff A told the resident to roll back over and at that time, the resident shifted and the resident's legs slid off the bed. Staff A stated Staff K did not stay to assist her because staff was encouraged to do as much as they can by themselves. On 2/17/14 at 4:10 p.m. Staff A stated she lowered the resident to the ground. The resident was on the floor with knees bent saying "My legs, my legs." Staff A then laid the resident back and straightened the resident's legs out. She then left the room to get help. She stated she did not get response when she used the walkie communication device to summon help. On 2/17/14 at 4:27 p.m. Staff K (nurse aide) confirmed she brought a bed pad to Staff A and then left the room. Staff k did not stay to assist because Staff A said she didn't need Staff K's help and call lights were on that Staff K needed to answer. On 2/13/14 at 2:50 p.m. Staff N (licensed practical nurse) stated she just returned from assisted living and was charting when Staff A summoned her for help. Staff N stated two staff were supposed to assist Resident #1. She did not know of anyone else not using two staff for the resident's cares. The resident requires two staff with body positioning, transfers and bed pan use. This had been reinforced to staff in January. Staff N stated she was available to assist and no one called her. On 2/13/14 at 10:18 a.m., observation showed the resident in bed. The resident stated he/she did not recall the fall or how it occurred. The resident stated he/she had pain and the facility keeps the pain under control as best they can but "it never goes away". Observation showed, on 2/13/14 at 12 p.m., three staff assist the resident with pericare and a dressing change to the right hip incision. At that time, staff identified that the resident was on bed rest until further notice. The resident grimaced with pain during cares and staff encouraged the resident to take deep breaths and frequently asked the resident how he/she was doing. The resident wore leg immobilizers on both legs with pillows between the legs and under the lower legs. Staff placed wedges beside both legs. When turned during cares, the resident commented, "I'm so close to the edge". Staff reassured the resident. A major injury determination form signed by the physician on 2/6/14 at 10:10 a.m. identified the injury sustained was a major injury. The facility investigation undated identified that, based on the care plan, Staff A should have kept Staff K in the room until the resident laid in a safe position. 2. A Minimum Data Set (MDS) with assessment reference date of 1/30/14 assessed Resident #3 with a brief interview for mental status (BIMS) score of "13" (no cognitive impairment). The MDS identified that resident utilized two staff assistance f with transfers and ambulation. A "balance during transitions and walking" test identified the resident as unsteady and only able to stabilize with staff assistance in all areas of testing (moving from seated to standing position, walking, turning around and during surface to surface transfers). The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury since the previous assessment. Interdisciplinary (ID) progress notes dated 2/15/14 at 2:10 p.m. and documented by Staff C (registered nurse) revealed staff assisted the resident out of the bathroom with the walker gait belt and assistance of one. The resident ambulated a few steps forward and staff then pulled the wheelchair up behind the resident. When the staff pulled the wheelchair up behind the resident, the brake handle came off and the resident sat on the wheelchair causing it to roll back. Staff hung onto the resident with a gait belt and a visitor in the room straightened the resident's left leg so staff could safely lower the resident to the floor. The resident did not sustain injury. ID notes dated 2/15/14 at 4:40 p.m. revealed the intervention following the incident was to have brake looked at and tightened. A resident care sheet identified the resident should have two staff for transfers. A care plan dated 12/18/13 contained an addendum dated 1/24/13 that directed one or two staff for transfers and one staff to ambulate the resident with one staff to follow in wheelchair. A functional maintenance program form dated 1/24/14 directed staff to continue transfers with one to two staff and gait belt and continue walking program with assist of two staff, gait belt and front wheel walker and follow with wheelchair. Staff Interviews: On 2/18/14 at 2:10 p.m. Staff Q (nurse aide) stated when the resident went to sit in the wheelchair only part of his/her bottom got on the seat and the wheelchair went back. Staff Q held the resident up by the gait belt. A visitor in the room pulled the resident's leg out so Staff Q could lower the resident safely. Staff Q stated if the visitor had not pulled the resident's leg out, he thought the resident may have sustained injury when lowered due to the position of the leg. He stated he transferred the resident off the toilet by himself and then ambulated the resident by himself with no one following behind in the wheelchair. He stated the wheelchair was folded up and he got it open and attempted to pull it towards him when the brake handle extender came off. He thought the incident could have been prevented if another staff would have followed behind in the wheelchair as the care plan directed. On 2/17/14 at 11:40 a.m. Staff C (registered nurse) stated the nurse aide reached behind him to pull the wheelchair up and the brake extender handle came off. The resident's bottom caught the edge of the chair and the resident went down. The resident's leg bent halfway so a visitor came around from the other side of the room and pulled it out so Staff Q could lower the resident to the ground. The resident did not sustain injury. On 2/17/14 at 10:04 a.m. observation showed the resident seated in the wheelchair. At that time, the resident denied having fallen recently or that staff lowered him/her to the floor. When asked, the resident was unable to identify the month or year and thought he/she was at St Peters Lutheran Church. Observation showed, on 2/18/14 at 12:10 p.m. two staff transfer the resident with a gait belt and walker. The resident remained bent forward and took a few slow shuffling steps to the wheelchair from a recliner. 3. A Minimum Data Set (MDS) with assessment reference date of 11/29/13 assessed Resident #4 with a brief interview for mental status (BIMS) score of "14" (no cognitive impairment). The resident required extensive assistance of one staff with bed mobility and dressing. The resident had [DIAGNOSES REDACTED]. An incident report form, dated 12/24/13 at 1:10 a.m. identified that two staff changed and repositioned the resident when the resident stated "Ow." The nurse aides then noted a 1/2 moon skin tear on the resident's left lateral shin. The skin tear measured 1 inch by 1/4 inch. Staff did not observe bleeding and did not know if it occurred at that time. A physician telephone order dated 12/24/13 identified the physician ordered staff to apply a nonadherent telpha dressing to cover the area. Change the bandage twice a week with baths. A nonpressure skin condition record identified the area as healed on 1/24/14. An incident report form, dated 2/1/14 at 3:15 a.m.. revealed staff observed blood on the resident's bed pad and a 2 centimeter (cm.) skin tear on the resident's right lateral calf. The incident report form identified the likely cause as a nurse aide's ring or fingernails during previous rounds. The resident stated he/she thought they felt something on his/her leg when staff was in the room previously. A facsimile (fax) form dated 2/4/14 identified the physician ordered staff to cleanse the area with normal saline and cover with nonstick Telpha and transparent dressing. Change every two days and as needed. A non pressure skin condition report, dated 2/6/14, identified the area on the right lateral calf measured 2 cm. by 0.5 cm. on that date (unchanged from 2/1/14). An incident report form dated 2/4/14 at 10:30 p.m. revealed the resident activated his/her call light and stated his/her leg hurt. Staff pulled the blanket down and observed blood on the bed pad. The resident stated that a girl that put him/her to bed did it. Staff assessed a triangle shaped skin tear 2 centimeters long and 2 centimeters wide on the resident's left lower leg. On 2/5/14 at 4:40 a.m. the facility sent a fax to the physician describing the area and that staff cleansed the area and patted it dry then covered it with telpha and a transparent dressing. The physician responded on the same date and directed staff to continue with current care and change the dressing every other day until healed. Observation showed, on 2/17/14 at 10:45 a.m. two staff transfer the resident via the EZ stand. The resident wore Ted Hose (elastic stockings) to both lower legs and long pants. 4. A Minimum Data Set (MDS) with assessment reference date of 1/3/14 assessed Resident #2 with a brief interview for mental status (BIMS) score of "15" (no cognitive impairments). The resident required extensive assistance of one staff with bed mobility, transfer and ambulation. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with a skin tear. Interdisciplinary Progress (ID) Notes, dated 2/8/14 at 10:30 p.m. revealed two staff assisted the resident from the commode to bed. When the two staff helped the resident into bed, the resident stated one of the staff's fingernails "got" him/her. The staff checked her thumb and noticed blood. The resident sustained [REDACTED].) by 0.5 cm. skin tear to the left arm near the wrist. ID notes dated 2/10/14 identified staff dressed the left wrist skin tear with a Telpha and transparent dressing after cleansing with normal saline. A nonpressure skin condition record dated 2/14/14 identified the area as healed. Observation on 2/13/14 at 11:18 a.m. revealed a small intact area on the resident's left wrist. When asked what happened to the area on the wrist, the resident stated that in the night two staff helped him/her and one "got me" with her fingernail. The resident identified the incident as "an accident". 5. On 2/18/14 at 9 a.m., the facility provided the surveyor with a daily stand up meeting form dated 2/3/14 that indicated they spoke with staff about wearing rings and that staff needed to remove them prior to cares/repositioning. On 2/18/14 at 2 p.m., when asked if there was further education or counseling about rings and fingernails after the 2/3/14 stand up meeting, since two additional incidents occurred since that time, the Administrator stated when Resident #2's incident occurred the charge nurse looked at the staff's fingernail after the incident so the nurse aide was aware he checked it. The nurse aide's nails were trimmed.

Based on observation, record review and staff and resident interviews, the facility staff person failed to display respect for Resident #2 when caring for as a constant affirmation of their individuality and dignity as human beings. The sample consisted of 4 residents and the facility reported a census of 54 residents. A nursing assistant spoke unkind to Resident #2. The intellectually disabled resident responded by punching a wall and fractured his/her hand. Findings include: 1. A Minimum Data Set (MDS) assessment, with a reference date of 5/3/13, identified Resident #2 had a BIMS (Brief Interview for Mental Status) test with a score of 4 (severe cognitive impairment). The resident required limited staff assistance with bed mobility, dressing, personal hygiene and bathing. The resident required extensive staff assistance with toileting. The resident was independent with ambulation. The MDS identified the resident as frequently incontinent of bowel and bladder and not on a bowel or bladder toileting program. The Interdisciplinary Progress Notes (IPN) dated 4/25/13 at 9:30 a.m. revealed a nursing instructor informed staff the resident needed assistance in the bathroom. The resident was incontinent of bowel movement (BM) and needed assistance. Staff X (Nursing Assistant) answered the page. At 10 a.m., Staff Q (Nursing Assistant) stated she was in the room with Staff X and the resident and felt very uncomfortable with what she witnessed. Staff Q stated the resident hit the wall because the resident got mad with the way Staff X spoke to him/her. At 10:15 a.m. an assessment of the resident's right hand identified 2 purple bruises, one centimeter (cm.) each in size. One bruise was located on the 1st knuckle and the other between the 1st and 2nd knuckles on the right hand. At 11 a.m., the resident's hand appeared swollen at the 1st knuckle with 5 cm. by 5 cm. deep bruising and tenderness at the anterior aspect of the 1st finger and 1st knuckle of the right hand. At 11:30 a.m. the physician ordered an x-ray of the hand. An x-ray radiology report dated 4/25/13 identified the resident with a probable acute right second metacarpal head fracture, with extension into the metacarpophalangeal joint. No evidence of malalignment. Correlation for focal tenderness and localization of trauma/pain to this region. An x-ray radiology follow up report dated 5/2/13 identified comparison made to the prior x-ray performed on 4/25/13 which showed resorption/healing associated with the index finger metacarpal; head fracture. Fracture fragments are in near-anatomic alignment. An x-ray radiology follow up dated 6/4/13 showed diffuse demineralization of the osseous structures with a fracture through the neck of the second metacarpal. On 7/25/13 at 1:25 p.m., the resident was interviewed and stated he/she was upset with someone because that person bossed him/her around all the time and wanted the resident to use the bathroom all the time. A care plan dated 3/29/12 identified the resident with a [DIAGNOSES REDACTED]. On 4/25/13 the facility interviewed Staff X. Staff X stated the resident asked her for help and she told him/her to be a grown up and get started cleaning up. Staff X stated she spoke to the resident as she always has. She has to use a firm tone with the resident when he/she doesn't want to help him/herself. Staff Q's (Nursing Assistant witness) documented in her written statement (undated) that Staff X raised his/her voice to the resident and told the resident to take off his/her pants. The resident became upset and pounded the wall. Staff Q left and reported the incident to a charge nurse. On 7/30/13 at 3:30 p.m. Resident #1 was interviewed and identified Staff X as moody and would throw a fit and threaten to leave. Resident #1 stated Staff X raised her voice to him/her. The resident did not report it to anyone. On 7/30/13 at 3:33 p.m. Resident #7 stated he/she didn't care for Staff X. Staff X was bossy and didn't take the job seriously. The resident did not report to anyone. On 7/30/13 at 3:38 p.m. Resident #3 stated he/she was not real happy with Staff X. Staff X was pushy but he/she liked her.

Based on observation, record review and resident and staff interviews, the facility failed to provide Resident #4 and Resident #2 with adequate supervision to prevent accidents and hazards from self and failed to revise the care plan to promote resident safety. The facility failed to protect Resident #1 against hazards from self when a heat pack was used which caused second degree burns on the resident ' s skin. The sample consisted of 4 residents and the facility identified a census of 54 residents. Resident #4 fell 5 times since [DATE] with the final fall on [DATE] resulting in fracture. After the resident fell on [DATE], (the fall prior to the [DATE] fracture) the facility sent a facsimile for a physical therapy (PT) screen at 5:35 a.m. which was not performed prior to the resident falling with a fracture of [DATE] at 6:50 a.m. Facility staff documented on the PT screen form the resident needed the screen due to decreased gait and/or transfer skills and decreased balance. In the meantime between [DATE] to the [DATE] fall with fracture, the Administrator stated the facility did what they had always done for the resident. Resident #2 sat in a wheelchair in the facility van. Facility staff failed to secure the resident and the wheelchair for the van ride and the resident fell backwards in the van hitting his/her head and causing back pain. Resident #1 requested staff place a hot pack on top of a Fentanyl (narcotic analgesic patch) on his/her upper thigh. Staff microwaved a moist cloth and placed it in a plastic bag on the resident's leg. The resident sustained [REDACTED]. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with an assessment reference date of [DATE], which identified Resident #4 with a brief interview for mental status (BIMS) score of 2 (severe impairment). The resident had fluctuating behavior of inattention and disorganized thinking. The resident required extensive staff assistance with bed mobility, transfers, ambulation in room, dressing and toileting. The MDS identified the resident required supervision while ambulating out of room. A balance during transitions and walking test identified the resident as not steady but able to stabilize without staff assistance. The resident utilized a walker while ambulating. The resident was frequently incontinent of bladder and was not on a toileting plan. The resident had [DIAGNOSES REDACTED]. The resident had 2 or more falls with injury and one fall without injury since the previous assessment. The most recent physical therapy (PT) screen, prior to the [DATE] fall and fracture, dated [DATE] identified the resident as independent with sit to stand, supine to stand and ambulation. The PT screen reflected there was no need for PT at this time. The resident had the following history of falls per the incident reports: An incident report form, dated [DATE] at 10:30 p.m., identified the resident fell sideways at 7:05 p.m. in the resident's room. The resident stood at the dresser with the walker and turned and fell over. Staff found the resident on his/her bottom resting on the right elbow. The resident did not sustain injury. The care plan identified the intervention following the incident dated [DATE] to encourage the resident to try and sleep in bed at bedtime. An incident report form, dated [DATE] at 11:45 p.m., identified a nursing assistant found the resident on the floor. Observation revealed the resident on the floor in his/her room, lying on his/her left side facing the window with walker in front of desk between the bookcase and the end of bed. The resident's wallet and checkbook lay on the floor next to the resident. The intervention following the incident indicated the staff will attempt to remove all personal belongings at bedtime. The Interdisciplinary Progress Notes (IPN) dated [DATE] at 10:10 a.m., identified staff heard the resident yelling from the resident's room at 6:35 a.m. Staff entered the room and found the resident sitting on the floor with her/his back against the recliner with legs extended. The resident stated he/she walked to the recliner and sat down too soon. The resident sustained [REDACTED]. red area on the left lower back. Staff observed bleeding from a superficial open area in the left upper buttock area measuring 2.3 cm. by 2.3 cm. A quality assurance investigation form identified the resident did not have gripper socks on. The intervention following the incident was: Education gripper socks. An incident report form dated [DATE] at 8 a.m. identified staff found the resident on the floor in his/her room right outside the bathroom at 2:30 a.m. The resident turned the bathroom door knob and stepped out. The resident then fell down. The resident wore gripper socks and the floor was unobstructed. The resident reported he/she hit head and rubbed the left ear and upper side of head. Staff did not observe injury on the resident's head but the left ear appeared red. The anterior left shoulder contained a 7 cm. by 1 cm. red area. The resident denied pain during the initial assessment. The resident denied pain until 5:35 a.m. when the resident complained of some soreness to the left shoulder. The incident report form did not contain an intervention following the fall. On [DATE] at 11:52 a.m. the Administrator identified a physical therapy (PT) screen sent on [DATE] at 5:48 a.m. as the intervention. Staff identified the resident need for the PT screen on the form. Staff indicated the resident had decreased gait and/or transfer skills and decreased balance. On [DATE] 2:40 p.m., the Administrator and Director of Nursing stated they waited to send the PT screen request because the therapy person comes to the facility on Tuesdays and [DATE] was a Tuesday. The Administrator stated, in the meantime between [DATE] to the [DATE] fall, they continued to do what they always did for the resident. They monitored and the amount of supervision remained unchanged. The resident was up with the walker. FALL WITH FRACTURE A Quality Assurance Investigation form, dated [DATE] at 6:50 a.m., identified staff found the resident on the floor at the foot of the resident's bed near the bathroom. Staff last observed the resident sitting in a chair in room at 6:45 a.m. The resident fell attempting to put a jacket on. After the fall, the resident complained of right hip and upper leg pain and also right elbow pain. The IDP notes dated [DATE] at 10:40 a.m., regarding the fall incident on [DATE] at 6:50 a.m., revealed the resident laid on the right side when staff entered the room. The right foot appeared rotated outward and shortened. The resident stated he/she bumped head on the wall. The resident did not use the walker and was incontinent of urine. The resident stated he/she was on his/her way to the bathroom when the fall occurred. The resident had one arm in his/her jacket and one arm out (of the jacket). The ID notes reflected the resident forgets to use his/her walker especially in the room. A hospital final report, dated [DATE], revealed the resident presented to them with right hip pain with known underlying fracture. Surgical options were discussed with the resident's family. Risks, benefits and alternatives to surgery to include a right hip nailing was reviewed. Potential risks were infection, possible need for subsequent surgery, blood loss with potential need for transfusion and its associated risks, delayed union, malunion or nonunion, persistent pain, persistent weakness, persistent stiffness, inability to ambulate, anesthetic risk, neurovascular damage, increased risk of blood clot and chance of loss of life or limb. The resident was at increased risk for surgery and anesthesia given advance age and [DIAGNOSES REDACTED]. The family agreed to surgery and the resident underwent [REDACTED]. The resident returned to the facility following surgical repair of the fracture on [DATE]. Observation on [DATE] at 12:57 p.m., revealed two staff members transfer the resident to the commode from the wheelchair. The resident stood with 2 staff, a gait belt and a walker. The resident denied pain when asked. A care plan, dated [DATE] and in place when the [DATE] fall/fracture occurred, contained an addendum dated [DATE] which directed staff to supervise the resident when in the hallway. The care plan did not identify increased supervision when in room. The care plan did not identify that the resident did not always use the walker. On [DATE] at 6:20 p.m. the Administrator stated the family sometimes had someone come and sit with the resident for a few hours over the supper hour. They came around 4 p.m. and were never at the facility later than 8 p.m. He stated they did not include the family help on the care plan. On [DATE] at 9:51 a.m., the Administrator stated via email that the family began bringing someone in to sit with the resident in the latter part of [DATE]. The resident's spouse expired and the resident became restless. The Care Area Assessment (CAA) for An Activity of Daily Living (ADL) dated [DATE], revealed the resident's assistance with ADLs fluctuated since admission. During the assessment period, the resident's need for assistance increased to extensive assistance with transfers, bed mobility, walking in the facility with walker and toilet use. The resident spends much of his/her day standing and walking making the resident tired and weak. Review of the resident's prior MDS, dated [DATE] revealed the resident's prior status with bed mobility, transfers, ambulation in room and toileting was independent. This identifies a decline in the resident's abilities from [DATE] MDS (independent) to the [DATE] MDS (extensive assistance). The record and care plan did not identify the facility addressed the resident's increased needs and declines. 2. Resident #2 had assessment reference date of [DATE], assessed Resident # 2 with a brief interview for mental status (BIMS) score of 4 (severe cognitive impairment). The resident required limited staff assistance with bed mobility, dressing, personal hygiene and bathing. The resident required extensive staff assistance with toileting. The resident was independent with ambulation. The MDS did not identify falls since the prior assessment. The IP Notes dated [DATE] at 3:45 p.m. revealed the resident tipped backward while sitting in a wheelchair in the facility van. Upon arrival to the facility while in the van, observation revealed the resident in a wheelchair tipped back with feet and legs at right angles in the air. The resident responded to questions and denied injury. An Assessment identified a pink area on the left shoulder. On [DATE] at 8 p.m. the resident complained of a very bad pain in his/her back. Staff administered scheduled pain medication and the resident then rested well. On [DATE] at 10:15 a.m., the resident complained of back pain. The resident complained of hitting his/her head during the incident. An assessment revealed no bruising or hematomas to the head. Staff administered pain medication and the resident reported feeling better later. Further IP notes did not identify any additional complaints of pain. A quality assurance investigation form dated [DATE] at 3:45 p.m. identified the Activity Director took the resident out in the facility van. The resident rode in a wheelchair on the van. The preliminary recommendation to prevent further occurrences was to conduct training for safe transport of resident in wheelchair. On [DATE] at 11:50 a.m. the Activity Director demonstrated how she secured the wheelchair. She stated she put the front hooks on the front bar of the wheelchair and she pushed the automatic red button to tighten the strap. She did not place the seat belt shoulder harness strap on the resident. She stated when they pulled up the hill into the facility driveway, she heard a noise and she saw the resident fell back in the wheelchair. The front hooks came off because they were not tight enough. She stated she did not tighten the front hook straps by manually tightening them with the crank. She just pushed the automatic tighten button. She stated she did not remember being shown to also manually tighten the hook straps with the crank. On [DATE] at 12 p.m., Staff W (Transportation Director) was interviewed and stated the staff are trained to tighten the front hook straps by using the automatic tighten red button and the manual crank. The staff are also to use the seat belt shoulder strap. He stated training for staff showed them how to do tighten and fasten the chair and use of belt straps. Staff had to perform a return demonstration to ensure competency. They also watch a video. The corporate transport trainer also trained the activity director before the incident. On one demonstration, the Activity Director was the resident in the wheelchair when a demonstration was performed on how to secure residents. On [DATE] at 1:25 p.m. the resident stated he/she was not strapped in when the fall occurred. The resident stated he/she hit their head and their back hurt due to the fall. 3. Resident #1 had an MDS assessment with a reference date of [DATE] which reflected the resident had a brief interview for mental status (BIMS) score of 15 (no cognitive impairment). The MDS identified the resident as totally depended on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing. The resident had functional limitations in range of motion in both the upper and lower extremities. The resident had [DIAGNOSES REDACTED]. The IP notes dated [DATE] at 10 a.m., revealed Staff E (Registered Nurse) went to the resident's room to apply new Fentanyl (narcotic) patches at 5 a.m.. The resident expressed concern about the patches not sticking and suggested Staff E apply heat to the patches to possibly make them stick better. Staff E placed a moist towel in the microwave for 45 seconds and then placed the moist towel in a plastic bag. Staff E carried the moist towel in the plastic bag to the resident's room. After approximately 10 minutes, Staff E placed the bag on top of the newly placed Fentanyl Patches for a few minutes before removing the bag and leaving the room. The IP notes on [DATE] at 7:15 a.m. indicated a nurse found two blisters, with redness surrounding the blisters, on the right upper thigh where Staff E had earlier placed the Fentanyl Patches and moist microwave heated towel. The red area measured 10 centimeters (cm.) by 8 cm. with 2 blisters in between the two patches. The blisters measured 0.5 cm. by 0.5 cm. and 0.3 cm. by 0.6 cm. The resident is unable to feel any localized pain or discomfort due to quadriplegia. At 8 a.m. of the same date, the redness measured 6 cm. by 5 cm. and the blistered measured 2 cm. by 1 cm. and 1 cm. by 0.3 cm. Staff notified the physician of the incident and skin involvement. The physician did not issue any new orders. At 3:30 p.m. the physician ordered Augmentin (antibiotic) 875 milligrams (mg.) twice a day for 10 days in response to a urine sample sent to the laboratory. On [DATE] at 12:15 p.m. the Administrator stated the facility did not have a policy for the use of hot packs. The facility stocks a Nexcare gel pack and staff should use that and follow the directions on the gel pack. He stated the facility does not recommend the use of a microwaved moist cloth that the staff used for Resident #1. On [DATE] at 9:02 a.m., Staff E (Registered Nurse) stated he put a moist cloth in the microwave and heated it. He then placed it in a plastic bag. He placed the plastic bag directly on the resident's leg. On [DATE] at 10:20 a.m., Resident #1 was interviewed and stated his/her leg became burned because he/she had requested the staff person heat the Fentanyl patch. On [DATE] at 3:30 p.m. observation revealed the resident sitting in an electric wheelchair. At that time, the resident refused to have the burned area examined.

Based on observation, clinical record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment and failed to implement the interventions identified on the care plan to prevent falls for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 64 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 1/30/11, Resident #1 demonstrated long and short term memory problems and modified independence in cognitive skills for daily decision making. Resident #1 exhibited an altered level of consciousness and psychomotor retardation with fluctuating occurrence. Resident #1 required limited physical assistance with transfers, ambulation, toilet use and personal hygiene. The MDS documented Resident #1's balance during transitions and walking as not steady when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Resident #1's [DIAGNOSES REDACTED]. The Interdisciplinary Progress Notes dated 1/08/11 at 9:30 a.m. documented staff received orders to transfer Resident #1 to the hospital and family would meet him/her there. At 1:00 p.m. Resident #1's family called and stated he/she would be admitted to the hospital. The Daily Notes dated 1/17/11 at 11:30 a.m. documented Resident #1 returned to the facility with a [DIAGNOSES REDACTED]. The Resident Care Plan dated 1/17/11 identified Resident #1 at high risk for falls. The approaches included: a. If fall occurs, assess for injury and notify the physician and the family. b. Assess decision making ability, muscle strength, and balance. c. Assure non-skid, well fitting footwear. d. PT/OT screening PRN and follow recommendations. The Resident Care Plan dated 1/17/11 identified Resident #1 with a self care deficit. The approaches included: a. Assist of 1 with transfers and ambulation, using wheelchair for long distances at this time. Able to self propel. b. Assist of 1 with dressing. Needs cues/prompts and reminders. c. Offer/assist of 1 with toileting upon rising, before and after meals/activities, at bedtime and with rounds at night. d. Assist of 1 with hygiene. The Daily Notes dated 1/19/11 at 10:45 a.m. documented Resident #1 received assist of 2 with activities of daily living (ADLs) in the morning and complained of feeling weak. At 9:30 p.m. Resident #1 seemed weak, and required assistance of 1 with cares and ambulation. The Daily Notes dated 1/21/11 at 5:00 p.m. documented Resident #1 as very tired and needed assist of 1 with ADLs. The Daily Notes dated 1/22/11 at 12:15 p.m. documented Resident #1 appeared to be weak, but eager to do things for him/herself. At 5:00 p.m. Resident #1 slept most of the afternoon. The Daily Notes dated 1/23/11 at 12:30 p.m. documented Resident #1 received assistance of 1 with ADLs and ambulated with a slow, slightly unsteady gait. At 5:00 p.m. Resident #1 remained weak. The Daily Notes dated 1/24/11 at 12:45 p.m. documented Resident #1 received assistance of 1 with ADLs and transfers. Resident #1 stated he/she finally felt better. Resident #1 responded slowly at times. Resident #1 needed assistance with hair and teeth and continued to state "just too weak yet". The Daily Notes dated 1/25/11 documented Resident #1 remained weak and required assistance with cares. The Daily Notes dated 1/26/11 documented staff assisted Resident #1 with ADLs and transfers and stated he/she felt weak. A later entry documented Resident #1 remained very weak. The Daily Notes dated 1/27/11 documented Resident #1 continued to be very pale and weak, needing assistance of 1 with ADLs and transfers. The Daily Notes dated 1/28/11 at 6:25 p.m. documented Resident #1 remained weak and needed assistance with cares. The Daily Notes dated 1/30/11 at 11:30 a.m. documented staff assisted Resident #1 with ADLs, transfers, and toileting; voice weak. The Daily Notes dated 1/31/11 at 10:25 a.m. documented Resident #1 responded very slow with answers when speaking with him/her. The Daily Notes dated 2/02/11 at 11:30 a.m. documented staff assisted Resident #1 with all ADLs and transfers. Resident #1 fed him/herself; appetite poor, weak, and coughing. A Plan of Treatment for Outpatient Rehabilitation for physical therapy with a start date of 1/18/11 documented on initial assessment Resident #1 demonstrated weakness and lethargy. A progress note dated 1/25/11 documented Resident #1 as cooperative, but lethargic. Resident #1 ambulated 150 feet with the walker with a very slow gait. Resident #1 needed verbal cues to correct for short stride length and gait mechanics. A progress note dated 2/11/11 documented Resident #1 placed on Hospice care and unlikely to return to the facility. Resident #1 had not reached goals or prior level of functioning. Resident #1 fatigued quickly with decreased stride and extremely slow gait. A Plan of Treatment for Outpatient Rehabilitation for occupational therapy (OT) with a start date of 1/17/11 documented Resident #1 would benefit from skilled OT to address decreased upper extremity strength, sitting/standing balance, activity tolerance, safety, cognition and return to prior level of function. A progress note dated 1/24/11 documented Resident #1 progressed well towards goals. Resident #1 continued to fatigue easily, however continued to improve. Resident #1 demonstrated slow performance time and increased time to process commands. A progress note dated 1/31/11 documented Resident #1 needed limited assist with total body dressing with cues for sequencing and task completion. Halfway through taking his/her shirt off Resident #1 quit. When asked what was wrong Resident #1 stated he/she got confused. Resident #1 needed a reminder he/she was taking his/her shirt off. Resident #1 continued to need limited assist with all steps of toileting. Resident #1 continued to demonstrate slow response time with all activities. The OT Daily Documentation dated 2/01/11 documented Resident #1 needed extensive verbal cues for total body dressing, and 3 step toileting with moderate assist of 1 with transfers. Resident #1 required extensive verbal cues to continue. On 2/02/11 Resident #1 required increased verbal cues for sequence, stating in the middle of upper body dressing "What am I doing?" OT notified nursing of Resident #1's decreased performance and increased verbal cues for processing and sequencing. An Incident Report Form dated 2/03/11 at 5:35 a.m. documented Resident #1 got off the toilet without assistance in his/her stocking feet and staff found him/her on the floor. Resident #1 could not state what happened, but denied hitting his/her head or pain. The Daily Notes dated 2/03/11 at 8:30 a.m. documented Resident #1 complained of his/her left hip hurting some and would not bear weight on it. Staff called the physician with an update and to get a left hip X-ray. At 9:30 a.m. staff received new orders to send Resident #1 to the hospital for an exam. An X-ray report dated 2/03/11 documented Resident #1 had a nondisplaced transtrochanteric fracture of the proximal left femur (thigh bone). A Major Injury Determination Form dated 2/03/11 documented Resident #1 fell in the bathroom. Resident #1 did not pull the call light or pendant. Resident #1 previously functioned with assistance of 1. The physician responded Resident #1 sustained a major injury. A History and Physical dated 2/03/11 documented Resident #1's admission to the hospital. The daily notes dated 2/08/11 documented the facility discharged Resident #1 due to his/her admission to the hospital hospice program. A facility Progress Note dated 1/17/11 to 01/27/11 documented Resident #1 demonstrated a risk for falls due to a fall history, incontinence of urine, [DIAGNOSES REDACTED]. On 2/03/11 Resident #1 sustained a fall. Resident #1 got up from the toilet without assistance, in his/her stocking feet. The Injury Investigation Follow-Up documented Resident #1 had no falls in the facility, but did have a history of falls at home. Resident #1 had [DIAGNOSES REDACTED]. The report indicated Resident #1 experienced a recent change in mental status, unsteady gait and balance, ADL ability, mobility and decline in cognitive skills. The report identified voiding urgency and "stocking footed" as potential contributing factors in the fall. The Quality Assurance Investigation Form dated 2/03/11 documented staff saw Resident #1 at 5:25 a.m. 10 minutes before the occurrence. The preliminary recommendations for further preventative measures were not to leave Resident #1 on the toilet until stronger, and encourage Resident #1 to wear gripper socks/slippers when ambulating. During an interview on 2/18/11 at 2:41 p.m. Staff C CNA (certified nursing assistant) stated she worked the night Resident #1 fell . Staff C did not think Resident #2 had been up during the night. Staff C did not assist Resident #1 on the toilet, but she found him/her on the floor. Staff C stated Resident #1 wore socks, not non-skid footwear. Staff C stated Resident #1 needed assistance of 1 staff person. Staff had caught Resident #1 returning from the bathroom him/herself since s/he returned from the hospital, and the resident did not always use the call light. Staff C stated if she found Resident #1 going to the bathroom him/herself she would stay with him/her because she would know Resident #1 was confused. She would leave Resident #1 on the toilet if he/she seemed alert and oriented. Staff C stated Resident #1 went to bed in socks or bare feet. Staff C always put Resident #1's shoes on before walking him/her to the bathroom. During an interview on 2/18/11 at 11:02 a.m. Staff D CNA stated she worked the morning (night shift) Resident #1 fell . Staff D stated as far as she knew, Resident #1 had not been up to the bathroom during the night. Staff D stated staff went to the resident's room and asked if s/he needed to use the toilet. Unsure, Resident #1 decided to try. Staff D walked Resident #1 to the bathroom and sat him/her on the toilet. Resident #1 said it would be awhile, and another resident had the call light on, so Staff D went to help them. Staff D stated she checked on Resident #1 several times and he/she indicated he/she was not ready. The last time someone checked on Resident #1 they found him/her on the floor. Staff D stated they caught Resident #1 getting up and not using the call light since returning from the hospital. Staff D stated Resident #1 wore regular socks (during the fall), not non-skid footwear. Staff D stated Resident #1 always wore socks at night. Staff D stated "I suppose it could be slippery, but he/she always wore socks at night ". During an interview on 2/22/11 at 9:28 a.m. Staff E CNA stated he worked full time night shift. Staff E stated Resident #1 usually slept through the night, but had episodes of incontinence so they would get him/her up 2 times a night to go to the bathroom. Staff E stated they were required to put shoes on Resident #1 when getting him/her up. Staff E stated he never witnessed Resident #1 getting up by himself/herself. Staff E stated he always stayed with Resident #1 when s/he sat on the toilet because the resident remained pretty shaky. If Resident #1 said it would be awhile, Staff E stated he would still stay with him/her. During an interview on 2/22/11 at 10:16 a.m. Staff F Licensed Practical Nurse (LPN) stated she worked the night Resident #1 fell . Staff F stated about 5:25 a.m. she finished the medication pass on the floor Resident #1 resided on and she saw Resident #1 on the toilet. Staff F assumed the CNAs knew. Staff F passed a couple of medications on another hall and probably 10 minutes later, she heard they found someone on the floor. Staff F stated it would be hard to know if Resident #1 got him/herself up at night because s/he was so quiet. Staff F thought Resident #1 normally used the call light, and that Staff D reminded him/her to use it when Staff D left him/her on the toilet. Staff F stated shoes or gripper socks should be put on any resident when getting them up to walk. Staff F stated Resident #1 should have worn non-skid footwear and she addressed it with the staff member who took him/her to the bathroom and the other staff. Staff F stated "once they hit that smooth linoleum they are going to slide ". Staff F stated it was not safe to wear socks if the resident walked by themselves or with staff. During an interview on 2/22/11 at 9:56 a.m. Staff G LPN stated Resident #1 usually slept through the night. Staff G stated Resident #1 did not use the call light or the call pendant. Staff G stated Resident #1 called out, or when they checked his/her roommate on rounds, they asked him/her if s/he wanted to get up. Staff G stated Resident #1 would get up on his/her own without using the call light. Staff G stated they always put Resident #1's shoes on when getting him/her up. Staff G stated they are always to put non-skid footwear on. Staff G stated Resident #1 should not have been left alone on the toilet. Staff G stated she received the report, if you got Resident #1 up, you stayed with him/her. During an interview on 2/22/11 at 9:06 a.m. Staff I CNA stated they checked on Resident #1 every 2 hours. Staff I stated if she got Resident #1 up she made sure s/he had slippers or shoes on. Sometimes Resident #1 would get out of bed before they got there. Staff I stated she stayed with Resident #1 when in the bathroom. She stayed with residents so they didn't try to get up by themselves and fall. Staff I stated she always made sure residents had non skid footwear on because the bathrooms had a smooth floor. During an interview on 2/18/11 at 11:21 a.m. Staff A, Co-Director of Nursing (Co-DON) verified the number of the room Resident #1 resided in. During an observation on 2/18/11 at 11:23 a.m. the room Resident #1 resided in had a carpeted floor. Resident #1's bathroom had a smooth vinyl surface with 1 grip strip in front of the toilet. During an interview on 2/22/11 at 8:31 a.m. Staff A stated Resident #1 should have worn non skid footwear when staff assisted him/her to the bathroom.