Every finding on record at Parkridge Specialty Care

Based on the Provider History Report, State Agency Website, Quality Assurance and Performance Improvement Plan (QAPI), staff interview, and facility policy review, the facility failed to adequately address repeat regulatory violations in the following regulatory categories: F812, F880, F725, and F684. The facility reported a census of 86. Findings include: A review of the State Agency Website documented the following deficiencies: F684: 8/11/22, 8/28/24, 10/7/25, and again most recently with the survey ending 5/20/26. F725: 8/11/22, 2/26/24, and again with the survey ending 5/20/26. F812: 8/11/22, 8/28/24, 10/7/25, and with the survey ending 5/20/26. F880: 8/11/22, 2/26/24, 8/28/24, and again with the survey ending 5/20/26. A review of the Federal Provider History Report, printed on 5/20/26, verified the findings of the State Agency Website. In an interview on 5/20/26 at 4:05 PM the Administrator acknowledged the repeat deficiencies and stated the facility would implement a performance Improvement Plans (PIPs), to address the four repeated categories. She cited staff turnover as the cause for repeated issues.

Based on direct observation, clinical record review, staff and resident interview, and facility policy review the facility failed to maintain adequate staffing to ensure residents had access to timely requests for help, as noted by excessively long call light times. The facility reported a census of 86. Findings include: 1. On 5/12/26 from 3:15 PM until 3:43 PM a continuous direct observation identified a call light for Resident #11 continuously engaged, only changing status at 3:43 PM when a staff member finally entered the room. Review of clinical records from this incident didn't document a call light. Resident #11 confirmed he pushed the call light. On 5/12/26 at 3:45 PM Resident #11 stated the staff member observed responding to the light at 3:43 PM was the first staff member to address his light.On 5/12/26 at 3:17 PM Resident #11 and Resident #11's Representative stated call lights take a significant amount of time, often lasting well over 15 minutes. Resident #11 stated It can take a while to get people in here. He added during times of high demand no one comes when he presses his call light, and Resident #11 Representative supported his statement.2. On 5/13/26 at 8:10 AM Resident #13 reported she has waited over an hour for assistance with her call light. She stated she's concerned the facility didn't have enough staff, and she noted weekends and the overnight shift are the worst when it comes to staffing.The Zone Activity Report 5/8/26 through 5/14/26 for room [ROOM NUMBER] documented the call light response time greater than 15 minutes on 5/12/26 at 4:50 PM until 5:19 PM, 29 minutes.The Zone Activity Report 5/8/26 through 5/14/26 for room [ROOM NUMBER] documented the following call light response times greater than 15 minutes:a. 5/8/26 i. 7:38 AM to 8:04 AM, 26 minutes ii. 9:13 AM to 9:31 AM, 18 minutesb. 5/9/26 i. 9:54 AM to 10:27 AM, 33 minutes ii. 1:46 PM to 2:11 PM, 25 minutesc. 5/10/26 i. 4:41 PM to 5:17 PM, 36 minutesd. 5/13/26 i. 6:43 PM to 7:01 PM, 18 minutesThe Zone Activity Report 5/8/26 through 5/14/26 for room [ROOM NUMBER] documented the following call light response times longer than 15 minutes:a. 5/8/26 i. 7:36 PM - 8:05 PM, 29 minutesb. 5/11/26 i. 5:20 PM - 5:56 PM, 36 minutesc. 5/12/26 i. 1:01 PM - 1:34 PM, 33 minutesd. 5/13/26 i. 11:34 PM - 11:59 PM, 25 minutese. 5/14/26 i. 5:49 PM - 6:07 PM, 18 minutesThe Zone Activity Report 5/8/26 through 5/14/26 for room [ROOM NUMBER]A included a call light response time greater than 15 minutes on 5/14/26 from 3:09 PM until 3:28 PM, 19 minutes.The Zone Activity Report 5/8/26 through 5/14/26 for room [ROOM NUMBER] A included the following call light response times greater than 15 minutes:a. 5/8/26 i. 12:43 PM - 1:05 PM, 22 minutes ii. 6:50 PM - 7:07 PM, 17 minutesThe Zone Activity Report 5/8/26 through 5/14/26 for room [ROOM NUMBER] B listed the following call light response times greater than 15 minutes:a. 5/19/26 i. 8:17 AM - 8:52 AM, 35 minutesb. 5/11/26 i. 8:39 AM - 9:06 AM, 27 minutesc. 5/12/26 i. 4:42 PM - 5:00 PM, 18 minutesd. 5/13/26 i. 9:02 AM - 9:21 AM, 19 minutes ii. 6:26 PM - 6:54 PM, 28 minutes iii. 7:12 PM - 7:32 PM, 20 minutesThe Zone Activity Report 5/8/26 through 5/14/26 for room [ROOM NUMBER] listed the following call light response times greater than 15 minutes:a. 5/9/26 i. 7:59 PM - 8:21 PM, 22 minutesb. 5/13/26 i. 4:53 PM - 5:23 PM, 30 minutes ii. 8:03 PM - 8:23 PM, 20 minuteOn 5/18/26 at 3:13 PM Staff H, Registered Nurse (RN), stated the facility standard is 10 minutes for a standard call light and 5 to 7 minutes for a bathroom call light. She stated this is better than the federally mandated 15 minutes. She stated while much of the time staffing's good, weekends are horribly understaffed and she's had residents complain to her about the long wait times.On 5/18/26 at 3:46 PM Staff D, Certified Medication Aide (CMA), stated the call light timeframes in the facility are 5 minutes for the bathroom and 15 minutes or less for everything else. She stated she didn't know if the call light system's accurate, she knows it had issues and made mistakes before. She noted when she reset the call lights sometimes, they stay on for a long period of time.On 5/20/26 at 10:30 AM the Director of Nursing (DON) stated she has provided substantial education on the 15-minute regulatory requirement for call lights, and noted it's something the facility's still working on. She noted the facility's still hiring staff members and providing education, and acknowledged it isn't appropriate for such long call lights to occur.The Answering the Call Light policy revised March 2021 directed it does not address appropriate call light timeframes. It states the purpose for the policy is to ensure timely response to the residents' requests and needs.

Based on clinical record review, facility policy review, resident and staff interview, the facility failed to uphold the established grievance process when staff members failed to report repeated resident grievances to management. The facility reported a census of 86.Findings include:Review of Grievance Logs from January 2026 through May 2026 documented at least 7 instances of lost or missing resident items, with 3 of them documenting missing clothing.1. On 5/12/26 at 11:39 AM Resident #1's Representative stated the family is constantly reporting missing clothing to the Certified Nurse Aides (CNAs). Resident #1's Representative stated they have clothing go missing so often they have started buying outfits every week to keep up.2. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #11's entry date as 4/1/26. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.On 5/12/26 at 3:17 PM Resident #11 stated he lost T-shirts when he first entered the building on 4/7/26. He stated he knew he'd told someone, but it'd been so long he gave up on getting them back.3. On 5/12/26 at 4:24 PM Resident #2's Representative stated their loved one's clothes are going missing so often the family is having to spend good money just to ensure their loved one has clothes at all. Resident #2's Representative stated they told a number of staff members but they have gave up on getting any of it back, and it felt like no one takes them seriously.On 5/13/26 at 2:54 PM Resident #3's Representative stated they have notified the facility of numerous items this year alone that have gone missing. Resident #3's Representative stated the most recent is a wallet/purse that has been missing for several weeks, and she knows she told CNAs about the issue but it hasn't been addressed.4. On 5/14/26 at 8:42 AM Resident #4 Representative stated clothing takes a very long time to come back from laundry if it comes back at all. Resident #4 Representative stated she looked for clothing herself in the laundry room and couldn't find what's missing, but noted she'd seen other residents wearing clothes she suspected belonged to her family members.5. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 13, indicating intact cognition.On 5/14/26 at 12:51 PM Resident #13 stated she's currently missing a number of articles of clothing, and stated she has told CNAs that they are missing. She stated she hasn't had anyone find the items or address the issue with her. Resident #13 stated the last time she brought it up to laundry they brought a small cart of items to her to look through, but she couldn't find the missing articles.6. On 5/15/26 at 1:29 PM Resident #5's Representative stated her loved one had clothes go missing that never returned. Resident #5's Representative stated the facility would take the clothes when they were soiled to wash them and often times, they would just not get them back. Resident #16 Representative knows she reported this, but it wasn't addressed.On 5/18/26 at 4:18 PM Staff K, CNA, stated residents have complained to her about missing clothing. Staff K stated when a resident complained about missing clothing she talked to laundry and if they can't find it, sometimes she tells her supervisor and sometimes she doesn't.On 5/18/26 at 3:46 PM Staff D, Certified Medication Aide (CMA), stated residents have complained to her about their clothing going missing. Staff D stated the laundry department can be slow about labeling things. Staff D stated when a family complained to her about laundry missing, she takes them to the laundry lost and found when able, but she didn't what the procedure is after that if they can't find the missing clothes.On 5/18/26 at 3:13 PM Staff H, Registered Nurse (RN), stated she had residents complain to her about missing laundry. Staff H stated she tried to resolve the issue by informing laundry and assisting them in looking for the missing items before getting leadership involved, but she didn't know when she should get leadership involved.On 5/13/26 at 1:45 PM observed a large amount of lost-and-found laundry, filling a small room with overflow kept in numerous plastic totes in the primary laundry room.On 5/13/26 at 1:45 PM the Laundry Supervisor (LS) stated the facility holds on to missing laundry for a period of about 6 months, after which staff members are free to take it home or donate it outside of the facility. LS stated she made every effort to locate the clothing before that period of time passed. LS acknowledged she got some reports of missing items, but couldn't articulate when she should get facility leadership involved.On 5/20/26 at 4:05 PM the Administrator stated anyone can fill out a grievance form. The Administrator reported they expected staff members to fill out a grievance form when they can't immediately find something that has been misplaced. The Administrator acknowledged this should've been done in each case for missing clothing.The Facility Policy and Procedure dated May 2026 directed a subsection of Grievance Procedure, does not contain instructions for staff members reporting complaints or grievances to facility leadership. It addresses the complaint process for non-staff members.

Based on observations, staff interview, and policy review, the facilty failed to complete glove change and hand hygiene during personal cares, implement Enhanced Barrier Precautions (EBP) as indicated, and proper glucometer cleaning for 3 of 7 residents reviewed for infection control (Resident #8, #11, and #15). The facility reported a census of 86. Findings include:1. Resident #8's Minimum Data Set (MDS) completed on 3/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Diagnoses included Alzheimer's disease (progressive memory loss) and stroke (brain tissue damage). The MDS noted Resident #8 depended on staff for chair to bed transfers, bed mobility, personal hygiene, and toileting hygiene.On 5/12/26 at 12:45 PM observed Staff F, Hospice Certified Nursing Assistant (CNA), and Staff G, Hospice CNA, enter Resident #8's room to complete toileting cares and personal hygiene. Staff F and Staff G put gloves on, transferred Resident #8 from the wheelchair to the bed via a mechanical lift, and proceeded to complete cares. After they removed the soiled incontinence brief, Staff F held Resident #8 on their side while Staff G used wet wipes to clean Resident #8's perineal area due to visible urine and fecal residue. Staff G didn't perform hand hygiene or change gloves after completing perineal cares. Both staff members rolled Resident #8 onto their back, placed a new incontinence brief, redressed, and repositioned them. During this time, Staff G touched Resident #8's hand, head wrap, glasses, clothing, blankets, and bed remote control with the same pair of gloves worn during perineal cares. After Resident #8 voiced no further needs, both staff members removed their gloves and completed hand hygiene.On 5/14/26 at 4:00 PM Director of Nursing (DON) acknowledged staff should've completed a glove change and hand hygiene after completing perineal cares and before resuming resident cares. The DON stated that staff shouldn't wear the same pair of gloves throughout cares.The Handwashing/Hand Hygiene policy revised August 2019 instructed that all personnel shall follow the handwashing and hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy directed staff to use an alcohol-based hand rub containing at least 62% alcohol or alternative soap and water for the following situations:a. Before and after direct contact with residentsb. Before moving from a contaminated body site to a clean body site during resident caresc. After handling used dressing or contaminated equipmentd. Use of gloves doesn't replace handwashing or hand hygiene, and integrating glove use along with routine hand hygiene represents the best practice for preventing healthcare-associated infections2. Resident #11's Minimum Data Set (MDS) completed on 4/7/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses included chronic obstructive pulmonary disease, dysphagia (swallowing difficulties), and stroke. The MDS documented the presence of a feeding tube due to swallowing difficulties.The Care Plan Focus initiated 4/2/26 indicated Resident #11 used tube feedings for nutrition. Interventions included Enhanced Barrier Precautions (EBP), which staff added to the Care Plan on 4/3/26.On 5/12/26 at 3:15 PM Resident #11's room lacked signage, either outside on the door or inside the room, indicating the need for staff to follow Enhanced Barrier Precautions (EBP) during cares. On 5/12/26 at 3:45 PM staff placed an EBP sign on the door.On 5/18/26 at 3:13 PM Registered Nurse (RN) Staff H explained that staff use Enhanced Barrier Precautions (EBP) as a standard when caring for residents with wounds and indwelling devices like catheters or gastric tubes (feeding tubes). Staff H noted personal protective equipment (PPE) included gloves and gowns.On 5/18/26 at 3:46 PM Staff D, Certified Medication Aide, reported Enhanced Barrier Precautions (EBP) consisted of gowns and gloves for residents with indwelling devices or wounds. Staff D stated EBP applied to all cares that involve touching the resident if a sign existed on the door, but staff don't need EBP if no sign existed on the door.On 5/20/26 at 10:30 AM the DON explained that staff should post Enhanced Barrier Precautions (EBP) warnings or signs on doors to alert staff.The Enhanced Barrier Precautions policy revised 3/28/24 directed:a. The facility will communicate with staff to ensure that staff are aware of which residents require the use of EBP prior to providing high-contact care activitiesb. Staff should use EBP for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk3. Resident #15's Minimum Data Set (MDS) completed on 5/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the presence of an infected wound.The Care Plan Focus initiated 5/7/26 indicated Resident #15 had a skin impairment due to the presence of a right foot surgical wound. The Interventions included the use of Enhanced Barrier Precautions (EBP).The Progress Note dated 5/7/26 at 8:51 PM documented Resident #15 admitted to the facility. The note indicated Resident #15 had a wound to the right fifth toe amputated site along with a wound vac (vacuum-like medical device that uses gentle suction to remove excess fluid and bacteria).The Progress Note dated 5/7/26 at 9:05 PM documented the presence of a peripherally inserted central catheter (PICC) line in Resident #15's left arm. The note defined a PICC line as a long, thin tube inserted into an arm vein and threaded through to a large central vein near the heart, which staff use for long-term treatments like administering antibiotics.Resident #15's May 2026 Medication Administration Record (MAR) included the following medication orders:a. Cefepime HCl (antibiotic): Infuse 2 grams intravenously (IV) every 8 hours related to pyoderma gangrenosum (painful skin wounds)b. Lantus (insulin): Inject 25 units subcutaneously two times a day for type 2 diabetesc. Lispro (insulin): Inject 10 units subcutaneously before meals related to type 2 diabetesd. Lispro: Inject sliding scale insulin subcutaneously per blood sugar readings 4 times per [NAME]. Flush PICC line with 10 milliliters (ml) normal saline before and after medication administration and every 12 hours as neededOn 5/13/26 at 11:21 AM Staff I, Licensed Practical Nurse (LPN), obtained a blood sugar reading on Resident #15 as ordered. Once Staff I received results, Staff I used an alcohol swab to wipe down the glucometer (small device used to test for blood sugar). After comparing the blood sugar results to physician orders, Staff I administered the sliding scale Lispro insulin into Resident #15's abdomen area. During this process, Staff I wore gloves but didn't wear a gown as outlined per Enhanced Barrier Precautions (EBP) standards.On 5/20/26 at 10:30 AM the DON explained that staff should've followed Enhanced Barrier Precautions (EBP) procedures. The DON expected staff to wear both gloves and gowns, per EBP guidelines, during medication administrations. The DON explained that when sanitizing a glucometer after resident use, staff shouldn't do a quick wipe-down with an alcohol swab. Instead, staff should place the glucometer on a non-permeable barrier, use a Sani wipe to wipe the machine down to maintain a wet surface area, and let it sit for the recommended amount of time.The Enhanced Barrier Precautions policy revised 3/28/24 outlined the following:a. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activitiesb. Staff will initiate an order for EBP for residents with wounds (such as unhealed surgical wounds) or indwelling medical devices (such as central intravenous lines)c. PPE for EBP remains necessary when performing high-contact care activitiesd. Staff should use EBP for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observations, clinical record review, resident interviews, staff interviews, and policy review, the facility failed to provide adequate resident supervision during severe weather warning as well implement Care Plan interventions after a series of falls (Resident #16) for 1 of 9 residents reviewed for supervision. The facility reported a census of 86. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS included diagnoses of difficulty in walking, cognitive communications defect, Wernicke's Encephalopathy (brain damage caused by vitamin B1 deficiency), weakness, need for assistance with personal cares, and generalized muscle weakness. The Care Plan revised 5/1/26 documented Resident #3's had a risk for falls. The Care Plan included the following Interventions:a. 4/23/26: Resident #3 had anxiety during tornadoes, please don't leave her unattended. b. 3/11/26: obtain a UA (urinary analysis) with a culture and sensitivity (C&S).c. 3/12/26: Obtain UA with C&S and treat. The Incident, Accident, Unusual Occurrence Note dated 4/23/26 labeled Late Entry indicated Resident #3 sat in their recliner during an active tornado warning with a call light nearby. Resident #3 attempted to self-transfer and lost her balance. The staff found Resident #3 on her right side with a cut on her lip and redness on her face. She had nonreactive pupils on her right eye. Attempts to contact the nurse who responded to Resident #3's fall on 4/23/26 occurred, but the nurse no longer worked at the facility and didn't respond to the contact attempts. On 5/18/26 at 3:13 PM Staff H, Registered Nurse (RN), stated cognitively disabled residents don't have the right to put themselves in dangerous situations. Staff H stated she didn't work the night of the tornado, but she'd have kept residents with cognitive disabilities close and make sure they're supervised and accounted for to keep them safe. On 5/18/26 at 3:46 PM Staff D, Certified Medication Aide (CMA), stated she didn't work the evening of the tornado. Staff D stated they're instructed to put cognitively disabled residents in a safe place where they can be monitored and assign staff to residents to ensure they have help close at hand. Staff D stated for their safety, residents prone to wandering or getting up on their own should be watched during the emergency. On 5/18/26 at 4:18 PM Staff K, Certified Nurse Aide (CNA), stated they assign staff members to people with dementia and other illnesses that impact cognition during disasters like tornadoes to keep them safe, but clarified she didn't work the evening of the tornado. On 5/18/26 at 4:39 PM Staff L, CNA, stated during disasters like the tornado, staff are instructed to take residents with dementia and other cognitive impairments to a shower room or other large safe area to ensure they have supervision during the disaster. On 5/20/26 at 10:30 AM the Director of Nursing (DON) stated she didn't have a good answer as to why supervision wasn't provided to Resident #3 during the disaster and agreed it should've been provided. The Severe Weather, Tornado Site Plan policy lacked instructions for cognitively disabled residents or residents who are prone to wandering.

Based on clinical record review, resident interviews, staff interviews, and policy review, the facility failed to complete resident assessments for 2 of 2 residents reviewed for assessment and interventions (Residents #3 and #4). Resident #3 lacked the completion of neurological checks (neuros) after an unwitnessed fall. Resident #4 lacked nursing assessment and follow-up post same-day surgery. The facility reported a census of 86.Findings include:1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #4 depended on staff for personal care needs (bathing and toileting) and relied on a wheelchair for ambulation. The MDS included diagnoses of acute kidney failure, diabetes, and incontinence. The Nurses Note dated 2/27/26 at 12:22 PM indicated the Advanced Registered Nurse Practitioner (ARNP) completed a pre-operative physical on Resident #4 related to same-day surgical procedures scheduled for 3/12/26. Procedures included assessments of the urinary bladder and urinary tubes, laser lithotripsy (kidney stone removal), and urinary stent exchange. The Alert Note dated 3/11/26 at 11:39 AM identified check in for surgery on 3/12/26 at 11:30 AM. The Orders - Administration Note dated 3/11/26 at 11:35 PM reflected Resident #4 had a nothing by mouth (NPO) status for their procedure on 3/12/26. The Patient Visit Information indicated Resident #4 received instructions with the packet on 3/12/26 at 3:26 PM. The instructions directed in handwriting to remove their stent on Monday. The Appointment/Visit Note dated 3/12/26 at 4:53 PM documented Resident #4 returned to the facility after a same-day surgical procedure. Resident #4's daughter gave paperwork to the nurse. The Encounter Note dated 3/13/26 at 12:00 AM the ARNP completed a post-operative visit and noted Resident #4 had kidney stones removed the day before. The Nurses Note dated 4/7/26 at 5:47 PM documented a urinary stent removal. Resident #4 tolerated it well with no issues noted. The clinical health record lacked post-surgical physician orders and nursing assessments upon Resident #4's return to the facility on 3/12/26. There weren't documented care instructions or any additional follow-up assessments related to the procedure. The Progress Note on 4/7/26 was the first documented nursing entry identified related to the surgical procedure on 3/12/26. On 5/13/26 at 4:15 PM Staff A, Registered Nurse (RN), recalled Resident #4 when returned to the facility from the same-day procedure. However, they weren't the nurse responsible for entering the new orders. Staff A explained afterwards they were off work for an extended time. Upon their return, Staff A learned Resident #4 still had their urinary stent in place. Staff A explained this is typically removed shortly after a procedure and made arrangements for this to be removed immediately. Staff A acknowledged the clinical health record lacked nursing assessment post-procedure for Resident #4. Ideally, when residents return from procedures like this, nursing staff would take at least a set of vitals and complete an assessment. Nursing staff would pass the information along and each nursing shift would monitor and document an assessment of the resident for the next 72 hours via Hot Charting. On 5/13/26 at 4:30 PM the Director of Nursing (DON) recalled discussions with nursing staff regarding Resident #4's procedures prior to the surgery date and the presence of a urinary stent upon their return. The DON reviewed how the stent should be removed and to reach out if any further questions or concerns with removal occurred. The DON stated staff alerted them to the presence of the urinary stent on 4/7/26. They ensured nursing staff completed an assessment prior to the stent removal. The DON reviewed Resident #4's Patient Visit Information from 3/12/26 and acknowledged the stent should've been removed prior to 4/7/26. Upon a resident's return, nursing staff should review for any orders. If none are provided, staff should contact the medical provider. Nursing staff should also complete an assessment, including vitals and visualization of the surgical site. Further nursing assessments and follow-up related to the surgery should be completed for the next 3 days. On 5/18/26 at 3:57 PM the facility's Medical Director explained urinary stents are typically removed about a week after placement. If indicated by the urologist, it can remain longer. The Medical Director confirmed the facility staff didn't contact them regarding the stent and was aware it wasn't removed after a week. The Change in Resident's Condition or Status policy revised February 2021 directed the following: a.The nurse will notify the resident's attending physician or physician on-call when there has been a significant change in the resident's physical/emotional/mental condition or need to alter the resident's medical treatment significantly. b.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 2. Resident #3's Minimum Data Set (MDS) discharge assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS included diagnoses of difficulty in walking, cognitive communications defect, Wernicke's Encephalopathy (brain damage caused by vitamin B1 deficiency), weakness, need for assistance with personal cares, and generalized muscle weakness. The Care Plan revised 5/1/26 documented Resident #3 had a risk for falls. The Incident, Accident, Unusual Occurrence Note dated 3/10/26 at 8:00 PM identified a Certified Nurses' Aide (CNA) told the nurse about Resident #3 on the floor. The Unwitnessed Fall report dated 3/10/26 at 8:00 PM The Communication – with Physician dated 3/13/26 at 3:05 AM documented notification to the physician of Resident #3's fall. The Incident, Accident, Unusual Occurrence Note dated 4/23/26 at 10:00 PM reflected during a tornado watch, Resident #3 attempted to self-transfer and lost her balance. The staff found her on her right side with a cut on her lip and redness on the right side of her face. He pupils were nonreactive on out right eye. The provider gave okay to send out. The Neurological Eval dated 4/23/26 at 8:45 PM printed 5/13/26 lacked signatures for the first 9 sections. Section 10 and 11 included signatures dated 5/11/26. Section 12 (third 8-hour check) was signed 4/25/26. Section 13 and 14 remained blank with section 15 (sixth 8-hour check) signed 4/26/26. Section 16 and 17 remained blank and Section 18 got signed 4/27/26. The SPN – Focused Evaluation dated 4/24/26 at 2:45 AM indicated Resident #3 returned from the hospital after her fall the night before. The CT Scan (specialized imaging) was negative. On 5/18/26 at 3:13 PM Staff H, RN, stated neurochecks are to be initiated immediately upon a resident having an unwitnessed fall. She clarified if the resident is sent out to the emergency room, neurochecks should resume as soon as the resident returned from the hospital and should be completed in sequence after that. On 5/20/26 at 10:30 AM the DON stated she expected staff to resume neurochecks at the time they returned to the facility. She clarified the nurse who should've started the neurochecks process had resigned from the facility and had been unavailable for follow-up after Resident #3's fall. The Neurological Assessment policy revised October 2010 directed neurological assessments are indicated in cases where a resident has an unwitnessed fall or a fall involving head trauma.

Based on observations, interviews, clinical record reviews, and facility policy review, the facility failed to have an order for a resident to self-administer their own medications before leaving them unattended with Miralax for 2 of 2 residents observed (Residents #10 and #16). The facility reported a census of 86. Findings include:Findings include:1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.The Physician Orders included an order dated 4/18/26 to give Miralax (powdered medication mixed with liquid) one time per day for constipation. The Physician Orders didn't include an order to allow Resident #10 to self-administer medications.On 5/12/26 at 12:27 PM Staff E, Certified Medication Aide (CMA), left a cup of prepared Miralax with Resident #10. By the end of lunch service, Resident #10 hadn't consumed the Miralax, and it's left behind on the table. Dietary staff eventually threw away the cup of Miralax as they cleaned up from the meal service.Resident #10's May 2026 Medication Administration Record (MAR) documented Resident #10 took the Miralax as ordered on 5/12/26.On 5/14/26 at 2:38 PM Staff E explained Resident #10's usually pretty good with taking Miralax but refuses every once in a while. Staff E reported Resident #10 took the medication on 5/12/26 and visually confirmed the cup's empty. When informed Resident #10 hadn't consumed the Miralax, Staff E stated they may've looked at a different empty cup.2. Resident #16's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment.The Physician Orders included an order dated 6/29/24 directed staff to give Miralax one time per day for constipation. The Physician Orders didn't include an order to allow Resident #16 to self-administer medications.On 5/14/26 at 6:50 AM watched Staff D, CMA, prepared Miralax for Resident #16. Staff D mixed the medication with approximately 8 ounces of water. Staff D took the Miralax and other oral medications into Resident #16's room to administer. Resident #16 took all oral medications, drank a few sips of Miralax, and placed the remaining amount on the bedside table. Staff D left the room with the unfinished Miralax sitting on the bedside table. Afterwards, Staff D explained Resident #16 didn't like to drink the Miralax all at once and sipped on it throughout the morning. Staff D noted Resident #16 took additional medications in the late morning and they would ensure Resident #16 consumed the Miralax.On 5/14/26 at 4:00 PM the Director of Nursing (DON) acknowledged staff left Miralax in Resident #16's room unattended, which isn't acceptable. The DON stated the Miralax timing or how staff presented it could be adjusted to better meet resident needs and preferences, such as offering the Miralax in smaller sips as Resident #16 takes each oral medication separately.On 5/20/26 at 10:30 AM the DON explained staff administering medications should stay with the resident and watch them to ensure they took all of their medications.The Administering Medications policy revised April 2019 directed the following: a. Medications are administered in accordance with prescriber orders, including any required time frame. b. Medication administration times are determined by the resident need and benefit and not staff convenience. c. Medications are administered within one hour of their prescribed time, unless otherwise specified. d. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on direct observation, clinical record review, facility policy review, resident and staff interview, the facility failed to treat residents with dignity and respect. An observation revealed a member of the therapy team ignored the wishes of the resident for 2 of 7 residents screened for dignity related concerns (Residents #13 and #14). The facility reported a census of 86.Findings include: 1. Resident #13's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of heart failure, hypertension (high blood pressure), orthostatic hypotension (low blood pressure upon standing), renal insufficiency (kidney failure), malnutrition, asthma, unsteadiness on feet, generalized muscle weakness, abnormality of gait and mobility.The Care Plan for Resident #13 identified they received Physical and Occupational Therapy services.On 5/14/26 at 12:51 PM Resident #13 identified Staff J, Physical Therapist (PT), and said they weren't a fan of Staff J providing Physical Therapy services because Staff J pushed too hard, often ignoring them when they said they couldn't stand anymore. Resident #13 described Staff J as rude and pushy, and stated other residents complained to them about Staff J.2. Resident #14's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of renal insufficiency, diabetes mellitus (diabetes), chronic pain, malignant neoplasm of bone (bone cancer), bilateral lumbago with sciatica (back pain and sciatic nerve pain impacting both legs), chronic pain.The Care Plan identified Resident #14 currently received Physical and Occupational Therapy services.On 5/14/26 at 12:27 PM Staff J provided therapy services for an unidentified resident. Staff J ignored 3 separate requests from the resident to sit down. The resident cried out I need to sit, but Staff J repeated Just keep going several times with a flat affect. Staff J placed a wheelchair underneath the resident once they began to lose balance.On 5/14/26 at 9:58 PM Resident #14 named Staff J directly and stated they felt Staff J was rude and pushy. Resident #14 shared an encounter with Staff J in which they asked for some water and Staff J told them, they had to say please before they could get some water. Resident #14 reported being out of breath at the time. Resident #14 described Staff J as always rude and condescending, and it makes them feel like Staff J doesn't care.On 5/14/26 at 3:27 PM Staff J described the therapy process as a tough love situation, and stated that's how they encourage residents, though Staff J agreed not all residents find it encouraging.On 5/18/26 at 3:13 PM Staff H, Registered Nurse (RN), stated residents should always be treated with kindness and respect, and Staff H always tried to honor a resident's wishes and requests for help.On 5/18/26 at 3:46 PM Staff D, Certified Medication Aide (CMA), stated the standard is to approach residents respectfully, and if a resident didn't find the approach respectful, Staff D's willing to apologize and reapproach.On 5/18/26 at 4:18 PM Staff K, Certified Nurse Aide (CNA), stated Staff K wants residents to be treated like family, and that means listening to them, honoring their wishes.On 5/20/26 at 1:23 PM the Area Director of Operations (ADO) stated some residents do need something that could be described as tough love. After explanation of the witnessed situation, the ADO clarified the resident should've been allowed to sit down when requested, not when they start to lose their balance.On 5/20/26 at 10:30 AM the Director of Nursing (DON) clarified Staff J's a contracted therapy staff, and not a direct facility staff member. The DON reported they expected all staff, contracted or not, to treat residents with respect and compassion. The DON agreed Staff J should've handled the situation differently, and agreed it's a concern.The Dignity policy revised February 2021 directed residents are treated with dignity and respect at all times.

Based on observations, staff interview, and policy review, the facility failed to ensure appropriate food handling practices were followed for 2 of 2 dining rooms observed. The facility reported a census of 86. Findings include: During a continuous lunch service observation in the Assist Dining Room on 5/12/26 at 12:12 PM, Staff B, Certified Nursing Assistant, used their bare hands to touch and butter a slice of bread at the table for a resident. Once finished the resident proceeded to eat the bread. At 12:38 PM, Staff B sneezed directly into their hand and without completing any hand hygiene, provided feeding assistance to a resident. During a continuous lunch service observation in the Main Dining Room on 5/12/16 at 12:10 PM, observed Staff C, Dietary Aide, touch, cut, and prepare a fresh [NAME] with their bare hands at the table for a resident.During an interview on 5/14/26 at 4:00 PM, the Administrator acknowledged staff should not touch ready-to-eat resident food with their bare hands. During an interview on 5/20/26 at 10:30 AM, the Director of Nursing (DON) reiterated staff should not touch resident food with their bare hands. The staff should wear gloves if they need to touch resident's ready-to-eat food. The DON noted Staff B should have completed hand hygiene after they sneezed into their hands and before assisting residents. The policy Bare Hand Contact with Food and Use of Gloves, February 2016 edition, noted gloves are to be worn whenever handling food directly with their hands (handling ready-to-eat foods, anything food directly touched).The policy Handwashing, February 2016 edition, outlined hands will be washed: a. After using a handkerchief or tissue b. After handling your hair or touching your face c. After using hands to cover your mouth to cough, etc.

Based on observations, facility policy review, clinical record review, staff, and Resident Representative interviews, the facility failed to follow-up after a significant change in weight in short period of time for 2 of 2 residents reviewed (Residents #2 and #11). Both residents had significant changes in weight in less than a month. The facility reported a census of 86 residents. Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] he MDS included diagnoses of diabetes mellitus (diabetes), cerebrovascular accident (stroke), hemiplegia or hemiparesis (partial paralysis), malnutrition, and oropharyngeal phase dysphagia (difficulty swallowing). It documented Resident #2 had an enteral feeding tube due to difficulty swallowing and had lost weight due to an inability to intake food normally.The Care Plan revised 4/14/26 documented Resident #2 had an altered nutritional status due to partial paralysis after a stroke. It instructed staff members to obtain weights as ordered by the physician and per facility policy due to the resident's altered nutritional status.The Weight Summary printed 5/20/26 included the following weights:a.2/11/26: 223.0 pounds (lbs.)b.3/14/26: 220.44 lbs.c.4/4/26: 208.2 lbs.d.4/22/26: 206.1 lbs.From 3/14/26 to 4/4/26, Resident #2 had a weight loss of 12.24 lbs. or 5.553%.The SPN-Nursing/Therapy Communication dated 3/11/26 at 2:25 PM listed a recommendation to discontinue enteral feed and continue with puree and thin liquids - encourage Resident #2 to be up for meals. The Dietary Note dated 4/1/26 at 10:48 AM indicated Resident #2 ate a regular no added salt (NAS) diet, with a level 4 pureed texture, a level 0 thin consistency. His intakes ranged from 0-100% with 14 meal refusals. He took in 0-480 milliliters (ml) and a daily bedtime (HS) snack as desired within the past 30 days. The RD recommended to encourage nutrient dense intakes and offer meal or snack alternates as needed. Continue current nutritional interventions as accepted. Notify the RD of nutritional concerns or changes.The Encounter Note dated 4/6/26 at 12:00 AM regarding an acute/follow-up included the weight from 3/14/26 of 220.44. The note lacked documentation of changes in weight.The Alert Note dated 4/8/26 at 7:26 PM reflected Resident #2 ate 25% or less for 2 or more meals in the day. The facility notified the provided on 3/31/26 and 4/5/26. Resident #2's oral intake appeared to improve. The note listed no new orders (NNO). The SPN - Care Plan Conference dated 4/15/26 at 10:37 AM listed the attendees as the MDS Nurse, the Social Services Designee, and the Activity Director, the family or resident didn't attend. The note reflected Resident #2 had a significant weight loss of over 5% in 30 days. The note lacked documentation of if the weight was expected or planned. He received a nutritional supplement 3 times a day (TID). The Social Services Note dated 4/16/26 at 4:23 PM indicated the facility spoke with Resident #2's Daughter about him discharging to home. The note lacked notification of Resident #2's weight loss.The SPN - Weight Change Notification dated 4/28/26 at 12:44 PM documented a weight of 206.1 as of 4/22/26. Resident #2 had a weight change of 6.5% within 1 month and a 7.5% loss within 3 months. Resident #2 ate 0-100% with a diet of regular NAS, pureed texture, and a thin consistency. His current Interventions were for 4 oz house supplement TID. The SPN-Nursing/Dietary Communication dated 4/28/26 at 12:44 PM listed RD recommendations of 3 oz nutritional juice drink TID with meals.Resident #2's clinical record lacked documentation of an Intervention related to a change in weight from 4/4/26 - 4/28/26.On 5/14/26 at 1:29 PM Resident #2's Representative stated during Resident #2's stay in the facility they noticed him losing weight. They'd mentioned it to staff but didn't know for sure if they did anything. When asked about the type of feeding Resident #2 received, they noted the machine used to provide the enteral feeding would beep often and they'd have to go get nursing staff to fix the problem, which would often take some time.2. Resident #11's Minimum Data Set (MDS) entry assessment dated [DATE] the MDS included diagnoses of diabetes, stroke, and esophageal obstruction (blocked food pipe). It documented the presence of a feeding tube.The Care Plan revised 5/13/26 documented Resident #11 had a potential for altered nutritional status due to the presence of an enteral feeding tube. It instructed staff to obtain weights as ordered and per facility policy.Review of the clinical records titled Weight Summary report revealed Resident #11 lost 27.6 pounds from 4/29/26 to 5/1/26.On 5/12/26 at 3:15 PM observed Resident #11's Representative talking to an unknown nurse and informed them Resident #11's enteral feeding tube wasn't functioning. The observation continued from 3:17 PM. During that time, witnessed Resident #11's enteral feeding not functioning until addressed by staff at 3:42 PM.On 5/12/26 at 3:17 PM Resident #11 and Resident #11 Representative stated it takes a significant amount of time to get staff members to address issues with his enteral feeding tube. Resident #11 believed he'd lost approximately 30 pounds in a short span, though he wasn't sure this was accurate.On 5/14/26 at 9:25 AM the Dietitian stated reweights should take place no later than 7 days after the initial weight showed a potential issue. She confirmed the weight loss for Resident #2 did constitute an issue and noted it could be challenging to get staff members to perform reweighs, though she didn't know why. She stated she's seen a trend in the facility where the standard of 7 days isn't being followed.On 5/14/26 at 11:06 AM Staff M, Certified Nurse Aide (CNA), stated staff members struggled to get reweighs done because staff members are too busy. She stated reweighs aren't as important as providing other care for residents, and it's something that gets cut when they are short-staffed.On 5/18/26 at 3:13 PM Staff H, RN, stated when a resident's weight is higher or lower than 2 pounds different from the last weight, it's standard procedure to reweigh the resident after notifying the provider. She acknowledged this didn't always happen.On 5/20/26 at 10:30 AM the DON acknowledged the sudden weight loss should've triggered a reweigh and noted she didn't have a good answer as to why it didn't happen.The Weight Assessment and Intervention policy revised September 2008 directed any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing.

Based on observation, clinical record review, staff interview, and facility policy review, the facility failed to administer significant medications correctly when a nurse failed to correctly prime an insulin pen before administration, risking the resident not receiving a sufficient dose of the medication for 1 of 8 residents sampled for medication administration (Resident #15). The facility reported a census of 86. Findings include: Resident #15's Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had intact cognition with a score of 15. The MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), renal insufficiency (kidney failure), diabetes mellitus (diabetes), and cellulitis (skin infection) of the right lower limb. The MDS indicated Resident #15 used insulin during the lookback period.The Care Plan revised 5/8/26, documented Resident #15 required insulin therapy for diabetes. The Interventions directed staff members to administer insulin as ordered.Resident #15's May 2026 Medication Administration Record (MAR) documented they received Insulin Lispro KwikPen for the management of diabetes.On 5/13/26 at 11:21 AM, observed Staff I, Licensed Practical Nurse (LPN), pressed the administration button on an Insulin Lispro autoinjector without setting any units of insulin to waste in the autoinjector. Staff I administered the insulin to Resident #15.On 5/13/26 at 11:21 AM, Staff I stated she'd primed the insulin pen.On 5/13/26 at 11:58 AM, Staff I stated she wasn't sure if she'd primed the pen with 2 units of insulin. She confirmed staff should prime the pen with 2 units of insulin before administering the medication.On 5/18/26 at 3:13 PM, Staff H, Registered Nurse (RN), stated facility standard practice required staff to prime two units of insulin before administering the medication. She explained this ensures the resident gets the full dose of insulin and ensures the needle works correctly.On 5/20/26 at 10:30 AM, the Director of Nursing (DON) stated the proper procedure for administering insulin depended on the order. She explained autoinjector pens require that staff prime them with typically 2 units, though that varied based on the autoinjector type. Staff then waste the units, set the correct dosage, and administer the insulin. She stated this ensured the needle worked and the resident received the full dose.The Instructions for Use - Insulin Lispro document Revised July 2023 directed users to prime the pen to remove air from the needle and cartridge that collects during normal use and ensures the pen works correctly. The priming procedure listed to set the pen to 2 units of insulin, holding the pen with the needle pointing upward to collect bubbles at the tip, and push the administration button until it reads zero units while assessing to ensure insulin comes out of the needle tip.

Based on clinical record review, policy review, and staff interview, the facility failed to carry out assessments for 1 of 3 residents reviewed for a change in condition(Resident #1) by failing to carry out timely skin assessments after a hospitalization. The facility reported a census of 38 residents. Findings included:The 11/21/25 Minimum Data Set(MDS) assessment tool, listed diagnoses for Resident #1 which included sepsis(an infection of the blood), weakness, and the need for assistance with personal care. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, stated the nursing staff would examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. A 9/8/25 Care Plan entry directed staff to monitor and document location, size, and treatment of skin injuries and to report abnormalities. 11/18/25 Care Plan entries stated the resident had moisture associated skin damage to the buttocks. 11/29/25 Nurses Notes stated the facility received an order to send the resident to the hospital for evaluation and he admitted for sepsis. A 12/5/25 Nurses Note stated the resident readmitted to the facility. The resident refused a full skin check because he wanted to stay in his chair for dinner.The facility lacked documentation staff reapproached the resident regarding a skin check to include the resident's buttocks between his readmission on [DATE] and 12/8/25. A 12/8/25 Skin Issues Note stated the resident had a new skin issue to the buttocks which measured 0.9 centimeters(cm) x 0.58 cm(length x width) with a pink/red wound bed.On 1/6/26 at 9:36 a.m. the facility Wound Nurse stated the nurse who completed resident admissions was in charge of completing a head to toe skin assessments. She stated with Resident #1, she knew the skin issues he had and there was a potential for deterioration. She stated because of this, she completed an assessment herself on 12/8/25. She stated there was likely the assumption the admitting nurse completed the assessment and that was why other staff did not follow up. On 1/6/26 at 3:22 p.m., the Director of Nursing(DON) stated staff should perform skin assessments on the day of admission and if it is not done, staff should pass this information along to the next shifts. If a resident refused a skin check, staff should offer to attempt again.

Based on clinical record review, policy review, and staff interview, the facility failed to treat 1 of 7 residents (Resident #1) reviewed for dignity with respect by applying multiple incontinent briefs during personal hygiene care. The facility reported a census of 38 residents. Findings included: The 11/21/25 Minimum Data Set(MDS) assessment tool, listed diagnoses for Resident #1 which included sepsis(an infection of the blood), weakness, the need for assistance with personal care. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The MDS stated the resident was dependent on staff for toileting hygiene and toilet transfers. The facility policy Dignity, revised February 2021, stated the facility would care for residents in a manner that promoted and enhanced a sense of well-being, level of satisfaction with life , and feelings of self-worth and self-esteem. 8/25/25 Care Plan entries stated the resident required the assistance of 2 staff for toilet transfers. The entries stated the resident had urinary incontinence and directed staff to assist him to the bathroom and with cleansing. An 11/29/25 Transfer Form stated the resident transferred to the hospital at 10:20 a.m. The resident's Census report documented the resident resided in the 300 Hall on 11/29/25. The Daily Nursing Assignments for 11/29/25 documented Staff C Certified Nursing Assistant(CNA) assigned to the 300 Hall during the 6:00 a.m. to 2:00 p.m. shift on 11/29/25. The November 2025 Documentation Survey Report v2 documented Staff C provided cares for the resident on the 6:00 a.m. to 2:00 p.m. shift on 11/29/25. A 12/2/25 Hospital Shift Summary stated the resident arrived (at the hospital) in 3 pairs of grossly soiled diapers with skin damage.A 12/9/25 Internal Investigation Witness Statement documented that the Director of Nursing(DON) interviewed Staff C. Staff C stated that she took care of the resident on Saturday morning(11/29/25). On 1/6/26 at 11:00 a.m. Staff A CNA stated when she first started at the facility, Staff C directed her to place more than 1 brief on residents. She stated she did not think this was a good idea so did not do this herself. On 1/6/26 at 11:09 a.m. Staff B CNA stated she told Staff C not to place more than one brief on residents because it could make them sick. She stated that she saw Staff C care for Resident #1 in this manner and the last time she told her not to do this was on 11/28/25. Staff B stated she did not report this right away because she thought it would affect Staff C's job. Staff B stated she received education regarding mandatory reporting. On 1/6/26 at 3:22 p.m., the DON stated staff should only apply one brief to residents unless their plan of care directed differently. She stated Resident #1's care plan did not include the use of more than one incontinent brief.

Based on document review, observations, staff interview, and policy review, the facility failed to ensure food served and prepared in accordance with professional standards for food service safety. The facility reported a census of 88.Findings include: Review of August 2025 food temperature logs noted the following: 1.No breakfast temperature documentation for 21 days out of 31 2.No lunch temperature documentation for 21 days out of 31 3.No supper temperature documentation for 10 days out of 31Review of September food temperature logs noted the following: 1.No breakfast temperature documentation for 9 days out of 30 2.No lunch temperature documentation for 11 days out of 30 3.No supper temperature documentation for 21 days out of 30During a continuous lunch service observation on 10/1/25 at 11:45 AM, the following noted 1.An electrical extension cord wrapped to a bar on the service table noted with visible dried food splatter and grime 2.Top of cabinets, which were located above a food prep area, noted with a layer of visible dust 3.Staff B, Dietary employee, noted with painted artificial fingernail with 2 nails having a small [NAME] embellishment During an interview of 10/2/25 at 9:20 AM, the Certified Dietary Manager (CDM) explained food temperatures should be obtained and documented before and after each meal. The CDM acknowledged the condition of the electrical extension cord and top of the cabinets. Both of these areas are wiped down as needed and not listed cleaning checklists. The CDM confirmed dietary staff should not have artificial nails. The policy Food Preparation and Service, version 2.1 (H5MAPL0333), outlined the following: 1. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy 2. The following internal cooking temperatures/times for specific foods are reached to kill or sufficiently inactivate pathogenic microorganisms: a. 145 F for 15 seconds for raw eggs cooked for immediate service, fish (except as listed below), meat (except as listed below) b. 155 F for 15 seconds for ground meat (beef, pork), ground fish c. 165 F for 15 seconds for poultry, stuffed fish, meat, pork, pasta, ratites & poultry, and stuffing containing fish, meat, ratites & poultry 3. Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135 F. 4. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 F for at least 15 seconds 5. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff 6. Food and nutrition services staff keep fingernails trimmed and clean. Jewelry is worn minimally and hand jewelry (i.e., wedding ring) is covered with gloves.The policy Sanitation, version 1.1 (H5MAPL0803), outlined kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The undated Personal Appearance Policy outlined false nails and nail polish not permitted for dietary team members.

Based on clinical record review, policy review, and staff and resident interviews, staff failed to transfer a resident using a technique which would not place pressure on the resident's compromised left foot and failed to notify the podiatrist in a timely manner of an open area for 1 of 3 residents reviewed for skin ulcers(Resident #6). The facility reported a census of 88 residents.Findings included: The Minimum Data Set(MDS) assessment tool, dated 8/20/25, listed diagnoses for Resident #6 which included osteomyelitis(infection of the bone) of the foot, diabetes, and heart failure. The MDS stated the resident required substantial to maximal assistance with chair to bed transfers and listed her Brief Interview for Mental Status(BIMS) score as 3 out of 15, indicating severely impaired cognition. The facility policy Wound Care, revised October 2010, stated the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The policy directed staff to review the resident's care plan to assess for any special needs of the resident.A 4/15/25 Foot and Ankle Surgery Progress note stated the resident had a history of ulceration of the left hallux(the big toe, the first digit of the foot) with underlying osteomyelitis and stated the resident underwent a left hallux amputation on 4/14/25.A 4/21/25 Care Plan entry stated the resident utilized opioid medications related to toe amputation and acute pain.7/17/25 podiatry clinic visit notes stated the resident presented for a follow up of the left hallux amputation completed on 4/14/25. The report stated the resident had no open wounds at the time and directed to follow up in two months or sooner if issues arose. A 7/18/25 Care Plan entry stated the resident had actual impairment of the skin and a diabetic ulcer.A 9/5/25 Advanced Registered Nurse Practitioner(ARNP) Encounter Note stated (the facility) would carry out a culture(a procedure which determined which type of bacteria was present in a specimen) of the left plantar(referring to the underside) foot to assess for possible infection due to deterioration and malaise(a general feeling of discomfort, illness, or uneasiness whose exact cause was difficult to identify) and a significant odor in room.The September Medication Administration Record(MAR) listed a 9/6/25 order for cephalexine(an antibiotic) 500 milligrams(mg) by mouth four times daily for left foot infection. The MAR listed a discontinuation date of 9/8/25. A 9/8/25 ARNP Encounter Note stated the foot culture showed moderate growth and the resident would receive Augmentin(a medication which contained two antibiotics, used to treat bacterial infections) per the susceptibility report for a toe infection. A 9/8/25 Nurses Note listed a new order for Augmentin 875/125 mg twice daily for 10 days. A 9/10/25 SW-Skin Issues Note stated the left plantar foot wound was deteriorating and measured 1.31 centimeters(cm) x 1.42 cm x 0.3 cm(length x width x depth) and stated the wound had pale, red, watery drainage with an odor after cleansing. The facility lacked documentation of podiatrist notification of the resident's left foot open area/infection from the discovery of the wound on 9/5/25 until her podiatrist appointment on 9/17/25. A 9/17/25 podiatry clinic visit note stated the resident presented for a follow up of the left hallux amputation completed on 4/14/25 and that the resident had a new opening on the plantar aspect. The resident did not know how long it had been there. The location of the wound was the subfirst metatarsal head(referred to the base of the big toe) and it probed to the bone. The note stated she did not wear her diabetic shoes and inserts today and was unsure why and wore a protective boot. The resident would continue strict nonweightbearing. Given that the wound probed to the bone, there was a high risk for underlying osteomyelitis. The resident would undergo Magnetic Resonance Imaging (MRI, a non-invasive imaging technique that used a powerful magnetic field, radio waves, and a computer to create detailed images of the body's internal structures, especially soft tissues) and a biopsy would be considered versus further amputation.A 9/17/25 Appointment/Visit Note stated the resident had an MRI scheduled on 10/8/25.A 9/17/25 Nurses Note stated the resident returned from podiatry with a new order for non-weight bearing on the left foot. A 9/24/25 SW-Skin Issues Note stated left plantar foot wound measured 2.03 cm x 1.55 cm x 0.2 cmOn 10/1/25 at 9:41 a.m., Staff C Registered Nurse(RN)/Wound Nurse measured a red open wound on the resident's left plantar foot as 3.5 cm x 2.0 cm(length x width). Staff C did not measure the depth of the wound but stated it was approximately 0.3 cm deep.On 10/2/25 at 2:01 p.m., Resident #6 stated she just had a shower and did not wear shoes but was bare footed when she transferred. She stated she did not wear her shoe unless someone made her. On 10/2/25 at 2:04 p.m., Staff E Certified Nursing Assistant(CNA) stated she assisted the resident in the shower today. She at first stated that the resident wore her post-op shoe during the transfer into the shower chair but then stated that the shoe was in the laundry so she did not wear it and instead wore her blue gripper socks. Staff E stated when the resident stood up, she placed pressure on both feet. On 10/6/25 at 10:47 a.m., Staff F CNA stated she assisted the resident out of bed this morning. She stated she stood and pivoted during the transfer and was flat footed with both feet. She stated the resident did not place pressure on only her heel during the transfer. On 10/6/25 at 11:01 a.m., Staff G CNA stated when they assisted the resident to transfer, she stood and pivoted. She stated staff instructed the resident to just use the right foot but she did place pressure on the left. She stated the resident was not able to avoid placing pressure on her left toe. On 10/6/25 at 11:57 a.m., Staff D Wound Nurse stated the reason she did not notify the podiatrist of the change in the resident's wound(on 9/5/25) was because she had an upcoming appointment(on 9/17/25). She stated during her last appointment, she changed to non-weight bearing.On 10/6/25 at 12:12 p.m., Staff H stated she assisted the resident out of bed on 10/1/25 or 10/2/25. She stated when the resident transferred, she was flat footed and didn't use her heel only. Staff H stated she did not know the resident was to only place pressure on her heel during transfers. On 10/6/25 at 12:39 p.m., the Director of Nursing(DON) stated if there was a concern with a wound, they tried to update the podiatrist as soon as possible, within 24 hours. She stated the resident was a 2 assist with no weight bearing to the lower left extremity. She stated the facility just updated her to be a mechanical lift transfer. When queried as to why this occurred just this morning, the DON stated it was her understanding that the resident completed transfers fairly well before this. She stated if the resident was not able to maintain non-weight bearing during a transfer, they would come up with a different plan. On 10/7/25 at 8:50 a.m., Staff C Podiatrist stated if the resident was not wearing her post-operative shoe or if she had been bearing weight on the left foot since 9/17/25, this could make the ulceration worse. He stated if the resident was unable to maintain non-weightbearing on the left, he expected the facility to make a different plan sooner than after a few weeks. The facility lacked documentation they modified the resident's transfer status to a mechanical lift prior to 10/6/25 in order to maintain non-weight bearing status.

Based on electronic health record (EHR) review, observations, resident and staff interviews, the facility failed to ensure residents were aware of and offered alternative menu options for 2 of 3 residents reviewed for food (Residents #4 and #79). The facility reported a census of 88.Findings include: 1. The Minimum Data Set (MDS) Assessment, completed 7/29/25, revealed Resident #4 with a Brief Interview for Metal Status (BIMS) score of 12, indicating moderately impaired cognitive status. Diagnoses include chronic obstructive pulmonary disease (COPD), chronic pain, diabetes, hemiplegia/hemiparesis, malnutrition, and peripheral vascular/arterial disease. The MDS indicated Resident #4 with a physician-prescribed weight loss regimen which resulted in a significant weight loss within the past six months. The Care Plan revised on 8/6/25 indicated Resident #4 at risk for altered nutrition status related to diabetes, COPD, and advanced age. The Care Plan noted the presence of right above the knee amputation surgical incision with dehiscence and the decision for palliative care. Interventions included to offer meal or snack alternatives as needed, provide meals that are within the diet, and to review the diet routinely by the dietitian/dietary manager. Physician Orders, obtained 10/2/25, listed a diet of small portions with regular textures and thin liquids. The Progress Note dated 9/4/25 at 6:52 PM documented Resident #4 disliked the facility food although trying to consume three meals daily. The Progress Note dated 8/7/25 at 11:48 AM, the RD documented nutritional supplement program had been started due to variable intake and increased nutrient needs related to surgical wound healing. During an interview on 9/29/25 at 1:30 PM, Resident #4 reported they prefer to eat in their room and does not go out to the dining room. The resident indicated they were not aware of how to order alternative menu items if they did not like what was offered. During an interview on 10/1/25 at 12:00 PM, Staff A, Dietary Services Assistant Manager, explained menus are reviewed with residents the day prior by either themselves or the dietary manager. Specific menu selections determined at this time. If a resident received a room tray and does not like what was served, the resident would need to inform one of the Certified Nurse Aide (CNA) who would inform kitchen staff of the alternative item. During an interview on 10/1/25 at 1:30 PM, Resident #4 stated a staff member had not reviewed the day's lunch menu with them prior to the meal. Resident #4 reported they were aware of alternative menu items but unable to recall what's available or where to go for these items. Resident #4 reported the lunch offered this day was so-so. 2. The MDS Assessment, completed 9/5/25, revealed Resident #79 with a BIMS score of 13 indicating intact cognition. Diagnoses include diabetes, hyperkalemia (high blood potassium levels), renal insufficiency/renal failure/end stage renal disease, and sarcopenia (loss of muscle mass, strength, and function). The Care Plan revised on 8/1/25 indicated Resident #79 at risk for altered nutrition status related to advanced age, chronic kidney disease, diabetes, and hyperkalemia. Interventions included to review the diet routinely by the dietitian/dietary manager, to provide meal that are within the diet, and to encourage nutrient-dense intake and offer meal or snack alternatives as needed. During an interview on 9/29/25 at 12:30 PM, Resident #79 reported they prefer to eat in their room & does not go out to the dining room. The resident indicated they are not are able to get alternative menu items. During an interview and observation on 10/1/25 at 1:15 PM, Resident #79 stated a staff member had not reviewed the day's lunch menu with them prior to the meal. The lunch offered was good today but that is not always the case. The lunch tray ticket was still present and noted to have a list of alternative menu items. Resident #79 was not aware of this and explained the print was too small for them to see. During an interview on 10/2/25 at 9:20 AM, the Certified Dietary Manager (CDM) explained they or the assistant dietary manager will visit residents daily to obtain menu selections. The CDM acknowledged they had not visited Resident #79 this week for menu selections. The CDM noted they may not get to Resident #4 every day for menu selections. A new dietary menu system was recently installed at the facility. The CDM reported food preferences do not print on individual tray tickets. Food preferences are available within the system but staff would need to log into the program to obtain. With the new system, the CDM noted residents may not be fully aware alternative menu items print at the bottom of tray tickets.

Based on observation, resident and staff interviews, clinical record review and policy review the facility failed to provide interventions to prevent a deep tissue injury (a type of pressure injury that occurs when underlying soft tissue is damaged due to prolonged pressure, often over bony prominence.) from performing for 1 of 5 residents reviewed (Resident #8) and failed to apply treatment to a Moisture Associated Skin Damage (MASD) area on the coccyx (the final bone at the bottom of the spine) for which resulted in the area had gotten worse and the Advance Registered Nurse Practitioner (ARNP was notified 7 days later. (Resident #9). The facility identified a census of 84 residents. Findings include: Determining the Stage of Pressure Injury: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 1. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] for Resident #8 reflected that the resident was able to make herself understood and able to understand others. The MDS identified the Brief Interview for Mental Status (BIMS) score of 9 for which indicated moderate impaired decision making. The MDS revealed the resident required substantial to maximal assistance for bed mobility, and transfers and totally dependent on putting on/off of footwear. The active diagnoses portion of the Electronic Health Record (EHR) of Resident #8 documented diagnoses of acute osteomyelitis (inflammation of bone caused by infection) of right ankle and foot, diabetes mellitus, heart failure, acquired absence of left great toe, cerebrovascular disease (a term for a group of conditions that impact the brains blood vessels and blood flow), anxiety and depression. The Comprehensive Care Plan of Resident #8, initiated 5/9/24, identified a Focus Area of an Activities of Daily Living (ADL) and will continue to participate during my ADL as my condition allows. The Care Plan directed staff that the resident required 1 staff assistance for bed mobility and I am stand by pivot, assisted with two staff, left lower extremity, heal weight bearing only with post op shoe for transfers. The Interact Transfer Form dated 4/14/25 at 2:51 p.m., documented resident transferred to hospital for left great toe amputation due to diabetic ulcer to left great toe. The Care Plan identified a Focus Area, initiated on 4/22/25, identifying the resident has an actual impairment to skin: left first toe, amputation/surgical incision-healed. The Wound Evaluation form dated 5/13/25 at 1:16 p.m., revealed first digit on left foot as resolved. The Wound Evaluation form dated 5/13/25 at 1:17 p.m , revealed deep tissue injury on left plantar foot, 6 hours old, in house acquired. Measurements of area =0.65 centimeters (cm) by length= 0.8 cm by width =1.13 cm., intake blister, with additional care of cushion, foam mattress, foot cradle, heel suspension/protective device and turning/repositioning program. The Health Status Note dated 5/13/25 at 1:30 p.m., Late entry, Certified Wound Ostomy Continence Nurse (CWOCN) to resident's bedside for weekly Skin & Wound Evaluation of left great toe amputation site. Resident sitting up in bed, removed resident's socks and thoroughly assessed both feet. Surgical incision to left foot found to be healed. Intact Deep Tissue Injury identified just distal to this area, to the resident's left plantar foot. Emphasized to resident the need for her feet to not come in contact with footboard as this is causing pressure to the skin. CWOCN placed resident's bilateral feet in heel protector boots and provided resident with education regarding when to wear the boots, when they should be removed. One Way Slide to be placed in resident's bed in an attempt to prevent her from sliding down and her feet coming in contact with the footboard. CWOCN educated staff of importance of keeping resident boosted in bed and bottom of feet from coming in contact with footboard. The Care Plan with revision dated 6/25/25, revealed resident with actual impairment to skin with left plantar foot deep tissue injury, with initiated date of 5/1/25, interventions to float my heels while in bed, I have a cushion I use while in bed to keep my heels floated, on 5/14/25, I have a one-way slide (a repositioning aid designed to help individuals maintain a seated position and assist care givers in reposition them without forward slippage) while in bed to keep me from sliding down in bed, preventing my feet from pressing against the foot board and on 6/18/25, Encourage me to wear a heel-protector boot to my left foot as tolerated. The Health Status Note dated 5/16/25, with no time, documented the resident is seen today for acute onset of foot pain. The patient also reports ongoing foot pain, which is present at the time of the visit. History of amputation of left great toe, patient reports current pain in foot. The Wound Evaluation form dated 5/20/25 at 3:28 p.m., revealed deep tissue injury on left plantar foot, 7 days old, in house acquired. Measurements of 0.89 cm by 1.03 cm by 1.03 cm., intake blister, with additional care of customized shoe wear and heel suspension/protective device. The Wound Evaluation form dated 5/27/25 at 12:27 p.m., revealed deep tissue injury of left plantar foot, 14 days old, in house acquired. Measurements of 1.69 cm by 1.29 cm by 1.19 cm. intake blister, with additional care of heel suspension/protection device and turning/repositioning program, The Wound Evaluation form dated 6/3/25 at 1:03 p.m., revealed deep tissue injury of left plantar foot, 21 days old, in house acquired. Measurements of 2.49 cm by 2.53 cm by 1.42 cm by deepest point= 0.3 cm intake blister, with additional care of heel suspension/protection device and turning/repositioning program. Progress is deteriorating. The Wound Evaluation form dated 6/10/25 at 5:24 p.m., revealed deep tissue injury of left plantar foot, 1 month old, in house acquired. Measurements of 5.02 cm by 2.3 cm by 2.62 cm by deepest point= 0.2 cm intake blister, with serosanguineous exudate (a type of wound drainage that contains both blood and serous fluid (a clear yellowish fluid also know as blood serum) additional care of heel suspension/protection device. Observation on 6/30/25 at 10:00 a.m., Staff F, Registered Nurse (RN) proceeded to do wound care to Resident #8 left plantar foot. Staff E, removed the old dressing and blood was noted to be on the dressing. Staff E, proceeded to apply new dressing as ordered to the bottom of the left plantar foot. No cushion to the bottom of the foot board. Interview on 7/1/25 at 2:30 p.m., Staff F, was not able to determine when the interventions were put into place with Resident #8 per the care plan. Staff F verified that the foot cradle needed to be on the foot of the bed and also the foot board needed to be padded and that a turning/repositioning program was implemented. Interview on 7/1/25 at 4:20 p.m., Staff G, Certified Medication Aide (CMA) verified that a turning and reposition program is that the resident is turned or repositioned every 2 hours and that she was not sure that the floor aides had the ability to get into the computer system to verify that a resident is on a turning/repositioning program and that if the floor staff did not know that, then not sure if the resident would be turned and repositioned. On 7/2/25 at 8:20 a.m., Resident #8 was lying in bed with a green boot on her left foot. The blue foot cradle pillow was on top of the closest. Resident #8 went on to say that depending on who works if the blue foot cradle pillow is placed underneath her feet. On 7/2/25 at 8:40 a.m., Staff A, CNA, verified that a turning/repositioning program means that a resident is turned or repositioned every 2 hours, and that no documentation in the computer program allows the staff to chart that the resident was turned or repositioned and if not on the care plan than she did not know to turn or reposition a resident. On 7/2/25 at 8:45 a.m., Staff B, CNA, verified that the care plan is where she goes to look for a turning/repositioning program and if it is not on the care plan than she does not know a resident has that program, and that the computer has not where for her to document that the resident was turned and repositioned. On 7/2/25 at 9:50 p.m., Staff J, RN, verified that it is the expectation of the staff to turn and reposition a resident every 2 hours and that the computer system has no where for staff to document that the resident was turned or repositioned and to follow the care plan. On 7/2/25 at 12:30 p.m., Staff F, RN, explained that the expectation of the staff are to keep the feet up off the bed by using the blue cradle pillow at all times and to make sure that Resident #8 feet are not touching the foot board. On 7/3/25 at 9:30 a.m., the Director of Nursing, verified that the clinical record lacked any documentation of the staff charting on a turning/repositioning program and that it is expected that staff follow the plan of care to use the blue foot cradle at the end of the bed. 2. The 5-Day Assessment MDS dated [DATE] for Resident #9 reflected that the resident was able to make herself understood and able to understand others. The MDS identified the BIMS score of 14 for which indicated no impaired decision making. The MDS revealed the resident required partial to moderate assistance for upper and lower body dressing and repositioning and dependent for toileting. The MDS revealed these diagnoses, diabetes mellitus, cerebravascular accident, and non-Alzheimer's dementia. The Comprehensive Care Plan of Resident #9, with a revision date 12/5/23, revealed the resident to have an Activities of Daily Living (ADL) self care deficit. The Care Plan directed staff the resident required 1 staff assist for transfers, toileting, upper and lower body dressing and personal hygiene. The Focus Area of the Care Plan of skin integrity revealed the resident to have left buttock-friction/shear Moisture Associated Skin Damage (MASD), revision dated 6/17/25. It directed staff to perform treatment to area as ordered per physician orders, pressure reducing mattress to me bed and pressure reducing cushion to wheelchair. The care plan failed to reveal the need to turn the resident side to side in bed or to keep the resident off of her back. The census line of Resident #9 Electronic Health Record (EHR) reflected that the resident was hospitalized from [DATE] to 5/5/25. The Progress note dated 4/28/25 at 2:04 p.m., from the wound consult visit assessment, resident presents today with wound to buttocks. She is alert and oriented, sitting in bed. admitted for weakness and falls. She was able to turn on her side with minimal help. She is on a waffle overlay. Wound from admission photos has mostly healed already. Buttocks are lightly red, blanchable. No pressure injury at this time. Wound looks to have been shearing wound. The Nursing Admission/readmission Evaluation dated 5/5/25 at 3:30 p.m., reflected the skin and wound portion, with no pressure injuries or non pressure wounds. The Health Status Note dated 5/5/25 for Resident #9 reflected the resident to have no non-pressure injury wounds upon returning to the facility from the hospital. The Wound Evaluation form dated 5/5/25 at 12:53 p.m., reflected MASD present on admission, with no measurements and stated that patient arrived with bordered foam dressing on buttocks/gluteal cleft. Once removed, nothing was underneath. The Wound Evaluation form dated 5/12/25 at 2:45 p.m., reflected Incontinence Associated Dermatitis (IAD), present on admission 7 days old with no measurements, and healable. The Wound Evaluation form dated 5/19/25 at 4:54 p.m., reflected IAD, now 14 days old, with measurements of area=177.42 cm by length of 18.8 cm by width of 14.7 cm., with monitoring. The Wound Evaluation form dated 5/21/25 at 4:00 p.m., reflected IAD to coccyx area present on admission with 16 day old. Measurements of area= 0.56 cm by length 1.44 cm by width-0.5 cm. Wound bed is pink or red, surrounding tissue is blanching, fragile and intact, additional care of cushion, foam mattress, incontinence management and mobility aid provided, moisture control and turning/repositioning program. Review of the Treatment Administration Record of Resident #9 for May of 2025 revealed the treatment was not documented as being completed on Wednesday May 21, 2025, Friday May 23, 2025 and Saturday May 24, 2025. The Wound Evaluation Form dated 5/28/25 at 2:09 p.m., reflected, MASD-IAD, to coccyx, 23 days old, with measurements of area= 0.91 cm by length=3.59 cm by width= 0.57 cm by deepest point = 0.1 cm. Wound bed is pink or red, additional care of cushion, foam mattress, incontinence management, mobility aid provided, moisture barrier, moisture control and turning/reposition program and is deteriorating and ARNP was notified. The Dietary Note dated 5/9/25 at 12:41 p.m., reflected that skin is free from pressure injuries. The Encounter note dated 6/3/25 with no time, documented resident is seen today for a sore on her bottom. She reports feeling wiped out and has been spending more time in bed than usual. She also reports a sore on her bottom, more pronounced on the left side, which has worsened recently. The patient has been repositioned to her right side more frequently to alleviate pressure. She notes that the padding used for cushion has been uncomfortable and ineffective. Plan: breakdown on buttock due to incontinence exposure, notify provider is area opens or becomes larger, frequent reposition and out of bed in afternoons. During an interview with Resident #9 on 7/2/25 at 2:30 p.m., she stated that her wound care is supposed to be done twice a day and the staff does provide that most days. The MDS of Resident #9 dated 5/9/25 indicated a BIMS score of 14, cognition intact. On 7/2/25 at 3:12 p.m., the DON stated that her expectation is that all interventions are on the care plan and are being followed by the staff and was unable to locate any information that a turning/reposition program was in the documentation survey portion of the clinical record. The policy Pressure Ulcers/Skin Breakdown, review date 4/2018, directed staff as follows: The nursing staff and practitioner will assess and document an individuals significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history or pressure ulcer. Neither Resident #8 nor Resident #9 had a positioning schedule documented in the Kardex.

Based on a document of call light start and end time, resident interview, staff interview, and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time for 4 of 4 residents. (#2, #5, #8 and #11) The facility reported a census of 84 residents. Findings include: 1 The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 documented a Brief Interview of Mental Status (BIMS) of 13 indicating no cognitive impairment and has the ability to be understood and understands others. The MDS documented diagnosis of diabetes mellitus, hemiplegia (muscle weakness or partial paralysis on one side of the body that affect the arms legs, and facial muscles) and macular degeneration (an eye disease that can blur your central vision) and required dependence with personal hygiene, transfer and toileting and always incontinent of bladder and bowel. On 6/25/25 at 11:40 a.m., Resident #2 stated that she can read the clock on the wall. Resident #2 stated that it takes longer than 15 minutes to answer the call light. Review of document titled Zone start and end time report revealed call light logs longer than 15 minutes for Resident #2. 6/24/25 7:59 a.m. to 8:18 a.m. 19 minutes 6/24/25 8:44 a.m. to 8:53 a.m. 23 minutes 6/24/25 12:04 p.m. to 12:13 p.m. 19 minutes 6/24/25 6:03 p.m., to 6:20 p.m. 17 minutes 62425 7:22 p.m. to 7:42 p.m. 20 minutes 6/25/25 2:41 p.m. to 3:06 p.m. 25 minutes 6/27/25 11:52 a.m. to 12:11 p.m. 19 minutes 6/27/25 7:18 p.m. to 7:47 p.m. 29 minutes 6/29/25 8:14 a.m. to 8:31 a.m. 17 minutes 6/29/25 11:48 a.m. to 11:55 a.m. 17 minutes 6/29/25 2:47 p.m. to 2:50 p.m. 23 minutes 6/30/25 4:09 p.m. to 4:31 p.m. 22 minutes 2. The Quarterly MDS dated [DATE] for Resident #5 documented a BIMS of 13 indicating no cognitive impairment and had the ability to be understood and understands others. The MDS documented diagnosis of diabetes mellitus, cerebrovascular accident, (damage to the brain from interruption of its blood supply) non-Alzheimer dementia, anxiety and depression and required dependence with personal hygiene, transfer, toileting and frequently incontinent of bladder. On 7/1/25 at 10:00 am. Resident #5 stated that it takes longer than 15 minutes to answer her call light and that she is able to see the clock on the wall. Review of document titled Zone start time and end time report revealed call light logs longer than 15 minutes for Resident #5. 6/24/25 6:39 p.m., to 7:02 p.m. 41 minutes 6/25/25 7:18 p.m., to 7:53 p.m. 35 minutes 6/28/25 5:19 a.m. to 5:55 a.m. 36 minutes 3. The Significant Change in status MDS dated [DATE] for Resident #8 documented a BIMS of 9 indicating moderate cognitive impairment and has the ability to be understood and understands others. The MDS documented diagnosis of diabetes mellitus, cerebrovascular accident, (damage to the brain from interruption of its blood supply), anxiety, depression and required dependence with personal hygiene, and substantial to maximal assistance with transfer, toileting. On 7/1/25 at 8:00 a.m., Resident #8 stated that it takes over 30 minutes to answer her call light, and that she is able to see the clock on her wall across from her bed. Review of document titled Zone start time and end time report revealed call light longer than 15 minutes for Resident #8. 6/24/25 8:50 a.m. to 9:14 a.m. 24 minutes 6/24/25 4:13 p.m. to 4:34 p.m. 21 minutes 6/25/25 6:39 a.m. to 6:58 a.m. 19 minutes 6/25/25 7:03 a.m. to 7:21 a.m. 18 minutes 6/25/25 12:22 p.m. to 12:44 p.m. 22 minutes 6/25/25 2:10 p.m. to 2:30 p.m. 20 minutes 6/25/25 2:45 p.m. to 3:09 p.m. 24 minutes 6/25/25 7:09 p.m. to 7:43 p.m. 34 minutes 6/26/25 12:02 p.m., to 12:47 p.m. 45 minutes 6/26/25 1:37 p.m. to 2:07 p.m. 44 minutes 6/26/25 7:01 p.m., to 8:44 p.m. 45 minutes 6/27/25 12:28 p.m. to 2:24 p.m. 2 hours 52 minutes 6/27/25 2:30 p.m. to 4:26 p.m., 2 hours, 26 minutes 6/27/25 7:48 p.m., to 8:28 p.m. 40 minutes 6/28/25 9:13 a.m. to 9:55 a.m. 42 minutes 6/28/25 12:52 p.m., to 1:30 p.m. 38 minutes 6/28/25 5:07 p.m. to 5:47 p.m. 40 minutes 6/29/25 8:30 a.m. to 9:24 a.m. 54 minutes 4. The Annual MDS dated [DATE] for Resident #11 documented a BIMS of 15 indicating no cognitive impairment and has the ability to be understood and understands others. The MDS documented diagnosis of diabetes mellitus, hemiplegia, anxiety, depression, schizophrenia and required substantial to maximal assistance with activities of daily living. On 6/30/25 at 3:15 p.m., Resident #11 stated that it takes over 15 minutes to have his call light answered and is able to time the response due to seeing the clock on the wall. Review of document titled Zone start and end time report revealed call light longer than 15 minutes for Resident #11. 6/25/25 6:12 p.m. to 6:51 p.m. 39 minutes 6/26/25 4:33 p.m., to 4:58 p.m. 25 minutes 6/27/25 11:50 a.m. to 12:12 p.m., 22 minutes 6/28/25 4:34 p.m. to 4:56 p.m. 22 minutes 6/29/25 10:03 a.m. to 10:25 a.m. 22 minutes On 7/1/25 at 3:15 p.m., the Administrator and Director of Nursing stated the facility expectation is that call lights are answered in 15 minutes or less. On 7/2/25 at 9:15 a.m., Staff A, Certified Nursing Assistant (CNA), stated that it takes longer than 15 minutes to answer a resident call light due to low staffing. On 7/2/25 at 9:30 a.m., Staff B, CNA, stated that it takes longer than 15 minutes to answer a resident call light. Review of a policy titled Call Light Answering dated 3/2021 provided by the Administrator revealed that the purpose of the policy was to meet the resident's needs and requests within an appropriate time frame. Call lights will be answered within 15 minutes.

Based on observation, staff interview and policy review, the facility failed to provide incontinence care appropriately to prevent cross contamination for 1 of 3 residents observed for incontinence care (Resident #3). The facility reported a census of 84 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had short and long term memory problems, severely impaired for decision making abilities, required substantial to maximal staff assistance for all aspects of daily living and incontinent of bowel. The MDS revealed diagnosis of quadriplegia (a condition characterized by paralysis in all four limbs (arms and legs). The Care Plan of Resident #3, revision date 8/16/24, identified a focus area of the Resident not experience any skin conditions from incontinence. The Care Plan directed the staff to assist me with perineal cleansing as needed and observe my skin daily for irritation and redness. Observation on 6/25/25 at 11:15 a.m., Staff K, Certified Nursing Assistant (CNA) provided incontinence cares on Resident #3. Staff K, CNA did hand hygiene and put on gloves. She then pulled enough wipes out and put them on a barrier surface next to the resident. She proceeded to clean the buttock area wiping from front to back. Once she cleaned the back side she then proceeded to clean her front peri area wiping from front to back with the wipe. Staff K failed to cleanse the right and left hips. Interview on 6/25/225 at 11:40 a.m., Staff F, RN, verbalized staff are to cleanse the thigh areas while providing incontinent cares to residents. Review of the facility's Perineal Care policy dated 2/2018, directed staff to continue to wash the perineum moving from inside outward to the thighs, Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth .

Based on observations, clinical record review, resident and staff interview, facility policy review, the facility failed to follow the comprehensive Care Plan for 1 of 3 (Resident #2) reviewed for care plans. The facility reported a census of 84 residents. Findings include: The Quarterly Minimum Data Set (MDS) of Resident #2, dated 6/18/25, coded the resident dependent on assistance for personal hygiene, transfers and bed mobility. The MDS documented diagnoses that included diabetes mellitus, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms legs, and facial muscles) and macular degeneration (damage to the eyes retina, causing loss of vision). The Care Plan of Resident #2, revision date 1/2/25, identified a focus area of the Resident will continue to participate during my activities of daily living (ADL) as my condition allows. The Care Plan directed the staff she required 2 staff to assist me with cares, and 2 assist with bed mobility and 2 assist with upper and lower body dressing. Observation on 6/25/25 at 11:40 a.m., with Resident #2, was lying in bed ready to get up for the noon meal. Staff C, Certified Nurse Aide (CNA) and Staff E, CNA assisted the resident to roll from side to side to position the Hoyer lift (mechanical lift) sling underneath her. Resident #2 protected her right upper arm as staff were rolling her. A Incident Accident Unusual Occurrence Note dated 4/29/25 at 3:00 p.m. documented as follows; It was brought to this nurse's attention that the resident complained that Staff E, CNA, was rough with her during the morning while assisting getting the resident up for the day and hurt her right arm. A Orders Administration Note dated 4/29/25 at 4:32 p.m. documented that Tramadol (opioid pain killer) 50 milligrams (mg) by mouth was given for residents complaint of right shoulder pain, for a scored pain level of 8 out of 10. A Orders Administration Note dated 4/29/25 at 5:40 p.m. documented that the resident reported a 6 out of 10 pain level. A Orders Administration Note dated 4/29/25 at 8:38 p.m. documented that the resident reported pain to the shoulder and Tramadol 50mgs was administered to the resident. A Orders Administration Note dated 4/29/25 at 9:08 p.m. documented that the resident reported she was comfortable, and did not have pain. On 6/25/25 at 2:00 p.m., Staff E, CNA, verified that she rolled Resident #2 by herself on 4/29/25, and that the plan of care instructed staff to have 2 staff for bed mobility and for upper body dressing. On 7/2/25 at 9:40 a.m., Resident #2, verified that 2 staff are to roll her over and reposition her, and the day of the incident, only 1 staff member came in to get her ready for the day. On 6/25/25 at 2:45 p.m., the DON verified that staff are to follow the resident plan of care. The facility policy titled Using the Care Plan revised 8/2006 instructed staff to use in developing the residents daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident.

Based on clinical record review, facility policy review, family, resident interviews, and staff interviews, the facility failed to promptly identify and intervene for an acute change in a resident's condition, chest pain, shortness of breath, cough and urinary incontinence related to fluid volume overload. As a result the family transported the resident to the emergency department. Resident #1 was admitted to the hospital with acute hypoxic (lack of oxygen) respiratory failure due to pulmonary edema (excessive fluid in the lungs), sinus bradycardia (slowing of the heart), acute diastolic heart failure and swelling in the scrotum due to the edema. Concerns were identified for 1 or 3 residents reviewed for assessment and intervention. (Resident#1). The facility reported a census 81 of residents. Findings include: The Admission Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnosis of atrial fibrillation (dysrthythmia of the heart), dementia, depression, alcohol abuse The MDS documented that the resident required supervision from 1 staff member for bathing but was independent with functional abilities, the resident had occasional urinary incontinence. Resident #1's had a Brief Interview for Mental Status (BIMS) score of 13 which suggested an intact cognition. The Care Plan failed to provide direction for staff regarding the dysrthymia of the heart and for weight gain. During an interview on 5/9/24 at 1:09 p.m., The Power of Attorney (POA) for the resident reported the facility staff called her on 4/22/24 to report the resident was congested and received an over the counter (OTC) nasal spray and cough medication. The POA stated on 4/26/24 she visited the resident and he didn't look good, stated he was short of breath, had urinated all over and this was reported to staff before leaving the center. She returned the next morning to find the resident in the same condition, He looked bad and couldn't breathe. The POA stated she changed his clothes and told the staff she was taking him to see a doctor and went to the emergency department where he was immediately placed on oxygen. The POA stated that when she returned to the facility to gather some clothes, the staff wanted to know why she took him to the hospital. The POA stated she told the staff that he was admitted to the hospital. Hospital record; History and Physical dated 4/27/24, for Resident #1 documented the following; a. Chest pain, shortness of breath, cough and urinary incontinence with hypoxic oxygen saturation of 85% (typical healthy reading is 95 - 100%). b. Cardiologist consulted and applied transcutaneous pacing (external pacing for bradycardia). c. Scrotal cellulitis (inflammation of the scrotum) treated with IV antibiotics. d. admitted to the intensive care unit on telemetry (continuous heart monitoring). On 5/14/24 at 10:24 a.m. Resident #1 stated he informed the staff that he did not feel well and was not assessed by a nurse and his daughter transported him to the hospital for an evaluation. During an interview on 5/14/24 at 10:42 a.m. Staff A, Certified Nursing Assistant (CNA) stated, A couple of days before he went to the hospital he (Resident #1) had a cough and I told the nurse. During an interview on 5/14/24 at 1:08 p.m. Staff B, Certified Nursing Assistant (CNA) stated Resident #1 was not feeling well before going to the hospital. Staff B stated Resident #1 refused to eat and refused to get out of bed as he was not feeling well. During an interview on 5/15/24 at 1:22 p.m. Staff E, Advanced Practice Registered Nurse (APRN), reported that the facility nurse had called the on-call practitioner on 4/21/24 and received an order for a nasal spray. Staff E stated she had visited Resident #1 the next day, discontinued the nasal spray and ordered Flonase. Staff E stated the facility nurse did not inform her of a weight gain nor difficulty breathing. Staff E stated I was told he had a cold. Staff E stated that she was not informed that Resident #1's condition had declined after her visit. Staff E stated, If it affects the ABC's (Airway, Breathing or Circulation), they should call me. On 5/14/24 at 12:20 PM, Staff D, Assistant Director of Nursing (ADON) stated she worked on 4/26/24 and had visualized Resident #1 in the front lobby area in a chair with several staff around him. Staff D stated that no one had alerted her that Resident #1 was not well and she was the on-call nurse that weekend. Staff D stated the daughter transported Resident #1 to the hospital on 4/27/24. During an interview on 5/15/24 at 1:45 p.m. Staff F, Registered Nurse (RN) stated that she did not know Resident #1 very well but was aware of his cough, had provided his nasal spray but was unaware that he had a weight gain. A document titled Weight Summary for Resident #1 revealed: a. On 1/18/24 admit weight measured at 266 pounds (lbs). b. On 3/20/24 weight measured 284.4 lbs. A hospital document titled Discharge Note dated 5/8/24 for Resident #1 revealed: a. Diagnosis Acute hypoxemic (lack of oxygen) respiratory failure. b. New onset Congestive Heart Failure (CHF). A document provided by facility titled Staff Interview dated 5/13/24 signed by Staff B, CNA, revealed that she was aware 2 days prior to Resident #1's admission to the hospital that the resident did not want to get out of bed, his breathing was labored and she had reported it but was not sure to whom. A Policy titled Weight Assessment and Intervention dated 2008 revealed: a. The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. b. Any weight change of 5% or more since the last weight assessment will be retaken as soon as possible for confirmation. If the weight is verified, nursing will notify the Dietitian. c. The Dietitian will respond and make recommendations as necessary. d. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. A Policy titled Acute Clinical Changes dated 2018 directed staff as follows: a. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay. b. In addition, the nurse shall assess and document/report the following baseline information: Vital signs and Neurological status. c. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; d. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). e. The nurse and physician will discuss and evaluate the situation. f. As needed, the physician will discuss with the staff and resident/patient and/or family the pros and cons of diagnosing and managing the situation in the facility or the need for hospitalization . During an interview on 5/14/24 at 2:10 p.m. The Corporate Nurse stated the facility was made aware of the daughters concern from the hospital Social Services note, initiated an investigation and provided education for the nursing staff on 5/10/24 to include the need for weights to be documented in Point Click Care, if an increase in edema is noted, report to the charge nurse immediately. She stated then the charge nurse would complete a head to toe and call the provider for further instructions and complete a Change of Condition Evaluation. She stated the nurses are to notify the provider of weight when assessing a resident for fluid retention.

Based on clinical record review, family interview and staff interviews, the facility failed to promptly assess a resident with a change in condition and provide skin assessments in accordance with professional standards of practice for 3 of 3 residents reviewed (Resident #13, #1 and #11). The facility reported census was 82. Findings include: 1. According to an admit Progress Note dated 9/1/23 at 2:40 p.m. Resident #13 is an [AGE] year old male admitted following a hospital stay for pneumonia. Resident is alert and awake and oriented to person, place and time. Resident #13 is calm and cooperative and voices no concerns. Resident #13 was admitted for further recovery and physical and occupational therapy. Resident #13 is an assist of one staff with his wheel walker during transfers and ambulation. The Care Plan dated 9/1/23 documented Resident #13 had chronic obstructive pulmonary disease and used oxygen therapy. The care plan directed staff to monitor for difficulty with breathing and to monitor for signs and symptoms of respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath, cyanosis and somnolence. In an interview on 9/7/23 at 10:34 a.m. Staff O, Certified Nurse Aide, stated she provided cares for Resident #13 on 9/4/23. That day Resident #13 stated he was not feeling well and in some pain. Resident #13 did not want to get out of bed, or eat that day. Staff O stated she reported Resident #13's complaints and not eating to the nurse (not identified) and was uncertain what the nurse said or did after that. In an interview on 9/7/23 at 11:40 a.m. Staff R, Occupational Therapist, stated on 9/4/23 at around 8:30 a.m. she entered Resident #13's room to complete a therapy evaluation. Staff R stated she was able to get Resident #13 up, changed, dressed and sitting up on his edge of bed. Staff R recalls asking Resident #13 is he was breathing okay and Resident #13 stated yes. Staff R provided Resident #13 a room tray and set it up, before leaving his room. At around noon, Staff R returned to Resident #13's room. Resident #13 was much less responsive and needed changed. He was a heavy lift and she and Staff O provided incontinence cares and changed him. Staff R stated Staff O stated she would let the nurse know of Resident #13's condition. In an interview on 9/7/23 at 12:11 p.m. the Director of Nursing (DON), stated on 9/4/23, Staff MN was the nurse on 300/400 hall and was responsible for all nurse related activities including insulin administration, evaluations, treatments and assessments. In an interview on 9/7/23 at 9:20 a.m. Staff MN, Licensed Practical Nurse, stated on 9/2/23 Resident #13 was doing well, up, alert and eating meals. On 9/3/23 Resident #13 was more tired and stayed in bed. Lung sounds were diminished in lower lobes and seemed mucous, but nothing warranting too much concern. Staff N stated on 9/4/23 she was on 300/400 halls providing treatments and not involved with passing medications or completing assessments. Staff N denied be informed of Resident #13's decline in condition. In an interview on 9/7/23 at 11:25 a.m. Staff P, Licensed Practical Nurse, stated she came over to cover the 400 hall at 2:00 p.m. to relieve Staff N. Staff P stated she was not informed of Resident #13's condition that day. At about 3:30 p.m. Resident #13's call light came on and she responded. Resident #13's spouse stated he was not his usual self. Staff P took a full set of vital signs and assessed Resident #13. They consulted with the on call physician who instructed her to monitor resident, but the spouse insisted he be sent out. Arrangements were made and Resident #13 was sent out by ambulance to the hospital. Review of Progress Notes finds Resident #13 to be stable through the skilled nursing assessment completed on 9/4/23 at 3:58 a.m. Progress note dated 9/4/23 at 3:47 p.m. indicates family concern with residents condition and not responding per normal self. Assessment and complete set of vitals conducted by Staff P noting a blood pressure of 143/68, pulse 115 and oxygen saturation at 80% per room air. Staff P administers oxygen at 2 liters per minute through a mask and oxygen saturation increases to 95%. Nebulizer treatment administered and scheduled four times daily. Progress note 9/4/23 at 4:01 p.m. notes Resident #13 has eyes opened, but is not responding to simple commands. Arrangements made to send Resident #13 out for evaluation and Resident #13 leaves the facility at 4:44 p.m. and was admitted to the hospital. 2. According to a Minimum Data Set (MDS) with a reference date of 6/29/23, Resident #1 had a Brief Mental Status (BIMS) score of 12 out of 15 indicating mildly impaired cognitive status. Resident #1 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included multiple sclerosis, lupus and unspecified abdominal pain. The Care Plan dated 6/19/23 documented Resident #1 was at risk for pressure ulcer risk and directed staff to assess, record and monitor wound healing, to monitor for any changes and report them to the physician. According to the Skin and Wound Evaluation dated 7/7/23, Resident #1 had moisture associated skin damage (MASD) and incontinence associated dermatitis (IAD) measuring 2.5 centimeters in length by 1.2 centimeters wide located on her left ischial tuberosity (tail bone). According to the Skin and Wound Evaluation dated 8/8/23, Resident #1 had moisture associated skin damage (MASD) measuring 0.9 centimeters in length by 5.4 centimeters in width located on her left trochanter (abdominal fold) without drainage. In an interview on 8/22/23 at 11:10 a.m. The Director of Nursing (DON) stated Resident #1's left ischial tuberosity wound was last assessed on 7/7/23. Resident #1 was hospitalized from 7/12/23 to 7/16/23. Upon returning to the facility on [DATE] an admission skin assessment was completed by Staff G, however she failed to initiate a skin and wound evaluation which would have triggered weekly wound assessments. Consequently no assessments of Resident #1's buttocks pressure sore have been completed since 7/16/23. According to a Progress Note dated 8/12/23 at 11:42 a.m. Resident #1 had a medical event following sun exposure while in the courtyard for over an hour. Symptoms included an elevated temperature, elevated heart rate, groaning and inability to respond or complete simple tasks. Emergency Medical Services (EMS) were notified and Resident #1 was transported to and admitted to the hospital. According to the hospital nursing summary note dated 8/13/23 at 11:15 a.m. written by Staff G, Resident #1 was admitted with an extremely excoriated peri area, groin, lower abdominal fold and buttocks, including inside the gluteal cleft and inner buttocks. According to the hospital wound clinic note dated 8/14/23 at 4:30 p.m. and written by Staff H, Resident #1 had a stage 2 pressure sore, left ischial 1.5 centimeters length by 1.0 centimeters in width with scant serosanguinous drainage, present on admission with shearing of the sacrum and moisture associated skin damage (MASD) anterior right pannus (abdominal fold) 1 centimeter in length by 12 centimeters in width with yellow slough drainage. In an interview on 8/22/23 at 10:50 a.m. Staff F, Registered Nurse, stated on the evening of 8/11/23, she would have observed Resident #1's left flank and right groin wound and provided treatment to her right buttocks as ordered. Staff F stated there was no worsening of wounds or new wound development on the evening of 8/11/23. In an interview on 8/24/23 at 9:18 a.m. Staff B, Registered Nurse, asked on the morning of 8/12/23, did she observe Resident #1's left flank and right groin wound and provided treatment to her right buttocks as ordered. Staff B stated it was a hectic morning and she did not have time, but noted the aides will cleanse Resident #1's bottom and apply the barrier cream (calazine) when they do the morning cares. 3. According to a MDS with a reference date of 8/24/23, Resident #11 had a BIMS score of 12 out of 15 indicating mildly impaired cognitive status. Resident #10 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #11's diagnosis included congestive heart failure, diabetes mellitus, renal failure and acute respiratory failure. The MDS documented the resident was at risk for pressure ulcer development but did not have any pressure ulcers or any other wounds. The Care Plan for Resident #11 dated 8/19/23 documented he had an impairment to his skin but lacked to identify where the impaired skin was. The care plan directed staff to monitor for and document location, size, and treatment of the skin injury and to report any abnormalities to the physician. The Skin Observation Tool dated 8/22/23 documented the resident did not have any new skin issues. In an interview on 9/6/23 at 11:00 a.m. a family friend stated she visited Resident #11 on Sunday, 8/27/23 and was concerned with the condition of Resident #11. The family friend stated the resident's brief was on too tight and when removed she noticed an external catheter that appeared not to be draining. As the family changed Resident #11's brief she noticed it was damp with urine leaking from the catheter and when rolled to his side friend noticed a sore on his coccyx. The friend reported the wound to the nurse who applied a barrier cream, but failed to properly assess and record the wound on a skin evaluation form.

Based on observation, record review, policy review, staff interviews, and facility investigation review, the facility failed to account for all residents after they received a report of a resident outside alone and failed to provide an adequate door alarm system to mitigate a resident's risk for elopement (Resident #3). These conditions constituted an Immediate Jeopardy to resident health and safety. The State Agency identified Immediate Jeopardy (IJ) on 8/25/22, which began on 8/20/22 when Resident #3 eloped from the facility, the IJ was removed on 8/30/22. The facility reported a census of 85. Findings include: 1. A Quarterly Minimum Data Set, dated dated dated [DATE], documented that Resident #3's diagnoses included dementia. This resident's Brief Interview for Mental Status (BIMS) score was 03 out of 15, which indicated severe cognitive impairment. Resident #3 required limited assistance with transfers and ambulation. Resident also required partial assistance with ambulation over 150 feet. The resident used a manual wheelchair. The MDS documented daily use of wander/elopement alarm in use. Resident #3 did not demonstrate any behaviors during the lookback period. Observation on 8/29/22 at 2:35 p.m. of Administrator test six exit doors and alarms of the facility revealed: a. NE door with Wander Guard panel and keypad that did not sound when tested [DATE] after the elopement and continued not to alarm with ADM attempt to alarm. Secondary Red Stop alarm attached to the top of the door jam alarmed when door opened, key used by ADM to disarm and reset alarm. b. North fire door located at the back of the resident dining room with AliMed pull cord alarm located at top of the door jam appropriately alarmed when door opened. ADM reset alarm by reinsertion of pin into the alarm. c. North West (NW) door with Wander Guard panel and keypad which did not alarm on the door when tested [DATE] after the elopement. ADM demonstrated a secondary keypad located on waist level of door frame which failed to alarm when opened five times by ADM before the alarm sounded. The ADM reset the keypad and pushed the door open an additional two times before the alarm on the NW door sounded. d. South West (SW) door located by the Outpatient Therapy department, door with Wander Guard panel and keypad which sounded when door opened and prompted end of hallway Marquee sign to flash to staff that the door had been opened. e. South or Front door when opened alarmed appropriately. f. South East (SE) door with AliMed pull cord alarm located at the top of the door jam, the door did not open after ADM pushed door longer than 3 minutes, unable to test alarm. Observation of Resident #3 on 8/30/22 at 11:15 a.m. self-propel in her wheelchair down the length of the hallway. Wander guard on residents left ankle. Observation on 8/29/22 at 1:05 p.m. revealed Resident#3 self-propel down the hallway at a quick pace in her wheelchair, wearing a wanderguard (device to sound alarm at exit doors) on her left lower extremity. Facility document titled Wandering Assessment, dated 7/12/22 revealed Resident #3 score 15, which indicated she was high risk for elopement based on: a. Statements of wanting to leave during the assessment period b. Ambulates independently c. History of wandering at home, hospital, or another facility d. Alert to self According to the Care Plan-I am a wanderer related to impaired safety awareness, dated 4/8/22, the Care Plan directed staff to place a monitoring device on her when she leaves the building, approach me positively and in calm, accepting manner, alert staff to my wandering behavior. Intervention with date of 8/22/22 directed maintenance to be contacted to fix door alarms due to recent elopement. Facility document titled Progress Note lacked details of Resident #3 elopement on 8/20/22. Physician Ordered dated 8/4/22 revealed staff directive to check Wander Guard every shift. Facility document titled Incident Report dated 8/20/22 revealed Staff E, Licensed Practical Nurse (LPN) documentation of two visitors advised her a resident in a mechanical wheelchair is on road, van driver entered building and stated he saw resident on road. Staff E exited building in personal vehicle to retrieve resident. Resident did not suffer any injuries. Facility policy titled Wandering and Elopement with revision date of 3/2019 revealed: a. If a resident is missing, initiate the elopement/missing resident emergency procedure. b. If the resident was not authorized to leave, initiate a search of the building and premises. Review of facility policy titled Emergency-Missing Resident with revision date of 8/2018 revealed: a. Resident elopement resulting in a missing resident is considered a facility emergency. b. Announce Code Pink with the residents room number. c. Note the time the resident was discovered missing. Step 12. Document the incident and events objectively in the resident record, including: a. circumstances and precipitating factors b. interventions utilized to return the resident to the unit c. resident's response to the interventions d. results of reassessment upon the resident's return and the condition of the resident e. care rendered f. notification of police, family, and physician g. physician orders following notification h. additional prevention strategies implemented Review of Elopement Education 8/20/22 provided by Administrator on door alarm response education with residents at risk for wandering and the missing resident procedure including a head count if no observation of the reason for the alarm was engaged to inspect the parameter. Once the outside staff member returns, the alarms may be silenced and paged all clear by the nurse. The State Agency identified IJ on 8/25/22, which began on 8/20/22 when Resident #3 eloped from the facility, the IJ was removed on 8/30/22 when the facility took the following actions: 1. Door alarm audit completed 8/20/22 2. Residents with Wander Guards in place had Wander Guards tested were check for placement and functioning. 3. Secondary alarms were added to facility doors pending review of alarm system by manufacturer scheduled for 9/1/22. 4. Missing residents drill was completed on 8/27/22 and 8/29/22 and will continue weekly for six weeks on varying shifts. 5. Education of the staff on door alarm response with residents at risks at wandering and the missing resident procedure including completing a head count if no observation of the reason for the alarm was engaged to inspect the parameter. Once the outside staff member returns the alarm may be silenced at that time and be paged all clear by the nurse. 6. Postings have been placed on the door as an emergency exit only. 7. Signs posted at the door, Attention, please do not assist residents out the door behind you, please contact staff for assistance. 8. Door alarm and missing resident protocol added to the agency orientation checklist. After the IJ was removed on 8/30/22, the scope and severity was lowered from a K to an E due to the need for ongoing monitoring. An interview and review of the facility investigation on 8/29/22 at 12:30 p.m. with Administrator (ADM) reported she was notified on Saturday, August 20, 2022 that Resident #3 had eloped the facility and was last seen around 1 p.m. in the dining room after the noon meal. The resident was believed to exit the North East (NE) door adjacent to the dining room and self-propel in a wheelchair along the East side of the building toward the street in front of the facility then turned East. The resident had been escorted safely back to the facility and did not sustain any injuries. When notified of the event, the Administrator and maintenance checked the six exit doors in the facility and she stated the NE door did not alarm when opened, a secondary alarm was added at that time. Some staff reported not having heard the alarm sound. Staff did not know resident was missing as the facility did not have cameras. The ADM gathered statements from staff shortly after arrival to the facility. ADM stated the resident head count was not performed and facility policy for missing persons was not followed. An interview on 8/29/22 at 3:17 p.m., Staff E, LPN revealed she encountered two visitors entering the building through the front doors who stated they believed they set the alarm off and that they saw a resident in a wheelchair in the road. Staff E stated she then spoke with the facility van driver who had just returned with a resident who also stated he saw the resident on the side of the road, the resident had self-propelled in a wheelchair. Staff E stated she then exited the facility in her personal vehicle in search of Resident #3. Staff E stated she was surprised Resident #3 was so fast and had self-propelled approximately 1500 feet from the facility past the NE 12th Avenue and NE 60th intersection and she observed 3 cars drive around the resident as she was in the middle of the road, the speed limit is 35 miles per hour (mph). Upon reaching Resident #3, Staff E stated she appeared scared yet was free of injury. Staff E stated the van driver appeared and assisted her in transporting Resident #3 back to the facility where she notified the physician and family. Staff E stated Resident #3 was not missed by staff as they did not realize she had exited the facility, she stated the alarm did sound when she observed the visitors enter the building and believed they set the alarm off at which time she disarmed the alarm. Staff E stated she had checked Resident #3's wander guard earlier that day. An interview on 8/29/22 at 3:45 p.m. with Staff F, Environmental Services Supervisor (EVS) reported she had assisted staff with noon meal pass when she heard the front door alarm. Staff F stated she went outside the front doors to see if anyone was outside the South of the building which she did not see anyone, she did not look on the East or West side. When Staff F re-entered the building she stated Staff E, LPN advised her visitors had set the front door alarm off and she had disarmed and reset it. An interview on 8/29/22 at 5:02 p.m. with Staff G, van driver reported that he had observed Resident #3 self-propel in a wheelchair down the left side of the road on 8/20/22. Resident #3 was approximately 50 yards beyond the facility in front of a house. Staff G stated he had returned another resident back to the facility when he saw the resident, he did not know her but assumed she was from the facility, he stopped and told the resident to return to the facility, he stated she seemed confused. Staff G stated he had room in the van for one resident and could not assist Resident #3 at that time and drove to the facility to deliver the resident in his van. He stated he spoke to Staff E, LPN, and shared his observation at which time Staff E exited the facility to retrieve Resident #3. Staff F followed Staff E and stated Resident #3 was beyond the intersection in the middle of the road upon his arrival and recalled that one car passed her. He stated he assisted her into the van and returned her to the facility.

Based on observations, clinical record review, Resident, family and staff interviews, the facility failed to complete timely assessments and interventions for 3 out of 3 (Residents #18, #35 and #328) residents reviewed, which resulted in immediate jeopardy for Resident #328. The facility failed to get emergency care in a timely manner for Resident #328. Staff were directed by the provider to contact family with an update in change of condition to see if the family wanted a higher level of care. There was a delay of approximately 3 hours in contacting the family followed by a delay of approximately 1 ,d+[DATE] hours of contacting emergency services. Resident #328 was pronounced dead shortly after arriving to the emergency room . The facility failed to complete an assessment for over 4 hours for Resident #18 when he complained of chest pain and document the change of condition. The facility failed to provide an accurate assessment of an xray showing a fracture to a provider which resulted in a delay in interventions given to Resident #35. The facility reported a census of 85 residents. Findings included: 1. A Minimum Data Set (MDS) dated [DATE], documented Resident #328's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resident's Brief Interview for Mental Status documented a score of 8 out of 15, which indicated moderately impaired cognition. This resident required extensive assist of 2 staff for bed mobility and toileting. This resident required supervision of one for eating. A care plan for this resident initiated on [DATE] documented that Advanced Directives were to be followed per resident/family request. It directed staff to honor Resident #328's wishes as indicated on her CPR declarations page. The cancel date for this resident's care plan was [DATE]. A Doctor's orders ordered by the Staff AA, ARNP (Nurse Practitioner) dated [DATE] at 9:00 A.M., directed that a CBC (complete blood count), CMP (complete metabolic profile) and CXR (chest x-ray) be done related to wheezing and inability to swallow. The order was discontinued on [DATE]. A doctor's order dated [DATE], directed that this resident's code status was CPR ((Cardio Pulmonary Resuscitation) was to be performed if this resident's heart stopped and if she stopped breathing)). On [DATE] at 8:49 AM, Resident #328's daughter and #1 emergency contact, stated she did not understand why it would take so long to get her mother to the hospital on the day her mother passed away ([DATE]). The daughter stated a nurse had called her at 9:00 AM about her mother's condition. The facility reported that Resident #328 was not eating or drinking and her blood sugar was 39. The nurse reported they were going to get an x-ray and check this resident's blood sugar. Then at 1:05 PM, the nurse called again and stated her mother's glucose was 100 and her x-ray was fine but her mother was still not responding. The daughter stated she was told she needed to make a decision on whether she wanted her mother to be taken to the hospital. The daughter stated it was posed in a life or death way and she told the nurse to take mother to the hospital and she, the daughter, would meet/go to the hospital to meet her mom there. The daughter stated she was surprised that her mother's condition at that time had declined that much from the earlier phone call that day. The daughter said she literally called the hospital 3 times and her mother was not there yet. The daughter stated that by the time her mother got to the hospital, the doctor told the daughter that her mother's heart rate was really faint and then her mother went in to [CONDITION(S)] and they couldn't revive her. She stated her time of death was 4:22 PM. The daughter said she received a text from the hospital which read check in was 4:27 PM. The daughter said she didn't understand why it took so long to get her mother to the hospital after the daughter told the nurse at the facility to send her mother to the hospital. A screen shot provided by the daughter of a call log from her phone showed on [DATE] there was an incoming call at 8:53 AM that lasted 1 minute and 43 seconds. The next call on the screen shot was an incoming call at 1:05 PM and lasted 1 minute and 45 seconds. A text message dated [DATE] at 4:27 PM and provided by the daughter, read (Resident's name) welcome to (Hospital's name). A State Of Iowa Death Certificate documented the actual time of death was on [DATE] at 4:24 PM. An email sent by a staff member of the Sheriff's Office and dated [DATE] at 10:53 AM, read that according to their Communications Division- the event for the first Fire Department was created at 2:40 PM, and the event for the second fire department was created at 2:41 PM. These events referenced when the facility contacted the EMS for transfer from the facility to the hospital of Resident #328. Progress Notes for Resident #328 documented the following: -On [DATE] at 3:08 PM, Nurses Note- this resident had an emesis (vomited) after the morning meal today and numerous loose stools as well. Vital Signs were stable and they did a covid test and it was negative as well. Temperature 97.9. -On [DATE] at 9:06 PM, Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vital Signs: T(temperature) 97.7 - [DATE] at 12:21PM Route: Forehead (non-contact) BP (blood pressure) ,d+[DATE] - [DATE] at 6:08 PM Position: Lying l(left)/arm P (pulse) 76 - [DATE] 6:08 PM Pulse Type: Regular R (Respirations) 22.0 - [DATE] at 12:21 PM O2 (oxygen saturation) 97.0 % - [DATE] at 12:21 PM Method: Room Air Pnl (pain level) 0 - [DATE] 12:02 AM Pain scale: Numerical No further N/V or loose stools. -On [DATE] at 3:51 AM, Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence). Vital Signs T 98.2 - [DATE] 3:50 AM Route: Tympanic (ear) BP ,d+[DATE] - [DATE] at 3:50 AM Position: Lying l/arm P 78 - [DATE] at 3:50 AM Pulse Type: Regular R 16. -[DATE] at 3:50 AM O2 95.0 % - [DATE] at 3:50 AM Method: Room Air Pnl 0 - [DATE] at 3:50 AM Pain scale: Numerical Resident alert and oriented by name and place only sleeping during this shift no c/o nausea no emesis noted, no loose stools denies any GI distress or pain. -On [DATE] at 8:34 AM CMA (Certified Medication Aide) came to this nurse (Staff C, Licensed Practical Nurse (LPN)) and stated residents blood sugar was only 39. This nurse went to resident room and noted resident to be in bed awake and responsive. Lethargic but responsive. Staff assisting with attempting to get blood sugar above 39 with drinking OJ that had sugar in it but resident would cough on it and was not swallowing well at all. So thickened liquids was given with sugar added. Resident noted as well to have audible expiratory wheezing only, no inspiratory wheezing. Nurse notified ARNP (Staff AA) received orders to do a 2 view CXR and lab work as well give [MEDICATION(S)] tablets following the label on the bottle per distributors directions. Notified daughter of concerns and condition, told would keep up to date. -On [DATE] at 8:46, eINTERACT SBAR Summary for Providers note, Situation: The Change In Condition/s reported on this Evaluation are/were: Abnormal At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP ,d+[DATE] - [DATE] at 8:43 AM Position: Lying r/arm Pulse: P 112 - [DATE] at 8:43 AM Pulse Type: Irregular - new onset - R 22.0 - [DATE] at 8:43 AM Temp: T 98.2 - [DATE] 08:43 Route: Tympanic Weight: (W) 144.6 lb - [DATE] at 7:54 PM Scale: Mechanical Lift Pulse Oximetry: O2 89.0 % -[DATE] at 8:43 AM Method: Room Air Blood Glucose: BS (blood sugar) 39.0 [DATE] at 8:43 AM Resident/Patient is in the facility for: Long Term Care Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Relevant medical history is: Diabetes Code Status: CPR Resident/Patient is on: Hypoglycemic medication(s)/Insulin Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: No changes observed. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: CXR CBC CMP glucose tablets per directions to bring blood sugar up above 80 B. New Testing Orders: Blood Tests X-ray C. New Intervention Orders: Other Labs CXR -On [DATE] at 9:03 AM, Nurses Note Residents blood sugar up to 78 but condition still the same eyes rolled back a lot of stimulation to get resident to swallow any type of liquids would respond to verbal ques still needing O2 but pulse tacky at 120 and this was apically (listened to the heart with a stethoscope) done. Resident's respirations were irregular and mouth breathing as well. This nurse attempted x 2 to obtain the lab work and was unsuccessful with the lab draws. Resident still stable with blood glucose but not presenting well. -On [DATE] at 10:43 AM, Nurses Note: CXR obtained and ARNP in house to review with no new orders ARNP went down to look at resident and is concerned with resident's presentation wants this nurse to call and speak to family about how far they want to pursue treatment. -On [DATE] at 2:44 PM, Nurses Note: Called daughter to give update on condition of mother and daughter states that she would like mom to be sent out to emergency room to be evaluated and treated. Daughter insist that mom be sent out so order obtained to send mom out to the hospital per ARNP. Called 911 -On [DATE] at 3:00 PM, Nurses Note: EMT (Emergency Medical Technicians) here to pick up resident report given resident very lethargic now and not responding well at all. EMT's perform sternum rub to wake resident up and get a response from her and had no luck resident eyes were rolled back into head and resident very flaccid in extremities. -On [DATE] at 5:00 PM, Notified that resident passed way at the hospital. On [DATE] at 12:23 PM, Staff AA, ARNP, stated she no longer worked at this facility. She stated the facility should have access to her notes. She stated she had ordered lab and a chest x-ray for this resident the morning of this resident's passing. She stated she doesn't remember exactly what the x-ray showed, and did not think they had obtained the lab work by the time she had went in and assessed Resident #328. After assessing this resident, the ARNP remembered telling the nurse to call family to get direction regarding whether or not they wanted this resident sent to the hospital, because if the family wanted this resident sent out she needed to be sent out. This ARNP stated that around noon, she told the nurse to transfer the resident out now, to get her to the hospital now. She stated she remembered that this resident did not go to the hospital right away. The ARNP stated there was no way to say whether or not the same outcome would have occurred if the facility would have transferred this resident out right away, however this ARNP remembered that after hearing the family wanted this resident transferred out, this ARNP felt this resident needed to be transferred out right away. The ARNP acknowledged that there was a lag of time between when the facility knew that the family wanted this resident transferred out to when they actually transferred the resident out On [DATE] at 2:45 PM, Staff C, Licensed Practical Nurse (LPN), stated she was trying to remember what the situation was with Resident #328. She knew Resident #328 had nausea and vomiting (N/V) and wasn't feeling the best. Resident #328's blood sugars were really weird, we were trying to give her OJ and milk trying to bring the blood sugar back up. The ARNP was here physically and said send her out. Staff C stated she was the covering nurse that day but didn't remember exactly what timing was and then she looked at her progress notes. Staff C stated she did not remember a delay in sending this resident out. Staff C stated she would have to find her notebook, to find out what she was doing that day. Staff C stated she would find her notebook to check into things. She stated she could almost guarantee there was something else going on that day because she would not have waited that long to send Resident #328 out. She stated she was covering 2 halls that day- there was probably only 2 nurses, with herself on halls 2 and 1 and the other nurse on halls 3 and 4. A CMA would have covered 1 and 4. She stated she would look into it further, look at her notebook and find out what else was going on. She said a CMA would have been on halls 1 and 4, so she would have been responsible for meds, treatments and insulins on hall 2 and insulins and treatments on hall 1. On [DATE] at 10:27 AM, Staff C stated she checked her notebook and what happened was the nurse practitioner, Staff AA, told her to call the family first. Staff C stated she kept trying to call the family. Staff C stated by the time she got the return call from the family it was 2:00 PM. Staff C stated she called the EMS (Emergency Medical Services) right away. Staff C stated the EMS sat there forever in the facility parking lot. She stated by the time they pulled away it was almost 3 PM. Staff C stated she did not know what the EMS was doing when they got Resident #328 in the ambulance. When told the daughter reported that Staff C had called her at 1 PM, Staff C stated yeah, that could have been. Staff C had no further information. On [DATE] at 2:02 PM, Staff AA, ARNP, stated she did not remember the exact time she gave the order to send out but remembered that Staff C was on the phone with the daughter at the time she gave the order. Staff AA stated she was [MEDICATION(S)] in telling Staff C that Resident #328 needed to be sent out now. Staff AA stated her order correlated directly to the time Staff C was on the phone with the daughter, and if the daughter has 1:05 p.m. screen shot, then it was 1:06 p.m. when this ARNP gave the order to transfer Resident #328 out. This ARNP stated she was shocked that the family hadn't already been called and she stood there as Staff C made the call to the family. Staff AA stated she knew she was standing there when Staff C made that call and Staff AA knew she had requested that the family be called at least twice that day, there may have even been a third time that she asked Staff C to call the family, but Staff AA couldn't say that for sure. Staff AA told Staff C when Staff C called the daughter that Staff AA was going to stand there while Staff C made the call because Staff AA wanted to act right away if the daughter wanted her mom to remain a full code and wanted her mom to be sent out. Staff AA also wanted to be there to give education to the daughter regarding palliative care if the daughter had questions about change of code status. Resident #328's daughter did not want code status changed and wanted her mother sent out. Staff AA gave the order right then to get this resident transferred up to the hospital. Staff AA stated she made sure she was present for that, so there was no delay. This ARNP stated she couldn't speak to why there was a delay in Staff C calling the ambulance. Staff AA did not know if there was any other crises going on in the building on that day. Staff AA stated she understand they had a lot of residents to take care of, but Staff AA felt this resident was definitely a priority. Staff AA stated she did see most of the population at the facility and this resident was her only hot patient there that day. Staff AA felt like a verbal order was given that day as it was clear to send this resident out. She stated that normally with orders, she would write them because there can be some question on interpretation such as dosage, or frequency of a medication. Staff AA stated this order was very clear. This whole situation was a little shocking to her. Staff AA stated she wouldn't say it was blatant neglect but it could be looked at as situational neglect. The ARNP stated she had worked with Staff C quite a while and this was unusual for Staff C to not be right on top of this. On [DATE] at 10:24 AM, the Director of Nursing (DON), stated that she was on 400 and 300 halls and Staff C was on 200 and 100 halls. The DON stated she had a CMA but didn't' remember which CMA was on Staff C's side. The DON remembered a resident's daughter came out told the DON that her mom was somewhat non-responsive. The DON went and spoke to Staff AA. Staff AA ordered to send her (a different resident, not Resident #328) out. The DON stated the resident on her side was then transferred to the hospital for further evaluation and treatment. The DON stated this was her first day and the DON had chosen to be on the floor, just to see how the flow went. The DON stated nothing was brought to her attention that day from the other side and she wasn't asked to help on the other side. The DON stated that in fact, she had went over and talked to Staff C regarding what forms the DON needed to send somebody to the hospital. The DON stated Staff C pointed out the forms the DON would need on the computer the e-interact form and the phone numbers the DON would need. The DON stated she had no idea there was anything going on over on Staff C's side, nor was the DON asked to help over there. On [DATE] at 10:56 AM, Staff BB, Certified Medication Aide (CMA), stated that when Resident #328 was very sick and had a low BP. Staff BB remembered that day ([DATE]) because Staff BB did not get her morning medications passed until late. Staff BB stated it was the same morning the doctor ordered a chest x-ray. Staff BB stated she was not usually on the 200 hall. Staff BB stated she had been at the facility for a while and knew everyone but she wasn't as fast on 200 hall as she was on the 300 hall. Staff BB stated she knew Resident #328. Staff BB had checked Resident #328's blood sugar and it was very low and Staff BB stated she was diabetic as well. Staff BB stated the aides had told her that Resident #328 wasn't acting right. She stated they started giving this resident thickened orange juice. Staff BB let the nurse (Staff C) know, and Staff C went and called the doctor. Staff BB wanted to say they checked Resident #328's blood sugar 6 or 7 times that day, so Staff BB was busy getting those blood sugars. The nurse had been in quite a few times to get updates. Staff BB stated the nurse was covering Staff BB's side, and she was on 100 hall that had like 6 or 7 residents on that hall. Staff BB did not remember if anyone over on 100 hall was sick. Staff BB stated she was very, very, busy with Resident #328. Staff BB stated that she was diabetic herself, so Staff BB spent a lot of time with Resident #328 trying to get her blood sugar up. Staff BB stated they would get the blood sugar up and it'd go back down again. Staff BB stated that she was very ocd-ish and remembered it all very well because she was falling behind with passing medications (meds) probably by an hour or two. Staff BB stated that she was pretty sure her shift was over at 2:00 PM. Staff BB had stopped to assist with the x-rays around lunch time. Staff BB stated she knew she was in the middle of passing meds. The x-rays were taken before Staff BB left but now long before she left. Usually Resident #328 was very quiet. Staff BB stated she would describe Resident #328 as more lethargic. It took longer with thickened liquids to raise her blood sugar. Staff BB stated that normally Resident #328 could talk but wouldn't talk a lot. That morning she wasn't unresponsive. Staff BB stated she knew finally that the doctor had okayed an x-ray and the people (to get the x-ray) got there and then her shift was over. Staff BB stated she had spent a lot of time in that room. When Staff BB was told the orders for x-ray and labwork were given earlier in the day, Staff BB stated that could be that the orders for xray and lab were given around 8:30 AM, because she knew Staff CC went in to get her labs at that time. Staff BB was fairly sure x-ray came in the afternoon. Staff BB stated that around lunch time she ate pudding and applesauce probably about a quarter of it. Staff BB had to prompt Resident #328 and remind her to swallow and make sure she wasn't pocketing her food. Staff BB stated that when she came in the morning, the aides were going to get Resident #328 up and when they laid her down she was already dressed and Resident #328 sounded like she needed to cough. Staff BB stated that Resident #328 was with it enough where she was following directions. Staff BB stated Resident #328 was very lethargic and was slow to respond. Staff BB stated she would definitely say Resident #328 wasn't her normal self. Staff BB didn't remember a conversation with Staff C regarding calling this residents family about a transfer to the hospital. Staff BB stated that Staff C relaying updates with the nurse practitioner to Staff BB. Staff BB said that Staff C told Staff BB about rechecking blood sugars and about the x-ray. They (the aides) said Resident #328 hadn't been feeling well for a couple days and Staff BB asked why and the aide said Resident #328 might have had a cold or something. Staff BB asked Staff CC, Temporary Nurse Aide (TNA), to keep an eye on Resident #328 when I had to go do other things because Resident #328 was crashing. Staff BB stated that she didn't think in all the years she'd been a med aide, she'd had to work that hard. Staff BB stated when it is acute blood sugars like that, the nurse comes in. Staff BB stated Staff C would ask Staff BB to go check Resident #328's blood sugars again. Staff BB stated Staff C knew that Staff BB was behind with the meds. Staff BB stated she knew that Staff C was really busy, but wasn't sure what was going on. Staff BB stated that Staff C had said even though she only had a few people to take care of (that weren't the regular residents on 100 hall), she was frustrated and said she was behind too. Staff BB did not know why. Staff BB thought maybe it was because of the x-ray and they weren't coming. Staff BB repeated she was not sure why Staff C was busy. Staff BB did not know if anyone was sick over on the 100 hall. Staff BB stated that Staff CC was one of the aides and a girl from agency who had been there a couple of times was the other aide working with Staff BB. Staff BB knew that Staff CC was there because she is one that Staff BB asked to keep a close eye on Resident #328 because Resident #328 was crashing and she had to go pass meds to other residents. On [DATE] at 12:27 PM, Staff CC, TNA, stated that morning ([DATE]), Resident #328 looked very sick. Staff CC stated they kept Resident #328 in bed that morning and they kept giving her OJ. Staff CC stated this resident kept puking it up and she was aspirating (inhaling liquid into her lungs). Staff CC stated that when they went into this resident's room that morning Resident #328's supper tray was still sitting in her room untouched. Staff CC stated she did not think they fed her anything the night before. Staff CC stated they used to get Resident #328 up to eat because she would actually eat better if we took her to the dining room. Staff CC stated this resident could eat in bed, she just wouldn't eat as much. Staff CC thought it was Staff BB that was working and took this resident's BS and it was low. Staff CC thought when Staff BB took the BS, it was super low. When asked if this resident showed improvement, Staff CC replied no, this resident did not improve. Staff CC said this resident was aspirating and giving this resident actual food wasn't really good. Staff CC stated this resident needed to be sent out, she needed to go to the hospital. Staff CC stated they did not send this resident out on her shift. Staff CC stated she spent like an hour and 45 minutes in this resident's room just trying to get her to drink her OJ. Staff CC stated this resident was very pale and almost looked jaundiced (yellow). Staff CC stated she had felt this resident's feet and her feet were very cold which was not typical. Staff CC stated when they put this resident up in the hoyer sling, this resident projectile vomited, so they just put her back down (into bed). Staff CC stated this was around 7:00 or 8:00 AM. Staff CC said Staff C came and took this resident's VS. Staff CC stated the last time she saw this resident on that day was around 11:00 AM and this resident wasn't doing any better. Staff CC stated she had the front of the hall so this resident wasn't assigned to her. On [DATE] at 1:34 PM, Staff DD, CNA (Certified Nurse Aide), stated (the morning of [DATE]), Resident #328 was sick in bed and she was not eating. Staff DD stated the nurse asked them to try and get some fluids down this resident. Staff DD stated this resident was not eating food and was acting weird. Staff DD stated at that time she was working for an agency and had worked a couple of days with this resident prior to this morning and this resident was just fine and didn't have any symptoms. Staff DD stated this resident was acting weird that day so Staff DD reported this because Staff DD was just a CNA. Staff DD stated this resident was actively eating the week before. When Staff DD came back from the weekend this resident had gone downhill. Staff DD stated that it was weird for her to see this resident like that. Staff DD stated this resident was a pretty quiet, calm, and relaxed lady. Staff DD said the person she knew from the week before was not the same person that she saw on Monday ([DATE]). Staff DD added that they need to keep on top of that there, she reported to the nurse. Staff DD stated that on the next day she returned to work and found out that this resident had died . On [DATE] at 3:02 PM, Staff D, Registered Nurse (RN), stated she thought the evening shift nurse (on [DATE]) told Staff D, that this resident had a low temperature and vomited. Staff D stated that this resident's VS were fine during the night ([DATE] night into [DATE] morning) and this resident didn't have a temperature. Staff D reported that this resident told Staff D no, when Staff D asked this resident if she had pain. Staff D stated this resident had been able to tell her if she would need a stronger medication [MEDICATION(S)] or Tylenol, she was able to tell me. Staff D stated aides told me at 6:00 AM in the morning that this resident did not look good. It was 6:00 or 6:30 AM, Staff D stated, that she gave report to Staff C. Staff D stated when a resident is a full code, she did not hesitate to send them to the hospital. Staff D stated if a resident was a DNR (do not resuscitate), she would ask first but would send the resident out, if that was their or their family's wishes. Staff D stated that night she did not see anything that made her think this resident had worsened. Staff D stated this resident didn't vomit during the night shift. Staff D stated that she was surprised when she returned to work, that this resident had passed away. Staff D stated that residents can get sick really fast. She added this resident was good for Staff D that night. On [DATE] at 10:00 AM, Staff EE, CNA, stated she worked night shift on [DATE]. She stated her coworker Staff FF, TNA called Staff EE to come in to help on last rounds, probably around 4:30ish/5 AM. Staff EE wasn't really sure what time it was, it was last rounds right before 6:00 AM ([DATE]). Staff FF had called Staff EE, because Staff FF had seen like a puddle of blood, a super thick puddle of blood. Staff EE stated she did not know if the blood was mixed with urine or if it was in the stool. Staff EE stated this resident didn't look like herself. Staff EE stated this resident normally responds with a nod or roll of her eyes but on that day she just kind of stared. Staff EE stated she knew something was wrong. Staff EE stated she didn't help change this resident and after Staff FF called the nurse, Staff EE went back to what she was doing. Staff EE stated she just knew Staff FF and the nurse took care of this resident. Staff EE stated she had never seen this resident like that. Staff EE added that there was definitely something wrong with this resident On [DATE] at 10:26 AM, Staff FF, TNA, stated she had worked at this facility since March. Staff FF stated she worked the night shift on [DATE] and it was her last rounds. Staff FF stated she had asked for assistance from a nurse because she noticed when she took this resident's brief down, that this resident had blood in her brief. Staff FF stated it looked like there was quite a bit of blood, kind of mucousy and bright red blood. Staff FF stated overall, most of the time when this resident was changed, she would not say much. Staff FF stated that the nurse (Staff D) had told them before if they saw anything like blood or anything out of the ordinary with any of the residents, not to clean it up but to come and get her first, so that's what Staff FF did. Staff FF stated the blood didn't appear to come out of this resident's bottom. Staff FF stated they turned this resident and looked at her back side. Staff FF stated Staff D was going to put an order in to see if this resident had a [CONDITION(S)]. On [DATE] at 1:38 PM, the DON stated she thought a lot of times, too many times, things are missed when it gets busy. The DON stated she wished there would have been a different outcome for this resident. The DON stated she would expect each nurse, no matter what their credentials were, to act promptly in acute situations. The DON stated she did not know what happened in the time between Staff C being told by the ARNP in the morning to call the family and get their wishes to when Staff C sent Resident #328 out. The DON stated it was her first day at the facility on that day and she was working on the other side. The DON stated Staff C did not talk with her about this situation. The DON stated she would expect a nurse to call for help if they needed it, especially in acute situations. On [DATE] at 2:17 PM, the Nursing Home Administrator (NHA), stated her expectation for nurses would be for them to follow the assessment policies. The NHA stated she is not a nurse and didn't even feel comfortable saying what exactly should have been done. The NHA stated she would expect a nurse to call a family in a prompt manner when given direction to do so from a provider. An Acute Condition Changes - Clinical Protocol Assessment and Recognition protocol dated ,d+[DATE], directed the following: 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia. 2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc.; j. All active diagnoses; and k. All current medications. 3. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications; for example, acute [CONDITION(S)] or gastrointestinal bleeding in someone with advanced [CONDITION(S)] who is receiving corticosteroids after a prolonged, complicated, recent hospitalization . 4. The physician will help identify medications and medication combinations that are associated with adverse consequences that could cause significant changes in condition. 5. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for [TRUNCATED]

Based on observation, clinical record review, family interview, and staff interview, the facility failed to thoroughly assess and initiate interventions for residents with pressure sores, to ensure necessary treatment, services and care for 3 of 3 residents. The facility failed to notify the physician of skin care needs leading to a resident's pressure sore necessitating debridement that caused resident pain and suffering (Resident #63). The facility failed to adhere to treatment orders to promote wound healing for (Resident #63, 74). The facility failed to complete weekly skin assessments of a pressure ulcer (Resident #24). The facility reported a census of 85 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: 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 (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The Minimum Data Set (MDS) assessment for Resident #63 dated 6/29/22 documented resident admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident required extensive physical assistance of two persons for bed mobility, transfers, , dressing, toilet use and personal hygiene. The MDS further revealed the resident was at risk of developing pressure ulcers, pressure injuries and did not have one or more unhealed pressure ulcer or pressure injury. The MDS identified the resident had a Brief Interview for Mental Status (BIMS) of 13 indicating intact cognition. The MDS coded a Braden scale assessment for predicting pressure sore risk score of 13 indicating moderate risk for pressure ulcers. The Care Plan revised 7/11/22 documented on pressure ulcer risk: Resident at risk for pressure ulcers due to decreased independent mobility and incontinence goal : to remain free of skin breakdown. Interventions: a. encourage me to weight shift while sitting up in chair, initiated 8/14/20 b. encourage nutritional intake, initiated 8/14/20, revised 8/27/20 c. have a pressure mattress on my bed, initiated 07/11/22 d. assist with repositioning to avoid skin friction, shearing, initiated 8/14/20 e. daily observation of skin with routine care, initiated 8/14/20 f. full skin evaluation weekly with bath/shower, initiated 8/14/20, revised 8/27/22 g. wheelchair as needed pressure reducing cushion to wheelchair, initiated 3/14/22 The progress notes for Resident #63 included wound templates which were completed inconsistently. The wound templates contained conflicting information or information missing in various categories. The progress notes revealed the initial skin breakdown identified on 5/18/22. The facility failed to notify the physician for treatment orders upon the discovered onset of skin breakdown. On 7/22/22 the progress note documented a Stage 3 full-thickness skin loss and deep tissue pressure wound. The progress notes contained the following information: a. On 5/18/22 at 11:14 AM wound measurements area 4.2 cm2 (square centimeter) x Length (L) 2.6 cm (centimeter) x Width (W) x 2.0 cm, Depth (D) 0 location: coccyx, wound type: Moisture Associated Skin Damage (MASD), Incontinence Associated [CONDITION(S)] (IAD), edges: non-attached, edge appears as a cliff, surrounding tissue: [CONDITION(S)] (redness of the skin), treatment was blank, goal: healable b. On 5/18/22 at 11:15 AM wound measurements: area 44.5 cm2 x L 9.6 cm x W 6.0 cm X D not applicable; location: sacrum, type: MASD, exudate amount: moderate, type: sanguineous, bloody, edges: non-attached: edge appears as a cliff, surrounding tissue: [CONDITION(S)], redness of the skin fragile, skin that is at risk for breakdown, treatment was blank, goal: healable c. On 5/25/22 at 11:09 AM wound measurements area 3.1 cm2 x L 2.8 x W 1.8, wound: MASD, IAD location: coccyx, sanguineous, bloody, edges: non-attached: edge appears as a cliff, surrounding tissue: fragile: skin that is at risk for breakdown, location: coccyx, treatment was blank, goal: healable d. On 5/25/22 at 11:09 AM wound measurements area 1.2 cm2 x L 2.5 cm, W 0.6 cm, wound type: MASD, IAD, location: sacrum, Tissue: fragile: skin that is at risk for breakdown, treatment was blank, goal: healable e. On 6/01/22 at 10:59 AM wound measurements area 0 cm2 x L 0 x W 0 cm, wound type: MASD, IAD location: coccyx, edges: non-attached, edge appears as a cliff, exudate amount:, light, type: sanguineous, bloody, treatment was blank, goal: healable f. On 6/08/22 at 2:38 PM wound measurements area 0 cm2 x L 0 cm x W 0 cm, D 0: no measurements: type: MASD, IAD location: coccyx, edges: epithelialization: new, pink to purple, shiny skin tissue, treatment was blank, goal: healable g. On 7/06/22 at 10:33 AM wound measurements area 1.4 cm2 x L 1.9 cm x W 1.0 cm, D .08 cm, wound type: not noted, location: sacrum, exudate amount: light, type: sanguineous/bloody, edges: non attached, edge appears as a cliff, surrounding tissue: fragile, skin that is at risk for breakdown, in house acquired, treatment was blank, goal: healable h. On 7/15/22 at 10:24 AM wound measurements area 1.0 cm2 x L 2.2 x, W 0.7 cm x D 0 location: not noted, obscured full-thickness skin, tissue loss and deep tissue slough and/or eschar, wound type: pressure, goal: healable, treatment: blank, Generic wound cleanser, debridement: sharp, new treatment per treatment record: collagen matrix-silver sheet 2X2, apply to coccyx wound topically one time a day for wound healing, cleanse area daily and pat dry, apply collagen pad and cover with border dressing till healed. i. On 7/22/22 at 2:45 PM wound measurements area 1.0 cm2 x L 1.7 cm, x W 0.8 cm, Depth not applicable location not noted , Stage 3 full-thickness skin loss and deep tissue pressure wound, Pain: complaints of discomfort with debridement and occasionally with positioning, intermittent pain , Goal: wound healing not achievable due to untreatable underlying condition, dressing: intact, additional care: cushion, incontinence management, moisture barrier , moisture control j. On 7/29/22 at 11:44 AM wound measurements area 1.0 cm2 x L1.5 cm x W 1.0 cm, Depth: not applicable, location: blank, acquired: present on admission (incorrectly documented), edges: non attached, appears as a cliff, goal: healing not achievable due to underlying condition, dressing: missing, cleansing solution: generic, debridement: sharp, care: air flow pad incontinence management, moisture control other, progress: stable Wound evaluations were documented with pictures in the Skin Section. a. 5/15/22 area 1.0 cm2 x L 2.15 cm x W 0.72 cm, coccyx wound b. 5/25/22 area 1.22 cm2 x L 2.48 cm x W 0.62 cm coccyx wound c. 6/29/22 area 1.05 cm2 x L 1.54 cm x W 1.01 cm coccyx wound d. 7/06/22 area 1.36 cm2 x L 1.92 cm x W 0.96 x 0.75 D coccyx wound e. 7/15/22 area 1.0 cm2 x L 2.15 cm x W 0.72 cm coccyx wound f. 7/22/22 area 0.97 cm2 x L 1.69 cm x W 0.82 cm coccyx wound g. 7/29/22 area 1.07 cm2 x L 1.54 cm x W 1.01 cm coccyx wound Wound clinic Evaluation and management summary Measurements: a. 7/15/22 area 1.40 cm2, 2.0 L x 0.7 W x D not measurable, unstageable due to necrosis b. 7/22/22 area 1.20 cm2, 1.5 L x 0.8 W x 0.1D stage 3 pressure wound full thickness c. 7/29/22 area 1.50 cm2, 1.5 L x 1.0 W x 0.1 D stage 3 pressure wound full thickness Wound clinic evaluation and management summary noted procedures, debridements: a. 7/15/22 surgically excised 1.4 cm2 of devitalized tissue, slough, biofilm & non-viable SQ fat, and surrounding connective tissue removed at a depth of 0.3 cm b. 7/22/22 surgically excised 0.6 cm2 of devitalized tissue, slough, biofilm & non-viable SQ fat, and surrounding connective tissue removed at a depth of 0.3 cm c. 7/29/22 surgically excised 0.75 cm2 of devitalized tissue, slough, biofilm & non-viable SQ fat, and surrounding connective tissue removed at a depth of 0.3 cm Skin Treatment Administration Record (TAR) for Resident #63 revealed no specific coccyx, sacrum care treatment documented May and June of 2022. July 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to adhere to the treatment orders, missed treatments noted in the TAR as follows: a. collagen matrix-silver sheet 2X2, apply to coccyx wound topically one time a day for wound healing, cleanse area daily and pat dry, apply collagen pad and cover with border dressing till healed. Start 7/15/2022 11:00 AM discontinue 7/22/22 2:55 PM The TAR was blank for dates indicating no treatment completion: 7/18 and 7/19 b. [MEDICATION(S)] wound/burn dressing gel apply to area to sacrum topically one time a day for wound healing cleanse area once daily; pat dry and apply honey gel, cover with border dressing till healed. Start 07/23/2022 11:00 AM The TAR was blank for dates indicating no treatment completion on 7/24/22 c. change wound dressing to right lower extremity daily as follows: remove old dressing, cleanse with warm soapy water, fill wound with xerform gauze, cover with abdominal dressing (ABD), secure with tubular netting one time a day. Start 04/27/2022 8:00 PM discontinue Date 06/15/2022 6:50 PM The TAR was blank for dates indicating no treatment completion in May on 5/12, 5/13, 5/14, 5/16, 5/17, 5/19, 5/20, 5/24, 5/25, 5/27, 5/28, 5/29 and 5/30 The TAR was blank for dates indicating no treatment completion in June on 6/4, 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11 & 6/12 On 07/20/22 at 11:31 AM, the residents family member relayed Resident #63 had COVID and they felt the resident was in bed a lot during that time and they felt that led to a sore on her bottom. The family member relayed that there were a few good nursing assistants here that kept them informed when they visited. The family member relayed the resident is not reliable for details, so they relied on CNAs (Certified Nursing Assistant) for updates. Observation on 07/25/22 11:05 AM revealed a coccyx wound care present on Resident #63. The resident stood with the stand lift assisted by Staff H, skin care RN (Registered Nurse) and an unknown certified nursing assistant. Staff H and the CNA removed the resident ' s pants, the wound was cleansed with normal saline, honey gel ointment applied into the wound, non adherent dressing and border dressing applied. The coccyx wound appeared about a quarter cent piece in size with evident depth noted, new dressing to cover the wound was dated and secured to the wound. There was no dressing present to be removed prior to the treatment. In an interview at the time of observation, the skin nurse acknowledged there was no dressing observed on the wound following resident ' s clothing removal and prior to this treatment. She acknowledged the treatment was not signed to indicate it was completed on 7/24/22. In an interview with the DON (Director of Nursing) and the Staff H, skin nurse RN, on 07/28/22 at 9:20 AM, DON reviewed skin notes and pictures in the resident records. The DON relayed that the expectation is that once a skin issue is identified that the staff discovering the skin issues would notify the nurse on duty, the nurse would assess further, a skin sheet is started and the staff nurse should notify the family and contact the doctor to obtain new orders. The DON acknowledged skin issues found on 5/18/22 for Resident #63 and no physician or family notification. The DON relayed that in a perfect world the care plan would also be updated within 24-48 hours to reflect a skin issue. The skin nurse, RN relayed they are in development of a better process and that treatment orders should not be missed. She acknowledges skin follow up assessments should be done weekly. The Pressure Injury Risk Assessment policy provided dated March 2020 included general guidelines for structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). The facility failed to provide MD notification of new skin alterations. a. If a new skin alteration is noted, initiate a pressure or non-pressure form related to the type of alteration in the skin. b. develop the resident-centered care plan and interventions based on the risk factors identified in the assessment, the condition of the skin, the resident ' s overall clinical condition, and the resident stated wishes and goals, interventions must be based on current, recognized standards of care. The effects of the interventions must be evaluated. The care plan must be modified as the residents condition changes or if current interventions are deemed inadequate. c. documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated d. documentation in the medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care if indicated The Pressure Ulcer/Skin Breakdown - Clinical procedure provided dated April 2018 included the following: a. as needed, the physician will assist the staff to identify the type and characteristics of an ulcer b. as needed, the physician will help identify and define any complication related to pressure ulcers c. as needed, the physician will help identify factors contributing or predisposing residents to skin breakdown d. as needed the physician will clarify the status of relevant medical issues e. the physician will order pertinent wound treatments f. as needed the physician will help identify medical interventions related to wound management g. as needed during resident visits the physician will evaluate and document the progress of wound healing h. as needed, the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wound develop despite existing interventions i. current approaches should be reviewed for whether they remain pertinent to the resident medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident patient or substitute decision maker. The Five-minute meeting for employees summarized key points to emphasize: Skin assessments will be completed weekly on residents with skin issues and documented 2 nurses attended on 7/20/22. 2. The Minimum Data Set (MDS) assessment for resident #74 dated 7/6/22 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She has a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and locomotion on and off the unit. The MDS further revealed the resident has 1 or more pressure ulcer/injuries. The resident had a Brief Interview for Mental Status (BIMS) of 13 indicating intact cognition. The Braden Scale assessment for predicting pressure sore risk dated 7/6/22 revealed a score of 15 indicating at risk for pressure ulcers. Review of skin Treatment Administration Record (TAR) for Resident #74 revealed the treatments not completed by staff. The facility failed to comply with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . a. [MEDICATION(S)] Solution, [MEDICATION(S)]-iodine, apply to right ankle wound topically one time a day for wound healing, cleanse area with wound cleanser, apply [MEDICATION(S)] and band aid daily till healed Start 07/16/2022 11:00 AM The TAR was blank for the following dates, indicating no treatment completion on 7/18/22. b. collagen matrix-silver sheet 2 X 2 inches, apply to right heel topically one time a day for wound healing cleanse area daily with wound cleanser and pat dry, cover with collagen pad and border dressing daily till healed. Start 07/16/2022 11:00 AM The TAR was blank for the following dates, indicating no treatment completion on 7/18 and 7/24/22. c. calazinc, house stock to buttocks daily and PRN until healed every day shift for buttocks Start 06/03/2022 6:00 AM discontinue 07/21/2022 4:46 PM The TAR was blank for the following dates, indicating no treatment completion on 7/3, 7/4, 7/6, 7/7, 7/10, 7/12 and 7/15/22. d. [MEDICATION(S)] Solution, [MEDICATION(S)]) apply to right foot, topically every day shift apply to right dorsal foot and right ankle area until healed Start 06/03/2022 6:00 AM discontinue 07/06/2022 2:41 PM The TAR was blank for the following dates, indicating no treatment completion on 7/3 & 7/4 & 7/6/22 e. [MEDICATION(S)] solution, [MEDICATION(S)] apply to right foot topically every day shift for right foot apply to right dorsal foot, back of leg and R ankle area until healed Start 07/07/2022 6:00 AM discontinue 07/15/2022 4:36 PM The TAR was blank for the following dates, indicating no treatment completion 7/7, 7/10, 7/11 and 7/15/22. f. collagen matrix-silver sheet 4, apply to right heel topically every day shift for right heel pressure area cleanse area apply collagen sheet to right heel cover with non-adherent pad and wrap with kerlix daily and as needed (PRN) start 05/17/2022 6:00 AM discontinue 07/15/2022 4:38 PM The TAR was blank for the following dates, indicating no treatment completion 7/3, 7/4, 7/6, 7/7, 7/10, 7/11 and 7/12. g. [MEDICATION(S)] capsule, ([MEDICATION(S)]) apply to right heel topically every day shift for right heel cleanse wound apply [MEDICATION(S)] to wound bed apply leptospermum honey to wound and apply nonadherent pad and wrap with kelix. Start 06/03/2022 6:00 AM discontinue 07/06/2022 2:23 PM The TAR was blank for the following dates, indicating no treatment completion 7/3, 7/4 & 7/6. h. [MEDICATION(S)] wound/burn dressing Paste apply to right heel topically every day shift, cleanse wound, apply [MEDICATION(S)] to wound bed, apply leptospermum honey to wound and apply nonadherent pad and wrap with kelix. Start 06/03/2022 6:00 AM discontinue 07/06/2022 2:22 PM The TAR was blank for the following dates, indicating no treatment completion 7/3, 7/4 and 7/6/22. 3. The MDS assessment for Resident #24 dated 7/21/22 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of 2 staff for bed mobility, transfers and toilet use. The MDS further indicated the resident had an unhealed pressure ulcer, identified as unstageable (suspect deep tissue injury). Review of the Treatment Administration Record (TAR) for Resident #24 documented an order with a start date 7/8/22 for wound cleanse to bilateral heals and left lower posterior leg, pat dry and cover with foam dressing until healed. Review of facility electronic health record form dated 7/26/22 and titled Skin and Wound Evaluation revealed the wounds had been present since 7/8/22. The clinical record lacked assessments for the wounds prior to 7/26/22. During an interview 07/28/22 at 10:21 AM the DON Revealed it is an expectation wound assessments are completed weekly like other skin assessments that are to be completed weekly.

Based on manufacturer's guidelines, clinical record review, staff interview, witness interview, observation, and facility record review the facility failed to ensure the straps of a sling for a mechanical lift securely attached to the machine prior to transferring a resident who subsequently fell from the sling during a transfer, for 1 out of 4 residents reviewed for transfer technique with a mechanical lift, (Resident #1). Resident # 1 sustained a non-displaced peri-prosthetic (around a prosthetic) femur fracture and parietal scalp hematoma (swelling). The facility identified the failure and corrected it on 7/2/19 when they retrained staff on the proper transfer technique for hoyer lifts. The facility reported a census of 80 residents. Findings include: 1. The EZ Way Smart Lift Operator's Instructions revised 6/13/11 included the following instructions on how to transfer a patient from a chair, wheelchair, or toilet with a full body mechanical lift (hoyer lift): Step 1. Position the Sling a. Lean the patient forward several inches to place the sling behind the patient. b. Make sure the base of the sling touches the chair seat and is 2 inches below the tailbone. Make sure the top of the sling above the patient's shoulders and lean the patient back in the chair. c. Pull the legs of the sling along the inside of the chair. d. To set the sling properly, you must do the following: On the patient's right side, position your right hand between the patient's hip and the sling. With your fingers, push down on the edge of the sling so it touches the base of the chair seat. Next, grasp the bottom edge of the sling leg with your left hand and pull with a tug towards you. e. Lift the patient's left knee and with a tug, pull the leg of the sling under the hip and thigh. Place the excess sling length over the left thigh. Repeat this procedure on the right side. Step 2. Position the EZ Way Smart Lift Step 3. Attach sling to the lift. a. Take the sling leg that is lying over the patient's left thigh and attach it to the right hook on the hanger bar. b. Take the sling leg lying over the right thigh and attach to the left hook on the hanger bar, again using the same length and color of loop strap on each side. c. Attach the straps located near the patient's shoulders to the lift hanger bar hooks using the same length and color of loop strap on each side. Example: If you choose the shortest loop on the strap for the right shoulder, you must use the shortest loop on the strap for the left shoulder. Step 4. Lifting the patient. a. Push the UP button on the hand control to initiate the upward motion of the lift. Continue the upward motion until there is tension on the legs of the sling, making sure all the loops on the sling are securely hooked on the hanger bars. b. Smooth the sling legs under the patient's thighs with a slight pull on the outside seam of the sling legs, if necessary. c. Lift the patient to the desired height (usually 2 to 3 inches above the chair). Step 5. Transferring the patient. a. Ensure there are no obstructions in the path of travel. b. Pull or push the lift using the operator's handles on the lift mast. Maneuver the lift to a desired location. Step 6. Lower the patient onto the bed. Step 7. Remove the sling. The facility Nursing Meeting Agenda dated 9/6/17 included the following documentation for Review of Lifts: a. No double looping of slings. b. Pause before lifting up to double check the resident's position. c. Do not lock brakes during lifting. d. Continue to bring ripped slings for replacement. Staff B, Certified Nurse Aide (CNA), signed attendance to the meeting. The facility list dated 7/17/19 identified 13 current residents utilized a hoyer lift for transfers. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified a Brief Interview for Mental Status Score (BIMS) of 8 indicating moderate cognitive impairment. The resident was totally dependent upon two persons for transfers. Resident #1 had [DIAGNOSES REDACTED]. The Care Plan focus area dated 5/25/18, identified Resident #1 was a risk for falls. On 4/25/19 the Care Plan was revised to inform staff the resident transferred with a hoyer lift and the assistance of two persons. The Witnessed Fall Report dated 7/1/19 at 9:05 p.m. completed by Staff C, Registered Nurse (RN) indicated she was called to Resident #1's room by a CNA who reported the resident fell to the floor during a hoyer transfer landing on her left side. Staff C recorded she arrived in the room to find the resident on her left side with head on pillow and a swollen bump on the back of the left side of head. Staff C recorded when the resident rolled onto her back the resident yelled out in pain stating her right hip and leg hurt. A hoyer transfer was completed with extra staff to keep the right leg to minimal movement as they moved the resident back to the bed. The report documented the witnesses were Staff A, CNA, and Staff B, CNA. The Progress Notes dated 7/1/19 at 10:17 p.m. documented Resident #1 fell to the floor during a hoyer transfer hitting her head on floor. The resident had a raised, tender area on the back left side of head. The on-call physician was contacted and an order received to send the resident to the emergency room for further evaluation. At 10:57 p.m. the notes recorded after the incident the sling was checked over with no tears or fraying found and the correct size sling was used for the transfer. The entry documented a visitor had been in the room at the time of the transfer and had witnessed the fall. The radiology report completed 7/1/19 at 11:05 p.m. documented findings of a proximal (toward the beginning) right femoral shaft fracture extending to the prosthetic caudad margin (toward the tail or posterior end). The hospital H&P (History & Physical) dated 7/2/19 at 9:46 a.m. documented the resident presented to the hospital after a fall from a hoyer lift and x-rays showed a right hip non-displaced peri-prosthetic (around artificial replacement part) femur fracture. The record documented while in the ED (Emergency Department) a head CT (computed tomography) scan showed a parietal (side) scalp hematoma (localized swelling). The Assessment section documented the resident had a very extensive medical history and was a very poor operative candidate. The fracture was non-displaced and therefore non-operative care was the reasonable course of action. On 7/3/19 at 12:56 p.m. the Progress Notes documented Resident #1 was readmitted to the facility after hospitalized with a right femur fracture. The undated witness statement written by Staff A documented the following: During HS (bedtime) cares, Resident #1 was being transferred into bed with a hoyer and the hoyer sling slipped out. Staff A's hall partner was busy so he asked Staff B for assistance. During the time that it took Staff B to come in, Staff A brought the hoyer (machine) into the room and hooked Resident #1 up (connected the sling straps to the machine). Staff A always slid in the sling straps all the way into the hooks before they got the resident up just as he did that day. Once Staff B came in the room, Staff A got behind the wheelchair and he always double checked the straps to make sure they were on correctly, which they were. As Staff B lifted Resident #1 up, Staff A started to pull away the wheelchair to make room for the hoyer to move and that's when it appeared as if one of the straps snapped and the resident fell . After the resident fell , Staff A checked the straps to see if it tore or ripped but it appeared to be fine. The sling was the right size and they were not rushing anything so still unsure as to how it came off. The Director of Nursing (DON) wrote a summary of her interview with Staff A. The DON documented the interview occurred on 7/2/19 at 4:30 p.m. During the interview, the DON had Staff A re-enact the hoyer transfer with the Administrator and her. The DON wrote: Staff A stated while he waited for Staff B to come to the room, he proceeded to hook up the hoyer sling to the lift. Staff A stated the sling already underneath the resident where she sat in a wheelchair. Staff A stated as he was hooking up the straps he paid attention to each strap and remembered they were all in good condition. During the re-enactment, Staff A placed the straps into the cross members of the lift and noted he double looped the straps. Re-education provided regarding the manufactures recommendation to refrain from double looping the straps. Staff A confirmed he double looped the straps on the evening of the transfer in question. Staff A proceeded to attach each strap to the cross members, starting at the top left, then going to the bottom left, then to the bottom right and finally ending with the top right. Staff A stated by that point, Staff B entered the room and they proceeded with the transfer. Staff A went behind the wheelchair while Staff B proceeded to raise the resident with the lift. Staff A stated as the resident raised off of the wheelchair enough for him to remove the chair, he moved the wheelchair behind him enough so the hoyer could be moved towards the bed. Staff A then said just as he moved the wheelchair, the resident jerked in the sling and fell out of the top left side of the sling onto the floor. Staff A stated he was still unsure as to how the resident fell out of the sling, because he checked the sling for any rips, tears, or frayed areas after the incident occurred and the sling was in good working condition. During the re-enactment scenario, they found that if the loop of the strap was on top of the cross member bar, they could lift the individual out of the chair. Once the individual moved slightly, the loop of the strap then slipped off of the cross member bar causing the sling to slip off. After completion of the return demonstration and their re-enactment of their plausible explanation, they concluded the sling strap was just above the cross member of the hoyer device instead of inside the cross member. The witness statement written by Staff B, signed 7/1/19, documented the following: Staff A asked her for transfer help so Staff B went to help him. Resident #1 was already hooked up with the sling and hoyer. Staff B started going up with the hoyer and it looked like the back strap had broke. After the resident fell , they looked at the straps and it wasn't broken. The DON wrote a summary of her interview with Staff B. The DON documented the interview occurred on 7/2/19 at 4:30 p.m. During the interview, the DON had Staff B re-enact the hoyer transfer with the Administrator and her. The DON wrote: Staff B stated Staff A asked her for help with a transfer because his hall partner was busy. Staff B finished up what she was doing then went into Resident #1's room to help Staff A. Staff B stated when she got into the room, Resident #1 was already hooked up to the hoyer and the sling already in place. Staff B recalled everything looked normal as far as the sling and the resident placement. Staff B stated she then proceeded to raise the hoyer up with the button, as the resident's bottom lifted off the wheelchair enough to allow the chair to be moved, Staff A moved the chair out of the way. Staff B said as soon as the wheelchair moved, the resident jerked in the sling and fell out of the upper left portion of the sling onto the floor. Staff B stated at first it appeared as if the strap broke, but after the fall they checked the strap and it was not broken. Staff B recalled the sling and all the straps were in good working condition and she did not remember seeing any rips, tears or frayed areas present. Staff B stated she was still unsure as to how the resident fell out of the sling. During the re-enactment scenario, they found that if the loop of the strap was on top of the cross member bar, they could lift the individual out of the chair. Once the individual moved slightly, the loop of the strap then slipped off of the cross member bar causing the sling to slip off. After completion of the return demonstration and their re-enactment of their plausible explanation, they concluded the sling strap was just above the cross member of they hoyer device instead of inside the cross member. The DON wrote a summary of her phone interview with Staff C, RN. The DON documented the interview occurred on 7/8/19 at 10:00 a.m. The DON wrote: Staff C stated on the evening of 7/1/19 at approximately 9:00 p.m., she was called to Resident #1's room by one of the CNAs; the aide told her the resident had fallen from the hoyer. Staff C was unable to recall if Staff A or Staff B called her to the room. Upon entering the resident room, Staff C noted the resident laid on the floor on her left side, a pillow underneath her head. Staff A and Staff B were the CNA's transferring the resident by use of the hoyer lift from the wheelchair to the bed. Staff A and Staff B stated to Staff C the resident had fallen out of the left side of the hoyer sling during the transfer. During Staff C's initial nursing assessment, the resident complained of right hip and leg pain. Staff C said as she finished her assessment, the resident stated her pain was better in her right hip then said, it hurt like it always did. Staff C stated after she completed her nursing assessment, she immediately checked the hoyer sling for any defects. Staff C recalled not finding anything wrong with the sling; no rips, tears, or frayed areas present. Staff C proceeded to inspect the hoyer device itself for any malfunction, found the lift to be in good working order, then assisted Staff A and Staff B to replace the sling underneath the resident. The three of them proceeded to transfer the resident off of the floor and into the bed with the use of the hoyer. Staff A and Staff B transferred the resident and Staff C provided additional support of the resident's right leg. Staff C stated she then began neurological assessments and placed a call to the physician. An order was received from the physician to send the resident to the emergency room for evaluation and treatment. Staff C said the resident's visitor had been present in the room during the transfer. Staff C spoke with the visitor privately and asked if there were any concerns with the transfer prior to the incident occurring. The visitor told Staff C they had no issues with anything they did and they did everything like they usually did. Staff C was unsure how the incident occurred and felt as though it was a fluke occurrence. The Corrective Action Form, signed by Staff B on 7/15/19, documented on 7/1/19 Staff B completed a hoyer transfer with a resident who experienced a fall from the hoyer lift. The hoyer device and the sling used in the transfer had been inspected and found to be in good working order. The fall appeared to have resulted from the lack of ensuring the straps hooked to the lift properly. The Corrective Action Form, signed by Staff A 7/16/19, documented on 7/1/19 Staff A completed a hoyer transfer with a resident who experienced a fall from the hoyer lift. The hoyer device and the sling used in the transfer had been inspected and found to be in good working order. The fall appeared to have resulted from the lack of ensuring the straps hooked to the lift properly. During interview on 7/17/19 at 11:30 a.m., the DON reported Resident #1's health was declining prior to the fall and after the fall the resident returned to the facility on hospice level of care. The DON said the resident now bed bound for comfort measures and would not be getting out of bed during the survey process. The DON commented discussion regarding hospice level of care had occurred prior to the resident falling between the physician, the family, and her. The DON said the resident was diagnosed with [REDACTED]. The DON stated the resident had chronic hip pain, worsened since the fall, but currently under control with orders for [MEDICATION NAME] and something for breakthrough pain. Observation on 7/17/19 at 1:09 p.m. revealed Staff D, CNA, and Staff E, CNA, entered the resident's room to provide repositioning. Resident #1 moaned when the pillows used for positioning were removed. The pillows were behind the right hip and under her calves. Resident #1 was able to say which way she wanted to turn. The resident was turned to the left side and the resident called out in pain. The DON stated the resident did not recall the fall. Once Resident #1 was not being moved she appeared to be comfortable and voiced she felt okay and what pillows she wanted. On 7/17/19 at 2:10 p.m. Staff C, RN, recalled working the 2 p.m. to 10 p.m. shift the night Resident #1 fell on [DATE]. Staff C stated either Staff A or Staff B came to get her saying Resident #1 fell out of the hoyer. Staff C reported the resident laid on the floor angled in front of the bed with feet towards the wall and head towards the bed on her left side. Staff C stated a bump was present on the left side of the resident's head towards the back and the resident reported her right leg hurt. Staff C said the aides only moved the resident's head to place a pillow under it. Staff C commented she wasn't concerned as much about the right leg because the resident laid on the left side. Staff C commented both she and the EMTs (Emergency Medical Technicians) asked the resident if the right hip pain was more than her normal chronic pain and the resident said no. Staff C stated she worried more about the resident's head but neurologically the resident her normal self. Staff C said after assessing the resident, they laid her back down in bed with the use of the hoyer. Staff C reported because the resident's leg sore, Staff C held the leg during the transfer. Staff C stated she looked at the sling as both aides said at the moment it happened they thought the strap broke over her left shoulder but further inspection revealed no rips or tears with all loops intact; same sling used to put the resident back into bed. Staff C reported she asked the aides if the usual size sling used for the resident and they said yes. Staff C commented again the aides said it looked like something broke loose from the machine. Staff C stated a visitor present in the room, she asked if they had concerns, and they did not. During interview on 7/17/19 at 2:30 p.m., Staff B reported she worked for the facility for 2 to 3 years and recalled being present the night Resident #1 fell from the hoyer. Staff B stated Staff A asked for help, she thought she was going to be a minute, so Staff A already connected the sling before she entered. Staff B said when she entered she started pushing the resident up with the controls, Staff A moved the chair back, then Staff B moved the hoyer back towards the bed when it looked like it broke at the left shoulder. Staff B stated the resident fell out hitting her head on the floor. Staff B said the resident's right foot tangled not up far from the ground no more than approximately 2 feet, left leg on the ground, and hips on the ground. Staff B said the right leg was on top of the sling so she lifted up the leg to get it off then put on the ground. Staff B stated she lowered the lift to untangle the sling, all 3 of the other hooks were still connected. Staff B reported she thought the black loop used on the shoulders (top), green loops used on the bottom, the other loops that weren't used double looped over the bar. Staff B stated Resident #1 made a groaning sound and she could tell the resident was in pain. Staff B then went to get Staff C to check her over. Staff B stated they then transferred the resident back into bed with the hoyer and with the same sling. They had looked it over and nothing was wrong with either the sling or the machine. Staff B responded she guessed the fall occurred due to the loop not in the hook all the way. It must have been on top or something or the weight balance wrong. Staff B reported when she entered the room it looked like everything was ready to go, she just glanced at it (the sling connection), then raised up the resident. Staff B stated the resident raised up okay, just when moved the machine back, the sling came off. Staff B believed at that moment Staff A had his hands on the resident's back. Staff B acknowledged the resident's visitor present in the recliner in the room at the time of the transfer. Staff B responded she felt trained on hoyers and knows if the right size sling used if a sling lined up to a resident's shoulders and below the tailbone. Staff B responded since the incident she watched a video, completed a quiz, and completed a demonstration of a transfer. During interview on 7/17/19 at 5:44 p.m., Staff A reported he worked for the facility for 3 and half years. Staff A recalled the night the resident fell from the hoyer. Staff A stated his hall partner was busy so he asked Staff B to help him. Staff A said when he asked for help it looked like Staff B could not come right away so he decided to get the straps hooked up to the hoyer. Staff B stated at that point he was behind the resident when Staff B entered and started to put the hoyer up. Staff A said he moved the chair, the hoyer was pretty high up, a loop came undone and the resident fell . Staff A recalled the loop that came undone was the very same loop he put in (connected) first. Staff A commented he had to reenact the whole scenario with the DON and the Administrator and he had never seen anything like that happen before. Staff A stated the sling looked like the average sling they used and he believed the sling the right size because it matched up to the shoulders and the bottom part to the tailbone. Staff A recalled the color loops used to be how trained, always use the black loops on the top and the green loops on the bottom; top meaning by the shoulders. Staff A reported the resident did not slide or anything and he did not recall the resident being restless or moving. Staff A stated he pulled the chair away, a couple seconds passed, going to move to the bed, then the left shoulder loop came out and the resident fell . Staff A recalled his witness statement writing he double looped the connection. Staff A responded he was trained originally when he became a CNA for safety double loop so if a loop tore there would be another loop there. Staff A recalled the loops already in place and he moved to get around the wheelchair to stand behind to pull the wheelchair back when Staff B entered. Staff A reported Staff B grabbed he controls as the resident already set up to transfer. Staff A stated it looked like the resident's left shoulder side hit first, it was a fast fall, saw very quick, and then the resident was on the floor. Staff A reported the resident's lower half on the floor but her right leg still hung onto the sling as it went behind the knee. Staff A commented all 3 other loops were still connected to the bar. While Staff B went to go get help, Staff A moved the hoyer away and put a pillow under the resident's head. Staff A stated the nurse arrived to complete an assessment. Then they got the resident up with the hoyer and back to the bed with the same sling. Staff A responded he had to re-enact the scenario and the DON said he left the loop on top but he knew to put it all the way in the hook. Staff A thought the loop was the first one he put on because of where the chair had been positioned it was always the closest one and the he would go around. Staff A thought maybe the loop came loose then as he put the other loops on. Staff A commented he was shocked as how got that high before coming loose. Staff A recalled receiving training prior to the fall incident via a video in orientation then trained on the floor during the first week of training. During interview on 7/17/19 at 6:05 p.m., the resident's visitor who witnessed the fall responded they hadn't been paying attention to the connection. The visitor thought they hooked it up then Staff A left the room, came back, and thought maybe staff did not check everything. The visitor stated one of the loops may have come off. The visitor said the resident went up fine, next thing they knew the resident going down. The visitor reported the resident fell almost 4 feet. The visitor reported they had observed the staff help before and the transfers were fine. During interview on 7/17/19 at 5:07 p.m., the DON stated they tell staff in training to use the black loops on top and green loops on bottom when connecting a sling to the hoyer machine. The DON commented in the lift video used for training it talked about using those loops as it put a resident in a sitting position. On 7/17/19 at 5:20 p.m., Staff F, CNA, reported she worked for the facility since (MONTH) (YEAR). Staff F responded the size sling to use for each resident was located on the kardex and she looked at the body size to tell if the sling comfortable for them. Staff F stated she was trained on the loops to use black loops for the top, shoulders, and green loops for bottom, legs; single loops not double. On 7/17/19 at 5:22 p.m., Staff G, Certified Medication Aide (CMA), responded she worked for the facility for 4 years. Staff G responded she knew which sling to use based on a list behind the supply room door and if not there she went to ask the nurse. Staff G said sling size was also on the iPad and responded the sling should be lined up from the shoulders to the tailbone. Staff G stated she used the green loops on legs and black loops for the top of the shoulders. On 7/17/19 at 5:26 p.m., Staff H, Licensed Practical Nurse (LPN), responded staff knew sling size to use by the kardex and the iPad listed size/color as well. The slings are marked with names and back ups were available. Staff H responded the sling should line up to the body with shoulders and the tailbone. Staff H stated the loops used depended on what transfer staff doing, bed or wheelchair and always a single loop to be used. On 7/17/19 at 5:28 p.m., Staff I, RN/Unit Manager, responded she worked for the facility since (MONTH) 2019. Staff I stated staff choose a sling by the sign in the supply room, the slings were labeled. There was a video training that all staff had to watch and then take a test. Staff I stated the sling should line up thru shoulders down around the bottom, centered equally. The loops used were dictated in the video and in chart and depended on the positioning staff wanted, if wanted to lay down or sit up. Staff I felt she had training before the incident. On 7/17/19 at 5:33 p.m Staff J, CNA, responded she worked for the facility for 4 years. Staff J stated the sling size varied by the person and staff needed to put the sling on to see if too wide or not. Staff J stated the sling should line up by the shoulders and down to the tailbone. Staff J responded the loops used were seen in video and in training, you put the black loops first on the top and the bottom the green loops. On 7/17/19 at 5:35 p.m., Staff K, CNA, responded she worked for the facility for a year and a half. Staff K stated she knew a sling was correct based on labeled and color. Staff K stated the sling was supposed to line up to the shoulders and the tailbone. Staff K stated she decided the loops by black for the shoulders and green for the legs except if on the floor then needed to use the longest loops. Staff K commented she did the computer program training when first started and watched the videos on transfers. Staff K stated since the fall happened, she did an example with a nurse and watched the video again. On 7/17/19 at 5:38 p.m., Staff L, CMA, responded she worked for the facility for 3 years. Staff L stated she knew the sling size to use by asking the nurse or by measuring from the shoulders to the tailbone and to make sure not too loose or tight around the resident. Staff L responded she chose loop by 1 black loop on the top and 1 green loop on the bottom and criss cross. Staff L commented if she needed to fully lay down a resident she would do green and green but must take into consideration their body size. Plan of Correction On 7/18/19 at 10:30 a.m., the DON reported the staff watched a video from EZ way and then staff took the quiz and signed off completion. After the 12 question quiz, the DON checked to see if staff had questions and discussed if unsure of the answers. A competency audit was performed where the staff physically got an employee up out of the bed and into the chair. The DON reported they did this training process for all nursing staff including the Administrator, DON, and all management nurses. The DON said the trainings started on 7/2/19 and Staff A and Staff B retrained immediately, first. On 7/18/19 at 11:35 a.m., the DON reported Staff C retrained on 7/11/19 as Staff C went on vacation on 7/2/19. The DON stated the facility planned to train PRN (as needed) staff as they were scheduled. The DON stated after the incident she did not allow any employee to work until they were retrained. The facility corrected the above non-compliance on 7/2/19 by completing the following actions: Immediate Corrective Action - a. On 7/2/19 all mechanical lifts and slings were checked by maintenance for any defects. No defects found with any of the lifts or slings. b. On 7/2/19 re-education provided to all current nursing staff members on hoyer lift safety. Staff members watched a 20 minute video regarding proper usage of the hoyer lift device, they took a 12 question quiz after the videos, and then each staff member performed a hoyer lift transfer and the DON completed a transfer audit on each person. c. On 7/2/19, both the DON and the Administrator completed a re-enactment of the transfer with both of the CNA's involved in the incident. Ongoing Corrective Actions - a. Continuation of the monthly safety checks on all mechanical lifts and slings. b. Periodic transfer audits of staff members. On 7/10/19 the DON documented Additional Ongoing Corrective Action: Prior to the incident occurring with Resident #1 on 7/2/19, the facility shared hoyer slings among all the residents. On 7/8/19 the facility placed an order to allow 2 hoyer slings to be dedicated to each resident. The shipment expected to arrive 7/12/19. Upon arrival, each sling would be labeled with the residents name and would stay in each resident's room for that specific resident use only. One sling would be used and the other sling would remain in the resident room to be available when needed.

Based on record review and staff interviews, the facility failed to use the planned pressure alarm to mitigate a resident's risk for falls (Resident #6). The sample consisted of 4 residents and the facility reported a census of 85 residents. Findings include: Resident #6 had a MDS (Minimum Data Set) assessment with a reference date of 1/13/17. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 4. A score of 4 indicated the resident had severe cognitive impairments. The MDS indicated the resident required extensive assistance with transfers, dressing, toilet use and personal hygiene needs. The MDS identified [DIAGNOSES REDACTED]. The Care Plan identified the resident at risk for falls due to poor safety awareness and attempts to get up unassisted. The approaches and Interventions included the use of a pressure alarm, initiated on 8/11/16 and a reminder to staff that Resident #6 has personal alarms and to ensure they are on and functioning (Initiated on 9/19/16). The Incident Report dated 3/20/17 at 11:45 p.m. indicated Staff A was summoned to the room of Resident #6 by Staff B. Resident #6 was found lying on the floor on his/her left side with his/her face towards the chair. Resident #6 had blood all over his/her face and was not speaking. Resident #6 was unable to open his/her eyes. The resident's left hand had no grip. The nurse immediately called 911. The resident had an abrasion to the top of his/her scalp, facial bruising and swelling and a bruise on the left elbow. The CT (computed tomography) Scan report of the resident's head, dated 3/21/17, noted small focus of intraparenchymal hemorrhage in the frontoparietal region, small amount of subarachnoid hemorrhage, small hemorrhagic contusion in the right temporal lobe and mild swelling in the extracranial soft tissues in the frontal region. On 3/28/17 at 1:26 p.m. Staff A, certified nurse aide, was interviewed and stated on the evening of 3/20/17, she assisted Resident #6 to bed at around 7:00 p.m. Staff A stated she attached the personal safety alarm (clip alarm) to the resident's nightgown and the box was attached to the right side rail. Staff A stated there was no pressure alarm noted in his/her room or on the resident's wheelchair. Staff A stated she was new to the facility and not familiar with the residents on 100 hall. Staff A stated at around 8:00 p.m. the alarm sounded in Resident #6's room. Staff A responded and re-attached the magnet to the box. Resident #6 was not attempting to get up at that time. Staff A stated she did rounds around 10:00 p.m. with the on-coming aide (Staff B) and Resident #6 was in bed with the personal safety alarm clip attached to his/her clothing. In an interview on 3/28/17 at 10:05 p.m. Staff B, certified nurse aide, stated on the evening of 3/20/17 she did rounds with the off going aide (Staff A) around 10:20 p.m. Resident #6 was lying in bed asleep with his/her head of bed up 30 degrees, 1/2 side rails up and the clip to his/her alarm attached to his/her gown at the right shoulder. At about 11:45 p.m. Staff B returned to Resident #6's room and found him/her lying on the floor next to his/her bed. There was no alarm sounding and the clip to the alarm was still on his/her bed. Staff B noticed emesis on the floor next to Resident #6 and his/her bed stand pushed away. Resident #6 appeared to be bleeding from his/her head. Staff B got the nurse (Staff C), who assessed Resident #6 and had him/her sent out to the hospital. Staff B stated there was no pressure alarm being used for Resident #6 that evening, but recalled it had been used a week earlier. Staff B stated there had been a push at the facility to reduce the use of alarms and thought maybe the pressure alarm had been discontinued. Staff B stated she has seen Resident #6 pull at the clip on occasion, but noted Resident #6 hasn't been getting up at night. In an interview on 3/28/17 at 2:12 p.m. Staff C, Registered Nurse, stated she typically works 200 hall and was not as familiar with residents on 100 hall. Staff C stated on the evening of 3/20/17 she was at the nurse's station documenting when Staff B summoned her to Resident #6's room. Staff C responded and noted the alarm was not sounding. Resident #6 was lying on the floor semiconscious. Blood was noted on the floor beneath his/her head. Staff C initiated an assessment and called 911. Staff C stated Resident #6's blood pressure was low, heart rate was high and he/she had no grip in his/her left hand. Resident #6 was sent out to be evaluated. Staff C stated Resident #6 used a clip alarm and was known to occasionally detach the magnet from the box and one time detached the clip, but noted she did not know if his/her actions were intentional. Staff C stated that evening the clip was removed from his/her clothing. Staff C stated she was unaware if a pressure alarm was to be used as well. In an interview on 3/28/17 at 10:26 p.m. Staff D, Registered Nurse, stated on the evening of 3/20/17 she was in another resident's room when she heard the commotion related to Resident #6's fall. Once finished she assisted Staff C with coordinating the transfer to the hospital. Staff D stated there was no alarm sounding and she noticed the clip was sitting on the bed. Staff D stated she did not know whether a pressure alarm was to be used. Staff D stated she has only worked overnight shifts since 2/1/17 and since that time she has never known Resident #6 to get up unassisted at night, noting he/she usually sleeps all night. In an interview on 3/28/17 at 2:00 p.m. Staff E, certified nurse aide, stated she was familiar with Resident #6 and it was her understanding that Resident #6 was using both the clip and pressure alarm. Staff E stated Resident #6 gets restless during the day if not toileted frequently. Resident #6 was often kept at the nurse's station during the day to maintain close supervision. In an interview on 3/28/17 at 2:05 p.m. Staff F, Registered Nurse, stated Resident #6 had a personal safety alarm (clip) and during the day sat at the nurse's station in between meals. Staff F stated at one time Resident #6 was also using a pressure alarm. Staff F was uncertain whether the pressure alarm was discontinued and if so why. Staff F stated she believed the pressure alarm is a much more reliable alarm system. In an interview on 3/28/17 at 3:00 p.m. the Director of Nursing (DON), stated following the fall of Resident #6 on 3/20/17, she discovered staff were using a clip alarm when a pressure alarm was care planned. The DON stated the pressure alarm was never discontinued and she was unable to find out who may have changed it and when. In an interview on 3/29/17 at 9:50 a.m. Staff G, Care Plan Coordinator, reviewed the records of Resident #6 and stated the personal safety alarm (clip) was first initiated upon Resident #6's admission on 7/15/16 and following a fall on 8/10/16, was changed to a pressure alarm and the clip alarm was discontinued. Staff G stated it did not appear that both alarms were to be used. Staff G stated she was not certain why staff was not using a pressure alarm as care planned.

Based on record review and staff interviews, the facility failed to ensure a resident was free of abuse (Resident #1). The sample consisted of 5 residents and the facility reported a census of 85 residents. Findings include: According to the Admission Record dated 3/22/17, Resident #1 had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, with a reference date of 3/3/17, identified Resident #1 with severe cognitive impairments. The MDS indicated the resident required extensive assistance of 2 staff members with transfers, dressing and toilet use. The MDS indicated the resident experienced frequent bowel and bladder incontinence. The document titled Alleged Abuse, dated 2/18/17 at 1:16 p.m., identified an aide reported to the nurse an incident with another staff member and Resident #1. The document identified It was reported during incontinence cares that the resident became combative with the staff member. The resident hit the staff and the staff member swatted the resident's leg and stated, How do you like it? The other staff member continued to care for Resident #1. The form titled ASE Complaint/Incident Investigation Report dated 2/27/17 identified the facility submitted a self-report to the Department of Inspections and Appeals. The facility reported on 2/18/17 at 11:20 a.m. Staff A (nurse aide) reported to Staff B (nurse) suspected abuse by Staff C (nurse aide) during cares. Staff A reported that Staff A and Staff C had Resident #1 in the bathroom providing incontinent cares. Resident #1 had agitation and combative behaviors during the care. Staff C hit Resident #1 on the left thigh and stated, How do you like it? Staff A reported this immediately to Staff B. Staff B completed an assessment of Resident #1. Resident #1 had no injuries and no recollection of the incident. On 3/23/17 at 11:00 a.m. the Administrator was interviewed and reported all staff received abuse training on 2/23/17. The policy and procedures titled, Dependent Adult Abuse, revised May 2016, directed the staff that all residents have the right to be free from verbal, sexual and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardians, friends or other individuals.

Based on observation, record review, review of facility protocols and staff, family, and physician interviews, the facility failed to ensure Resident #2 received treatment and care timely for 1 of 4 residents reviewed. Resident #2 displayed symptoms of a stroke and the facility did not implement timely interventions (ongoing assessments and timely inform physician of urgent change of condition events) to prevent further decline of the resident's condition. The facility identified a census of 88 residents. Findings include: 1.The Admission Record for Resident #2, identified [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment with a reference date of 01/27/17 indicated Resident #2 had a BIMS (Brief Interview for Mental Status) score of 5. A score of 5 represented the resident with severely impaired cognitive status. The MDS identified the resident required extensive assistance of 1 staff person for ambulating and transferring. The resident independently fed self with staff assistance setting up the service. The MDS indicated the resident had no functional limitations of range of motion on either the upper or the lower extremities. The Care Plan, updated on 11/11/16, directed a facility staff person to provide assistance with ambulation as well as to not leave the resident unattended in the wheelchair in order to prevent self-transfers. According to the 12/27/12 Cardiopulmonary Resuscitation/DNR Order Declaration Form (signed by physician and resident responsible party), Resident #2 did not want resuscitation. The Progress Notes documentation identified the following: On 2/13/17 at 11:17 a.m., staff monitored the resident due to a change in condition and possible TIA ([MEDICAL CONDITION]), mini - stroke which often resolves). The resident had slight left side facial drooping, left side weakness with grips, and was unable to do push/pulls. The resident's speech was clear, with stable vital signs as well as pupils equal and reactive to light and accommodation (PERLA) (normal). The resident thought the change of condition to be from the water. The nurse faxed the physician. On 2/13/17 at 11:33 am, staff left messages for the power of attorney (POA) and next of kin (NOK) to call for an update on the resident's condition change. The certified nurse's aide (CNA) reported Resident # 2 had increased difficulty with transfers in the bathroom. The note indicated the staff would continue to monitor. On 2/13/17, at 21:30 PM, staff received a return fax regarding that the resident was having a possible stroke. There was a nursing order for speech therapy to evaluate and treat. The POA had returned the phone call. Neither the POA nor the NOK wanted anything further done regarding a possible stroke. On 2/14/17, at 3:22 am, Resident # 2 was confused and forgetful at times. The resident had slight left side facial drooping, clear speech, and equal grips. The resident was able to move all extremities as per usual. On 2/14/17 at 10:23 AM, Resident # 2 continued to have right-sided weakness that was almost flaccid. The resident did not lift either the right arm or leg. The left grip was much stronger than the right. The resident's face was asymmetrical. The resident was now in the assisted dining room for monitoring. On 2/14/17, at 3:45 PM, the resident's daughter gave permission for speech therapy to evaluate and treat Resident # 2. At 9:49 PM on 2/14/17, resident #2 continued to have difficulty swallowing. The resident coughed with eating and drinking. The left sided facial drooping was more prominent. The resident's right arm was flaccid. There was no right grip. There was a weak left grip. The resident was the assist of 2 staff with transfers. The 2/13/17 physician notification sheet revealed the following information. There was a date/time stamp of 02/13/17 at 3:30 PM across the top. The resident had slight left side facial droop with normal speech. The left grip was weak. The push pulls were uncertain, as the resident was unable to perform these. The resident was a DNR. Additionally, the resident was having increased coughing with water and food, as well as medications. The staff requested an order for [REDACTED]. The staff was advised to ask the family what, if anything, the family wanted done. The doctor was fine with the speech evaluation and treatment request. The document was acknowledged on 2/13/17 at 9:30 PM. The facility protocol titled, Change of Condition/Hot Chart Protocol, dated January 2015, directed the staff to do the following: Observe/assess the resident to determine the resident's status; Notify the physician as appropriate; Notify the responsible party/family; Carry out the new orders; Monitor the resident for a response; Establish advanced directive status as needed. The same document directed facility staff to document: The date and time of assessments and interventions until the problem resolved; The date and time of physician notification and if there were any orders received; The date and time of the family/responsible party notification. During a 2/20/17 telephone interview at 1:47 PM, Resident # 2's (POA) stated that over last weekend, Resident #2 apparently had suffered a slight stoke. When staff called the POA, the staff indicated Resident # 2 had suffered minimal changes. When the POA saw the resident the next day, the POA was surprised at the resident's condition. The POA thought that the resident's changes were more than minimal. On 2/21/17, during another telephone interview at 4:02 PM, the POA stated that the staff contacted the POA in the afternoon. The unknown staff member told the POA that Resident # 2 had had a mini stroke. The resident's mouth drooped on one side. Additionally, the resident was weak on either one or both sides, but mainly the one side. The staff member didn't ask the caller about sending the resident to the hospital. Rather, the staff member told the POA that they were watching Resident # 2 and had notified the doctor. The POA told the staff member this was fine as long as they were doing what Resident # 2 indicated. The POA thought she had talked to the facility on ce that day regarding Resident # 2's condition. The POA stated she was shocked at Resident # 2's condition when visiting the next morning. The POA reported she trusted the staff to tell her when Resident # 2 needed to go to the hospital. The staff told the POA at this visit that they thought the resident was a little worse. The POA clarified that upon admission, when there were several facility staff members in the room, Resident # 2 had indicated he/she didn't want to be kept alive artificially but didn't want to be in pain. The POA stated she was upset over the resident's decline. In an interview on 2/20/17 at 1:12 PM, Staff A, a Registered Nurse (RN), reported being Resident # 2's nurse on 02/13/17. The resident was a DNR. A CNA, possibly Staff B, told Staff A that Resident # 2's face was drooping on the right side. The facial drooping was so slight that Staff A didn't initially see it. The resident's right grip was slightly less strong than the left, but the resident was able to move both sides of his/her body. The resident was confused, but spoke clearly. Additionally, the resident's vital signs were within normal limits (WNL). Staff A left messages for both the POA and the NOK. Both called back. The POA didn't want to do anything. The decision was to see how things progressed, so Staff A faxed the doctor. Resident # 2 had no additional changes by the time that Staff A left at the end of the day shift. Staff A gave Resident # 2 medications and a nebulizer breathing later in the shift. Staff A stated by the time she returned to work a few days later, Resident # 2 had gotten worse. The Unit Manager, Staff C, stated she had talked to the family. Currently, the resident was not using his/her right arm to feed him/herself as per usual. During a 2/21/17 at 2:57 PM interview, Staff A stated that on 2/13/17, Staff B and another staff member brought Resident # 2 to the nursing station, saying, I think Resident # 2's just had a stroke. Staff B reported the resident had right facial drooping. This was right after breakfast, when Staff A was finishing up med pass. Staff A thought this was between 9:30 and 10:00 am, as this was when Staff A usually completed the medication pass. Staff A did Resident # 2's vital signs, and had the resident talk and smile. It was hard to see the facial drooping. Staff A stated she checked the resident's hand grips. Staff A tried to get Resident # 2 to push/pull with his/her feet against Staff A's hands. Resident # 2 was unable to do this. However, Staff A couldn't determine if the resident couldn't do this, or wasn't able to follow directions, which was typical for the resident due to his/her cognition. Resident #2's smile was a little crooked, but the resident spoke clearly. The resident stated that all of this was from the water. Staff C then assessed Resident # 2. Staff A did not again assess Resident # 2 that shift. Staff A reviewed the 2/13/17 progress notes and 2/13/17 fax. Staff A clarified that she thought she had spoken to the family before preparing the fax and sending it to the doctor. The incident might have happened closer to 11 am, which would explain the 11:17 am entry re faxing the doctor. Staff A stated that she was going to fax Resident # 2's doctor anyway due to the resident having some swallowing problems - the day before, Resident # 2 was coughing and spitting when taking crushed medications. Staff A stated earlier on 2/13/17; Staff A had given Resident # 2 his/her medications. The resident was able to hold the cup when drinking, and seemed ok. Staff A couldn't remember which hand the resident had used to hold the cup and the resident coughed quite a bit when taking medications and sprayed out fluid. The resident subsequently settled down and ate breakfast without difficulty. Staff A stated Resident # 2 seemed per usual self at that time. There had been nothing in shift change report regarding the resident acting differently. Staff A stated that on 2/13/17, all of Resident # 2's changes were subtle. Staff A thought that the resident was having a TIA. Staff A clarified that the fax was incorrect - the concerns regarding the left sided facial drooping and left side movement should be written as right sided. Staff A also clarified that she didn't remember the exact times - everything was nonstop once Staff B had said that Resident # 2 was having a stroke. During a 2/20/17 3:05 interview, Staff C, the Unit Manager, couldn't remember the date of this incident. Staff C stated Staff A notified her that Resident # 2 was weak on the right side. This information was from the aides. Staff A asked Staff C to check out the resident's right leg. This limb had the largest deficit - the resident wasn't helping to hold it up - it dropped when Staff C lifted and then let it go. The resident could faintly squeeze with the right hand. Staff C told Staff A to contact the family and fax the doctor. The resident's face drooped a bit on the right side. All of this was a change. The staff wanted to wait on the family's response to see how aggressive they wanted to be. Staff C stated the staff was always to call the doctor for a change of condition. The family didn't want to send Resident # 2 to the hospital. The family wanted to have the staff watch the resident at the facility to try to figure out if the changes were long term or temporary. The family wanted speech therapy, but not hospitalization . Staff C stated she did not think any facility staff contacted the doctor again on Resident # 2's condition, including when the resident really wasn't able to move his/her right side. The staff did tell therapy. The family was at the facility or calling for updates more frequently than usual. Staff C stated she thought that the facility had followed the family's direction to keep Resident # 2 at the facility. During a 2/20/17 interview at 3:26 PM, Staff D, CNA, reported being assigned to Resident # 2 on the 2/13/17, 2:00 PM to 10:00 PM shift. Staff D noticed Resident # 2 was no longer able to pull him/herself up and turn as he/she had been. The resident now needed a second person to transfer. Staff D reported that the day shift CNA said she had told the nurse about this. Staff D didn't double check with the 2/13/17 evening nurse to ensure that this nurse was aware of Resident # 2's condition. The resident stayed the same that shift and didn't have any additional changes. Staff D didn't think she had cared for Resident # 2 since then. During a 2/21/17 9:16 am interview, Staff E, an RN, stated that staff should call the doctor if a resident had a significant condition change, as well as make the family aware. Staff E was not assigned to Resident # 2 the day of the incident. However, Staff C had asked her to look at Resident # 2. The resident's right side was flaccid. Staff E thought that the resident must have had a big one. Before this incident, Resident # 2 was able to walk to the bathroom. Staff E had cared for Resident #2 post incident. Staff E had not updated the doctor on the resident's condition. Staff E knew that the family didn't want the resident sent to the hospital because other staff had told her this. During an interview on 2/21/17 at 9:40 am, Staff G, an evening shift nurse, stated that after report she typically checked on the residents, and then called the doctor if there was anything concerning. On the day of the incident, Staff G thought Resident # 2 had woken up with the possible stroke. The day nurse had left the fax for Staff G to do. Staff G called one of the family members and read what the doctor had written on the fax. Staff G didn't remember the time. The family didn't want anything done. Staff G thought that the stroke had already happened by the time Staff G arrived at work. Therefore, it was past time to do anything about it. Staff G thought that she had contact with the family over the next few days as they were at the facility a lot then. Staff G, during a second interview on 2/22/17 at 3:09 PM, stated that she had assumed that Resident # 2's symptoms had started when the CNA had gotten her up for breakfast that morning. However, no one had given Staff G a specific time so she didn't actually know when the resident's symptoms had started. Staff G hadn't contacted the doctor - why would she? The 2/13/17 fax was back when Staff G arrived at 2:00 PM. Staff spoke with the resident's POA. Staff G read the doctor's response to the POA, and asked if the POA wanted to do anything further. The POA declined. Staff G thought that she had spoken with the POA after supper. Staff G stated that she had assessed Resident # 2 the evening of 2/13/17, probably at the start of the shift. Staff G expressed dismay that she hadn't documented the assessment after the surveyor read the 9:30 PM 2/13/17 entry. When assessed, Resident # 2 was unable to lift her right arm, but had a little bit of a grip. The resident also had a little bit of left sided facial drooping, not right sided. The resident was able to drink but coughed with her medications. The resident's speech was clear. Staff G thought that Resident # 2 was currently doing better. Today, the resident was able to lift his/her right arm above his/her head, and fed himself/herself at breakfast. Staff F, a CNA, was interviewed on 2/21/17 at 1:21 PM. Before 2/13/17, Resident # 2 could walk to the bathroom with a walker and stand by assistance. The resident probably couldn't walk as far as the dining room. Staff F stated on 2/13/17, she got Resident # 2 up around 6:45 to 7:00 am. Resident # 2 said he/she was too tired to get up out of bed. The resident needed a lot more help to get to the wheelchair, as he/she could only partially bear weight. Staff F stated she had to get help to get the resident to the bathroom. This was unusual. Staff F didn't really look at the resident's face. Staff F took Resident # 2 out to the main dining room after completing cares. Staff F told the nurse, possibly Staff A. Staff F also passed on this information to the oncoming evening shift CNA. Staff F stated Resident # 2 usually didn't eat much, but was having more trouble that day. Resident # 2 was choking and coughing consistently on nectar thick fluids. The resident had some issues already with his/her right hand, but had a lot more that meal. If one of the CNAs lifted the resident's right hand, and let go, the arm fell back into the resident's lap. The resident wasn't using his/her right hand. Staff F fed Resident #2. It was unusual for the resident to need to be fed. Staff F thought she had spoken to Staff A around 7:15 am. Staff F told the nursing that the resident was weak, and needed 2 staff to transfer. This needed to be passed on to the second shift nurse. After breakfast, another CNA, Staff B, noticed that Resident # 2 was having facial drooping. Staff B took the resident out to the nursing station. The nurse was possibly on a break, so staff F found Staff C. Staff F thought this was around 9:00 am. Staff F watched Staff C assess Resident # 2. Staff C spoke out loud. Staff C said that Resident # 2's right hand grip was weaker. If Staff C lifted Resident # 2's right hand, it would just fall because the resident didn't have the strength to keep it up. The same thing happened when Staff C lifted the resident's right leg. Staff C told the resident, don't just let me push it, and the resident's leg fell . Staff F left to go answer lights after Staff A arrived. Resident # 2 stayed out at the desk. Staff C stated Resident # 2 was having signs of a stroke. Staff A said there wasn't much to do for the resident and that Resident # 2 was now assist of 2 staff. Staff A also said the family didn't want Resident # 2 sent to the hospital. Staff F told the oncoming shift that Resident # 2 was now required the assistance of 2 staff members. During a 1:50 PM interview on 2/22/17, the Director of Nursing, (DON) stated not knowing if the facility had a specific policy for physician notification. It was up to nursing judgement to decide how to notify the doctor. The DON expected the nurses to call versus fax if that the concern needed immediate attention. During a 3:34 PM interview on 2/22/17, the resident's doctor stated that he was a resident who worked under faculty supervision. The residents and faculty took turns covering for each other. The doctor was not the one that was notified and responded to the 2/13/17 fax. The doctor couldn't answer if it would have been more appropriate to call versus faxing. However, if a resident had similar progressing symptoms, the doctor thought it would be appropriate to send the resident to a higher level of care for an evaluation. Staff B was interviewed on 2/25/17 at 10:31 am. Staff B stated that prior to this incident; Resident # 2 used a walker to walk to and from the bathroom. The resident fed him/herself. He/she may have hurt one wrist as he/she sometimes had trouble gripping with that hand and said it hurt. The resident could, however, move both arms. On the day of the incident, Staff B didn't get report on Resident # 2 as Staff B was assigned to different residents. After breakfast, Staff B noticed that one side of Resident # 2's face was drooping. Staff B didn't remember which side. Also, the resident's dominant side seemed weaker. Staff B and another staff member took Resident # 2 out to the nursing station. Staff B told the other staff member to notify both Staff A and Staff C of the resident's symptoms. Staff B stated that Staff A didn't always follow through on concerns, so she wanted staff C also notified. Staff B then left the area. Staff B saw the resident later that day at lunch. Resident # 2 couldn't lift up the affected hand. Staff B also said something to the facility administrator regarding the resident now possibly needing to eat in the assisted dining room. At 9:08 am, on 2/20/17, Resident # 2 was observed sitting in a wheelchair in the assisted dining room. The resident was using his/her left hand to eat. The resident did not move his/her right arm/hand. The resident sat angled away from the surveyor so his/her face was not fully visible. The resident's face looked asymmetrical. On 02/21/17, at 8:04 am, Resident # 2 was again sitting in the assisted dining room. The resident's face drooped on the right side. Note: At the time of the complaint investigation, the complaint was coded at a J, immediate and serious jeopardy. By 2/22/17, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the D level. The facility provided in-services to the nurses. The nurses received education about the change of condition evaluation assessment form (previously known as SBAR) must be completed on every resident with an acute condition change when contacting the physician by a telephone. The nurses received direction they must contact the physician by telephone instead of fax with any acute condition change that required physician intervention, regardless of family decision for treatment. As of the 2/27/17 exit conference, the facility continued to need to: · Continue to monitor the licensed nursing staff compliance with the use of the Change in Condition Evaluation form and informing physician's by telephone for any acute condition changes.

Based on clinical record review, observation, facility policy review, resident and staff interview, revealed the facility failed to provide a safe environment and transfer technique for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 87 residents. Findings include: The Minimum Dated Set (MDS) assessment dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) score of 13 that indicated a lack of cognitive impairment. The MDS documented Resident #1 exhibited signs of psychosis. Resident #1 required extensive assistance of two staff members for bed mobility, toileting, required extensive assistance of one staff member for transfers, personal hygiene and walk in the room but did not walk in the corridor. The MDS listed Resident #1 ' s [DIAGNOSES REDACTED]. The MDS listed Resident #1 as a high risk for falls. The care plan dated 7/20/15 listed Resident #1 as at risk for falls. The care plan instructed staff to assist Resident #1 for transfers and walking. The care plan did not include the use of a gait belt. The gait belt policy dated January 2015 stated gait belts should be used by all staff for easier handling of residents which should help to avoid injuries to both resident and staff. The policy also instructed that if a resident did lose their balance, draw the resident close and ease the resident down with a grip on the gait belt. This will protect the resident and staff from head or bodily injury. The nurse's notes dated 8/8/15 at 2:12 a.m. documented Staff A, certified nursing assistant (CNA), walked Resident #1 to the bathroom. Staff A witnessed the fall and notified Staff B registered nurse (RN). The nurse's notes documented Resident #1 had an abrasion to the back of head, abrasion on the right shoulder, and complained of right hip pain. Staff B assessed Resident #1 and noted full range of motion. On 8/8/15 at 2:30 a.m. the nurse's notes document Resident #1 hurt all over. According to the nurse ' s note the pain was identified as 8 out of 10. On 8/8/15 at 2:50 p.m. the nurse's notes documented Resident #1 blamed the facility for the fall . On 8/8/15 at 3:10 a.m., the nurse's notes documented Resident #1 continued to have pain and felt fear of ever walking again. Staff B RN notified the physician and received orders at 3:40 a.m. to send Resident #1 to the hospital. On 8/8/15 at 8:30 a.m., the nurse's notes documented family notified the facility Resident #1 was admitted to the hospital with [REDACTED]. The incident report dated 8/8/15 at 2:12 a.m. documented Resident #1 fell while Staff A CNA assisted Resident #1 to the bathroom and sustained abrasions to the shoulder as well as an abrasion the resident's head. According to the incident report Resident #1 complained of pain all over of 9 out of 10. The radiology report dated 8/8/15 that showed a nondisplaced fracture of the inferior right pubic bone extending into the hip joint. During an interview on 8/31/15 at 9:00 a.m. Staff C CNA, stated she used a gait belt with all residents During an interview on 8/31/15 at 9:07 a.m. Staff D CNA, stated she used the gait belt with all residents. During an interview on 8/31/15 at 9:15 a.m. the director of nursing (DON) stated the facility issued a gait belt to all new employees and staff members received training on gait belt usage. During an interview on 8/31/15 at 10:46 a.m. Resident #1 stated around 2:15 a.m. she/he needed to use the bathroom. Resident #1 asked staff to use the gait belt. Staff A CNA replied she did not have a gait belt and would hold onto Resident #1 ' s adult undergarment. Resident #1 asked for the gait belt three times. Resident #1 stated she/he does not remember the fall but did recall Staff A CNA fell on top of her/him. Resident #1 stated since the fall, staff members use the gait belt for transfers. During an interview on 8/31/15 at 1:44 p.m. the social service designee stated she did all the orientation for new employees. The employees watched a video regarding gait belt use. She could not provide a written content of the video but stated the video directed all staff must use the gait belt when assisting a resident. The social service designee stated the orientation process did not include any demonstrations of gait belt use but the new employee did follow another certified nurse aide for 3 days to 1 week for more in depth orientation. Staff A CNA wrote a statement (undated) after the incident. The statement documented Staff A CNA answered Resident#1's call light. Resident #1 stated he/she needed to go to the bathroom. Staff A CNA asked Resident #1 about her/his ability to stand. Resident #1 told Staff A CNA she/he could walk and did not want the gait belt. Staff A CNA stated Resident #1 lost his/her balance and fell . Staff A CNA stated Resident #1 hit his/her head during the fall. Staff A CNA summoned the nurse During an interview on 8/31/15 at 1:22 p.m. Staff A CNA stated she worked on 8/8/15 on the 2:00 p.m. to 10:00 p.m. but stayed for the overnight shift. Staff A CNA stated she answered Resident #1's call light and Resident #1 asked to go to the bathroom. Staff A CNA asked Resident #1 about wearing the gait belt and Resident #1 stated was she/he was steady and he/she did not need one. Staff A CNA stated she did not have a gait belt with her. Resident #1 stood and walked into the bathroom. Staff A CNA held onto Resident #1's adult undergarment. Resident #1 fell sideways then backwards landing hard on the floor. Staff A CNA stated she fell forward to prevent falling on Resident #1. Staff A CNA hit her head trying to break Resident #1's fall. Staff A stated she learned in training to always use the gait but did not know what to do if the resident refused. Staff A CNA later learned Resident #1 often refused to wear the gait belt. During an interview on 8/31/15 at 7:32 p.m. Staff G, CNA and CMA (certified medication aide), stated she always used the gait belt and could not recall if any residents refused to wear a bait belt. During an interview on 8/31/15 at 7:55 p.m. Staff H, CNA, stated he just started working at the facility. Staff H completed new employee orientation and it stressed the use of the gait belt on every resident. During an interview on 9/1/15 at 5:50 a.m. Staff E LPN (licensed practical nurse), stated she used the gait belt for all residents. During an interview on 9/1/15 at 6:00 a.m. Staff F CNA, stated she used the gait belt on every resident. Staff B RN typed a statement (undated) after the incident. Staff A CNA told her Resident #1 fell . Upon examination, Staff B RN noted Resident #1 on the floor without a gait belt. Resident #1 had a small scrape on the back of the head and a cut on the back of the head. Staff B RN wrote 3 staff assisted Resident #1 to the wheelchair then Resident #1 wanted to sit in the recliner. Staff B RN began neurological checks. Staff B RN stated she was unable get Resident #1's pain under control and phoned the physician to obtain an order to transfer Resident #1 to the hospital. During an interview on 9/1/15 at 8:40 a.m. Staff B RN stated she just worked as needed and only worked the night shift four other times. Staff A CNA approached her and stated Resident #1 fell in the bathroom. Staff B RN stated Resident #1 usually did not get out of bed in the night. Resident #1 had an indwelling catheter and only needed to get up to have a bowel movement. When she entered the room, Resident #1 had adult undergarment on with no gait belt. Staff B stated Resident #1 slept with no clothes on and just wore the adult undergarment. Staff B RN and 2 other staff members assisted Resident #1 off the floor. Staff B RN stated she asked Resident #1 to wear a gait belt but Resident #1 refused and just wanted to get off the floor. Staff B RN assessed Resident #1. According to Staff B RN Resident #1 exhibited full range of motion but was unable to control the pain for Resident #1 so received an order to transport Resident #1 to the hospital for an evaluation. During an interview on 9/1/15 at 9:26 a.m. Staff K RN, stated she worked 10:00 p.m. to 6:00 a.m. shift every weekend. Staff B RN informed her that Resident #1 fell . Staff B RN obtained vital signs and completed an assessment of Resident #1. Staff A CNA left the room to get a gait belt. Resident #1 refused to wear the gait belt. Resident #1 had a catheter. Staff K RN stated Resident #1 usually remained in bed at night unless he/she needed to have a bowel movement. As soon Resident #1 sat safely in the recliner, Staff K RN left the room. During an interview on 9/1/15 at 10:35 a.m. Staff J CNA believed the facility failed to have enough staff on 8/8/15. Staff J CNA stated only two nurses and three CNA ' s worked the night of 8/8/15. Staff J CNA stated Staff A CNA stayed to help the night shift. This was Staff A CNA ' s first night shift. Staff J CNA stated the facility normally staffed 2 nurses and 4 CNA ' s. Staff J CNA stated she was not directly involved with Resident #1 ' s fall. During an interview on 9/1/15 at 11:00 a.m. the administrator stated they did not interview Resident #1 after the incident. During an interview on 9/1/15 at 1:32 p.m. Staff I CNA, stated Resident #1 has refused to use the gait belt and wanted staff to hold the back of the adult undergarment. Staff I stated she did not know if Resident #1's refusal of the gait belt was reported to the charge nurse. Review of Staff A CNA's personnel record revealed a hire date on 9/4/14 and terminated on 8/8/15 for not using a gait belt resulting in resident injury. The employee had an active certified nurse aide when checked on 7/29/14. The single contact license and background check dated 8/20/14 showed the employee had no criminal or dependent adult abuse background. Staff A CNA signed an acknowledgment form on 9/4/14 that she received the employee handbook. Review on the Non-Exempt Employee Handbook dated March 2015 contained no information regarding the use of gait belts. The job description signed 9/4/14 instructed staff to follow established performance standards and duties according to nursing services policies and procedures. The job description instructed staff to perform resident care techniques and procedures according to certification instruction, in-service education or instruction from supervisor. Staff members are expected to comply with procedures for safe lifting, transferring, and handling of residents; assuming responsibility for safety of residents. The Essential functions also direct staff to participate in the development of an individual plan of care of assigned residents. The job description instructed employees to review the care plan and perform nursing care as outlined. The employee education dated 9/4/14 documented the facility issued a uniform and gait belt. Staff A CNA signed the acknowledgment and receipt of an uniform and gait belt on 9/4/14. Staff A CNA had a correction action form signed 6/1/15 for not checking a resident's alarm which resulted in a fall. Staff A CNA received an employee coaching worksheet dated 6/18/15 for lack of documentation in the computer system. The facility held an all nursing staff meeting on 6/11/15 to include gait belt use. Staff A CNA attended. The facility had a Five Minute Meeting for Employees on 8/10/15. The meeting content included gait belt use for all residents that needed assistance with transfers and walking. The content included that if a resident refuses to wear the gait belt then tell the charge nurse before staff assisting that resident. During observation on 8/31/15 at 11:57 a.m. Staff L CNA assisted Resident #1 to the recliner. Staff L CNA used a gait belt to assist Resident #1. The facility used a resident roster to indicate which residents had a BIMS score of 10-15. During an interview on 8/31/15 at 11:05 a.m. Resident #3 stated staff members used the gait belt when Resident #3 required transfers and for ambulation. During an interview on 8/31/15 at 10:40 a.m. Resident #4 stated staff members utilized a gait belt recently for transfers and walking. During an interview on 8/31/15 at 10:14 a.m. Resident #5 stated the aides failed to use a gait belt for transfers.

Based on record review and staff interviews, the facility failed to provide adequate supervision and implement Resident #1's care plan intervention to prevent accidents. Record review identified the facility used alarms to alert staff when Resident #1 attempted to self-transfer. On 3/7/14, staff interviews identified the resident's alarm did not sound to alert staff of his/her safety needs; and the alarm device had not been attached to the resident. Resident #1 fell and sustained a hip fracture. The facility identified a census of 81 residents, with three (3) additional residents reviewed. Findings include: 1. According to a Minimum Data Set (MDS) assessment form dated 2/20/14, Resident #1 had displayed sporadic signs of delirium (disorganized thinking) and had been diagnosed with [REDACTED]. Resident #1 scored 7 on the Brief Interview for Mental Status (BIMS) cognitive test. A score of 7 established Resident #1 with severe cognitive impairments. The MDS assessment determined Resident #1 required one staff person to assist with transfers, walking, bed mobility, dressing and for personal hygiene; and he/she required two staff to assist with toilet use. The test for balance identified Resident #1 was not steady and only able to stabilize his/her balance with staff assistance when moving from seated to standing position, when walking, when turning around, when moving on and off the toilet and when completing surface transfers. (Surface transfers are described as transfers between bed and chair or wheelchair.) A Care Plan with a goal dated 4/2/14, indicated the resident as at risk for falls. The care plan directed staff on the following safety measures: a. Assist Resident #1 with one staff member for transfers and when walking. b. Remind Resident #1 to ask for assistance for transfers and ambulation. c. Utilized a PSA (personal sound alarm) (clip alarm) at all times for Resident #1. d. Utilized a pressure alarm on his/her bed. e. Monitor Resident #1 for changes in his/her condition that warranted an increased supervision/assistance and notify the physician. f. Utilized a wheelchair for long distance mobility. g. Assist Resident #1 to ambulate without a walker but rather utilize a gait belt and hands on assist only (dated 2/3/14) A Fall Risk Evaluation form dated 2/21/14, indicated the resident with a score of 14. (A score of 10 or higher equal a fall risk.) Nurse's Notes forms indicated the following entries: a. 2/24/14 at 12:15 a.m. - The resident had been up and down all HS (hour of sleep) shift. b. 2/24/14 at 12 p.m. - Resident very anxious, multiple attempts to self-transfer. c. 2/24/14 at 8:25 p.m. - Resident attempted to self-transfer this afternoon. d. 2/25/14 at 6 a.m. - Resident tried standing up by himself/herself. e. 2/26/14 at 9:45 p.m. - Resident attempted to get out of bed one time. Increased anxiety at times. f. 2/27/14 at 5:45 a.m. - Resident getting out of bed 2 times without assistance and up and down in bed all night with increased anxiety and very confused per usual. g. 2/27/14 at 6:15 a.m. - The overnight nurse stated the resident had been up most of the night, would not stay in bed. The resident showed increase anxiety, this morning, restless, and unable to redirect. The resident attempted to climb out of the wheelchair without the brakes locked and over the foot pedals. After breakfast the resident's alarm had been sounding and the resident self-transferred him/her(self) into the bathroom. h. 2/27/14 at 9:55 p.m. - The resident transferred self to the bathroom. i. 2/28/14 at 6:45 a.m. - The resident had increased anxiety. j. 3/1/14 at 12:50 p.m. - The resident attempted to ambulate without assistance. k. 3/2/14 at 12:30 p.m. - The resident continued very anxious and confused. l. 3/2/14 at 3:10 p.m. - The resident appeared anxious. m. 3/3/14 at 10 a.m. - The resident displayed an increase in anxiety. n. 3/3/14 at 4 p.m. - The resident attempted to ambulate without assistance and the resident did not utilized the call light. o. 3/4/14 at 9 a.m. - The resident appeared very anxious that morning. The resident climbed out of wheelchair that morning, over the foot pedals, wheelchair brakes unlocked partially walked up the hallway while the alarm had been sounding. p. 3/5/14 at 9:40 p.m. - The resident self-transferred from the bed to the chair. Unable to make needs known, continues with increased anxiety and paranoia. q. 3/6/14 at 12:30 a.m. - Increased anxiety, up and down out of bed with alarms sounding and alerting staff. r. 3/6/14 at 11:45 a.m. - Multiple attempts to self-transfer. s. 3/7/14 at 1:39 a.m. - Resident continued to get out of bed without staff assistance. t. 3/7/14 at 10:15 a.m. - The resident showed an increase in anxiety, restlessness, confusion and forgetfulness. u. 3/7/14 at 4:45 p.m. - The writer had been called to the resident's room by a CNA (certified nursing assistant) who stated an LPN (licensed practical nurse) found resident on the floor. This nurse entered the room and found the resident on the right side; with his/her head lying on a trash can with the LPN at the resident's side. Vitals signs taken = temperature (T) 99.2 degrees Fahrenheit (F), pulse (P) 98, respiration (R) 20, blood pressure (B/P) 173/107. The resident complained of right hip pain and unable to move the right lower extremity or straightened the right leg/hip due to pain. The resident had been assisted to bed with a Hoyer lift and 4 staff; and the nurse attached the PSA and the resident's pressure alarm. This nurse spoke to the CNA's after the resident had been transferred to the hospital. A CNA stated the resident as toileted shortly before the fall. The nurse asked the CNA if the PSA had been attached after taking the resident to the toilet and the CNA stated "yes". The PSA had not sounded when the LPN entered the room. The alarm had been on the wheelchair handle. The ambulance service arrived to transport the resident to the hospital. An Incident/Accident/Unusual Occurrences Form dated 3/7/14 at 4:45 p.m., documented Resident #1 had been found on the floor in their room by a nursing calling for help. Resident #1 had been positioned on his/her right side. The resident ' s head had been held up by a trash can. His/her wheelchair had been on left side of resident, with the brakes locked and foot pedals out to the front of the wheelchair. The PSA did not sound and had been hanging on the wheelchair handle. The resident complained of right hip pain at a 9 out of 10 scale. The form documented the resident had been unable to move his/her right extremity and had pain. The area had been slightly pink and with no bruising. The resident stated he/she had not hit his/her head and the resident had been able to move all other extremities which had been within normal limits for the resident. Four (4) staff assisted the resident up with a Hoyer lift device without bending the resident ' s right hip. No other injuries were noted. Radiology Transcription Report dated 3/7/14 at 7:22 p.m., indicated the resident with a subcapital right femoral neck fracture. Slight superior migration of the femoral shaft and with the adjacent pelvis intact. The report identified the resident had pain after the falling. During an interview with the Director of Nursing (DON) on 3/26/14 at 11:40 a.m., she reported when Resident #1 was anxious, staff try to keep him/her supervised. That day he/she was not anxious. (The day of the fall that resulted in a fracture.) During a staff interview on 3/26/14 at 10:50 a.m., Staff A, CNA indicated at approximately 4:30 p.m. she assisted the resident to the bathroom and then positioned him/her back into the wheelchair in his/her room. Staff A reported she attached the PSA alarm to the resident's left shoulder as Staff B, CNA and Staff C, CNA entered the room. Staff A reported the next time she observed Resident #1, he/she had been on the floor, on their right hip with a staff assessing the resident. The resident complained of right hip pain. Staff D assisted the resident to his/her back to further assess the resident. When the resident had been asked to move his/her legs he/she complained of pain in/on the right side. The staff retrieved a Hoyer pad as the resident requested to get off the floor and transferred the resident to bed as they supported with right leg with the transfer. During a staff interview 3/26/14 at approximately 1 p.m., Staff A confirmed she had been frustrated with Resident #1 the day of the fall. Staff A reported Resident #1 had been up and down all afternoon setting off his/her alarm. The staff member explained she was " done with the resident " as done with the care of the resident and explained she was not exactly happy. The staff member also indicated she had been written up in the past by the facility for not attaching a resident ' s PSA which resulted in another resident falling which caused a skin tear to the resident. A Corrective Action Form dated 12/19/13, indicated the staff member received a Corrective Action Form for not attaching a resident ' s alarm to a resident prior to a fall. During a staff interview on 3/26/14 at 11 a.m., Staff B indicated she and Staff C entered Resident #1's room to assist his/her roommate prior to the fall. Resident #1 had been positioned in the wheelchair in front of the bed and facing the television. Staff B did not notice if the alarm had been attached to Resident #1. Staff B reported Staff A verbalized frustration however she did not know why. Both Staff B and Staff C assisted the resident's roommate and exited the room. Later, Staff B walked by Resident #1's room and observed him/her positioned on their right side on the floor with no alarm sounding. Staff B reported Staff D (LPN) had been with the resident. Staff B reported Resident #1's head had been propped up against a trash can, a pillow under his/her head, positioned next to the wheelchair with the foot pedals in place. When Staff B entered the resident's room, the resident's alarm had been hooked on the wheelchair handle with the snap clip on the PSA. The resident complained of right hip pain however the staff attempted not to move the resident much. The resident wanted off the floor as staff assessed him/her. Four staff members transferred the resident per a Hoyer lift device off of the floor while maintained a straight position of the resident's lower extremities in the event something had been broken. The staff members positioned the resident in bed and the hospital had been called. During an interview 3/26/14 at 12:53 a.m., Staff B confirmed when she entered the resident's room and Staff A exited the room that afternoon Staff A threw up her hands and said something like she (Staff A) was done and/or she (Staff A) cannot do this anymore. During an interview 3/26/14 at 11:30 a.m., Staff C confirmed she entered the resident's room with Staff B and as Staff A exited Resident #1's room stating, she was so done with him/her. The staff members assisted the resident's roommate and left the room. At approximately 4:45 p.m. she heard the resident had fallen but she had been assigned to another hallway and never returned to Resident #1's room. During an interview 3/26/14 at 9:05 a.m. Staff D, indicated she had been ambulating up the south hallway and heard someone saying," Help,Help". The staff member then observed Resident #1 positioned on his/her right side on the floor with his/he head leaning against a garbage can. The wheelchair had been facing the windows in the resident's room and the resident facing the room door. Staff D reported the alarm had not sounded but had been positioned on the left handle of the wheelchair with the snap clip wrapped around the handle. (The alarm is a two part device with an outer circle that's clipped to the resident's clothing with an inner circle that connected to the opposite side of the resident's clothing.) The resident complained of hip pain. The staff member called for assistance while she stayed with the resident. Staff A, C and E responded immediately. Staff E assessed the resident which included range of motion (ROM) exercises which had not included the right hip as the resident complained of right hip pain. As the resident had been carefully positioned on his/her back he/she kept requesting to get off of the floor and became angry and tried to pull him/her(self) up. There had been no deformity of the resident's hip and the staff member had been unsure of a change in length. Four staff members transferred the resident to bed with a Hoyer lift device while they maintained complete alignment of the hip with no complaints of pain with the transfer. The CNA's then stayed with the resident while Staff D returned to her assigned hallway to care for residents. During an interview 3/26/14 at 2:50 p.m. Staff D clarified the snap clap cord position as wrapped around the handle of the wheelchair just a couple of times as if to shorten the length of the cord/string but long enough to enable the staff to properly attach the device to the resident. During an interview 3/26/14 at 3:25 p.m., Staff D clarified the snap clip device (both parts) as completely intact together which meant the inner circle of the clip device had been attached to the outer circle. (Neither part of the device had been attached to the resident.) During an interview on 3/25/14 at 5:15 pm., Staff E indicated Staff D found Resident #1 on the floor and she asked for staff to call for assistance immediately. When she entered Resident #1's room she found the resident positioned on the floor on his/her right side. The resident's wheelchair positioned against the bed. Staff E reported the PSA had been on the back of the wheelchair and the snap clamp wrapped around the handle which Staff D told her had not been attached (upon entry to the room.) Upon assessment the resident complained of right hip pain rated at 9 out of 10. Vital signs and neurological checks were performed and slowed repositioned on his/her back. The resident's hip had been pink and painful to the touch. The resident also complained of shoulder pain. The staff member further assessed the resident with no deformity of the right leg however she noted the leg had been 2 inches shorter than the left. The staff member called the resident's physician, family and an ambulance. During an interview 3/26/14 at 3:33 p.m., Staff E clarified the PSA snap clip alarm string hanging approximately down to the seat of the wheelchair if not further down with the snap clip device totally intact with the inner circle attached to the outer circle.