Every finding on record at Parkview Home

Based on observation, clinical record review, facility policy review, pharmacist and staff interviews, the facility failed to ensure proper packaging and labeling of controlled medications for 6 of 6 residents (Resident #1, Resident #8, Resident #11, Resident #12, Resident #19, and Resident #21) reviewed for medication storage and labeling. The facility reported a census of 25 residents. Findings include:1. During an observation on 7/8/26 at 8:13 AM, Staff D, Certified Medication Aide (CMA) prepared Resident #12 medications for administration. After popping medications from single-dose bubble pack cards, Staff D pulled a locked box out of the medication cart, unlocked it, and removed an unlocked pencil box which contained multiple envelopes. Each envelope had the residents name, name of medication with the dosage and time handwritten on the outside of the envelope, and was sealed. Staff D found the envelope handwritten with tramadol 50 mg (milligrams). Staff D opened the envelope and placed the pill in medication cup, crushed the pill, mixed the pill into pudding before administering it to Resident #12. During an interview on 7/8/26 at 8:13 AM, Staff D, CMA explained the envelopes were set up by the nurses for the CMA's to administer. Review of the electronic health record (EHR) revealed Resident #12 had a physician order for tramadol HCL (hydrochloride) oral tablet 50 mg- give 50 mg by mouth two times a day for pain management. 2. During an observation on 7/9/26 that started at 8:20 AM, Staff E, CMA and the State Agency reviewed the packaging and labeling of controlled medications prescribed for the following residents: Resident #21, Resident #8, Resident #1, Resident #19 and Resident #11. Each envelope had handwritten information which consisted of the resident's name, medication, dosage and time of administration. a. Resident #21:1. One envelope identified to have contained lorazepam 1 mg tablet and tramadol 50 mg tablet for the AM dose.2. One envelope identified to have contained lorazepam 1 mg dose for noon.3. Review of the EHR confirmed Resident #21 had a physician order for each medication.b. Resident #8:1. One envelope identified to have contained alprazolam 0.5 mg - 2 tablets and pregabalin 50 mg tablet for AM dose.2. One envelope identified to have contained pregabalin 50 mg for 1 PM dose.3. One envelope identified to have contained alprazolam 0.5 mg - 2 tabs at 2 pm.4. Review of the EHR confirmed Resident #8 had a physician for each medication.c. Resident #1:1. One envelope with lorazepam 0.5 mg - 1 tab and oral suspension morphine 100 mg/5 ml (milligrams) - 0.5 ml in a pre-drawn syringe for AM dose.2. lorazepam 0.5 mg- 1 tablet and oral suspension morphine 100 mg/5 ml- 0.25 ml in a pre-drawn syringe for noon dose.3. Review of the EHR confirmed Resident #1 had a physician for each medication.d. Resident #19:1. One envelope with oxycodone 5 mg at noon2. Review of the EHR confirmed Resident #19 had a physician for the medication.e. Resident #111. One envelope with hydrocodone/acetaminophen 5/325 mg- 2 tabs (tablets)- sign out PRN (as needed)- give after 8:00 AM.2. Review of the EHR confirmed Resident #11 had a physician for the medication.During an interview on 7/9/26 at 10:00 AM, Staff F, Pharmacist Consultant queried on the controlled medications being placed in envelopes for the CMAs and Staff F stated he had no idea the facility was doing it. Staff F stated the facility needed to get locked boxes for the medication cart and the medications needed to be in their packages right before administering. Staff F stated technically the facility was relabeling the medications and the facility can't do that. Staff F asked about the pre-drawn morphine suspension syringe and Staff F stated the facility shouldn't be doing that and the facility should only draw up the morphine right before administering. During an interview on 7/9/26 at 12:36 PM, Staff C, Registered Nurse (RN) queried on the controlled medications Staff C stated the narcotic packaging were placed in the nurse's medication cart and when Staff C came in, she signed out the controlled substances for the CMA cart and placed them in envelopes with the resident's name, date, and the medication with the dose. Staff C stated she didn't pop out the PRN narcotics unless it was for Resident #11 because Resident #11 always asked for pain medications every 4 hours. Staff C asked about the pre-drawn morphine suspension and Staff C stated the syringes had caps on it and they didn't reuse the syringes. Staff C stated they set up the controlled medications so the CMA didn't have to ask the nurse every time a resident needed a narcotic. During an interview on 7/9/26 at 12:52 PM, Staff D, CMA queried how she knew the pills in the envelopes were the correct and Staff D stated she had to trust the nurse because the CMAs did not do the narcotic count with the nurse and the nurses didn't show the CMAs what was going in the envelopes. Staff D stated if she had concerns about the pills, Staff D could look up the pills on pill verification. During an interview on 7/9/26 at 2:16 PM, the Director of Nursing (DON) queried about the controlled medications in the envelopes and the DON stated she took full responsibility for the process. The DON stated she thought it was safer to set up the controlled meds in the envelopes rather than the nurse handing the CMA a pill in a medication cup. The DON stated Staff F explained to the DON why the facility can't do it and the DON would put a new process in place. Review of the facility undated policy titled Medication Storage Policy directed, in part: a. Controlled substances: Schedule II-V controlled drugs must be stored in a locked compartment, unless using a single-unit package system with minimal storage and detectable doses.a. Labeling: Medications must be labeled with generic/brand name, prescribed dose, strength, expiration date, resident's name, route of administration, and any required instructions or precautions.Review of the facility Medication Administration dated 4/12/19 revealed a Procedure section which directed, in part: a. Remove the cards labeled for that resident at the administration time. b. Compare the medications listed on the cards to the MAR (Medication Administration Record).c. Take the card to the resident, or prepare the medication in a medication cup. When placing medications from the card into a cup, be careful not to touch medications. Take the cup with the card to the resident. Keep the medications in sight at all times. Lock the medication cart when walking away.d. Verify this is the correct resident and the correct time of administration by comparing the name on the card to the resident and double check the date and time. If uncertain as to the identity of the resident, ask the resident to state her name and time. Ask if they prefer to take the medications in their hand, have them placed on a napkin or placemat, or placed in a spoon for administration.

Based on clinical record, policy review, and staff interviews, the facility failed to provide education on the risks and benefits of psychotropic medications and obtain a signed consent prior to starting the medications for 1 of 5 (Resident #16) residents reviewed for unnecessary medications. The facility reported a census of 25 residents.Findings include: Review of the Minimum Data Set (MDS) assessment, dated 5/19/2026, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition.The MDS identified Resident #16 required antipsychotic and antidepressant medications during the look back period. Review of Resident #16's Care Plan revealed a diagnosis of Unspecified Mood (Affective) disorder. A Focus area initiated on 9/24/25 addressed I use psychotropic medications (antipsychotic aripiprazole and antidepressant duloxetine) r/t (related to) depression. Interventions included, in part:a. Administer psychotropic medications as ordered by physician. Reports concerns to my provider. Date Initiated: 9/24/25. b. I have been educated about risks, benefits and the side effects of anti-depressant and antipsychotic medications being given. Date Initiated: 09/24/25. c. I see [Name redacted] ARNP (Advanced Registered Nurse Practitioner) for mental health care via telehealth routinely. Date initiated: 11/20/25. d. Monitor, document, report as needed (PRN) adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Date initiated: 09/24/2025. Review of Resident #16's Medication Administration Record, dated July 2026, revealed orders for the following medications: a. Aripiprazole (Abilify) (antipsychotic medication primarily prescribed to treat mental health conditions like schizophrenia, bipolar disorder, and major depressive disorder) 2 milligrams (mg) with instructions to give one tablet by mouth every day shift for depression. Start date: 3/28/26. b. Duloxetine hydrochloride (HCl) (antidepressant medication used to treat major depression, generalized anxiety, fibromyalgia, diabetic neuropathy, and chronic musculoskeletal pain) 30 mg, with instructions to give one capsule by mouth every day shift for depression. Start date: 9/25/25 Review of Resident #16's clinical record found no documentation that the facility informed the resident of the risks and benefits of the medication, the treatment alternatives, or other options so the resident could make an informed choice. During an interview on 7/09/26 at 2:45 PM, the Director of Nursing (DON) denied having documentation of Resident #16's informed consent to receive antipsychotic and antidepressant medications after risks and benefits were explained. Review of the facility policy titled, Psychotropic Drug Consent, dated 7/26/2012, revealed: Policy Statement: Residents should be fully informed of the benefits and side effects of the medications they receive. Physicians and staff of facility will educate residents and/or their family or decision maker regarding the benefits and side effects of psychotropic drugs prior to initiating their use. Procedure: The charge nurse, Assistant Director of Nursing (ADON), or DON, or physician will review the benefits of the psychotropic medication and the risks with the resident or family member or decision maker. A consent for use will be signed prior to use. Copy of consent to follow this policy.

Based on observation, clinical record review, Facility Assessment review, resident and staff interview, the facility failed to provide routine podiatry services for 1 of 5 residents (Resident #16) reviewed for foot care. The facility reported a census of 25 residents. Findings include:Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included diabetes mellitus, congestive heart failure, respiratory failure, and morbid obesity.During an interview on 7/06/26 at 12:42 PM, Resident #16 stated she does not see podiatry often enough and said because she is diabetic not just anyone can take care of her toenails. Resident #16 stated it had been a long time since podiatry visited to trim her toenails. Review of Resident #16's Care Plan initiated on 9/24/25, revealed the following Focus area's:a. I have venous statis related to diabetes and heart disease. Interventions include with the goal that Resident #16 would remain free of major complications related to peripheral vascular disease.1. Educate the resident on the importance of proper foot care including: proper fitting shoes, wash and dry feet thoroughly, Keep toenails cut, inspect feet daily, daily change of hosiery and socks. Date Initiated: 09/24/2025b. I have Diabetes Mellitus II and am dependent on insulin.1. Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Date initiated: 9/24/25.Review of the electronic health record (EHR) revealed an Order Note dated 4/03/26 at 1:41 PM: [Name redacted] in to see resident today. [Name redacted] would like resident to see podiatry when they round.During an interview on 7/08/26 at 9:41 AM, the Social Services Worker explained the facility notified the Podiatrist office of new residents wanting podiatry services and then the provider sends a list of residents they plan to see at the next scheduled visit. The Social Services Worker explained it had been very hard to schedule for the podiatry visits to occur in the facility, and was unsure of when the last visit occurred.Review of a facility provided facsimile (fax), dated 7/08/26 from the podiatrist whom the facility generally uses for in house services: Here is the list of patients from our last visit 11/15/25 [names redacted]. The list consisted of 28 residents, with the reason 12 residents not seen. The list identified 16 residents seen by podiatry on 11/15/25. one of which was Resident #16. During an observation on 7/08/26 at 9:58 AM, Resident #16 stated that her toenails on the left foot were worse than the right, especially the left big toenail. Resident #16 left great toe had a long, jagged toenail, and the other nails on the left foot appeared long and in need of a trim. Resident #16 stated the left great toenail caused pain if she crossed her legs and the jagged nail edge scratched her other foot or when the toenail gets caught on the bed sheets. Resident #16 explained she would go to an outside Podiatrist instead of waiting for in-house podiatry services but had not been notified when the next visit would be.During an interview on 7/08/26 at 10:04 AM, Social Services worker reported that she just called the Podiatrist office in attempt to get an in-house visit scheduled and was informed that the Podiatrist office was unable to schedule a date/time. The Social Services Worker stated that the Director of Nursing (DON) was currently working on scheduling appointments and transportation with a different outside Podiatrist clinic for residents and said, especially those who are diabetic. At 10:12 AM, the Social Services worker informed the State Agency that five residents, including Resident #16 had been scheduled for an offsite podiatry visit on 7/29/26.During an interview on 7/09/26 at 2:19 PM, the DON stated it is her expectation that residents receive podiatry services every 2 to 3 months and stated that the primary care provider would see residents if something came up between visits. The DON stated that she started scheduling the diabetic residents with a different offsite provider while working to get in-house podiatry services scheduled. Review of the Facility assessment dated [DATE], revealed, in part: Part 3: Facility resources needed to provide competent support and care for our resident population every day and during emergencies.Section 1. Staff type: Bullet point number 5: Medical/Physician Services (in example, Medical Director, Attending Physician, Nurse Practitioner, Dentist, Podiatrist). Section 6. Working with Medical Practitioners: We maintain a constant relationship with our local hospital. We are in contact with providers and administration to ensure our relationships are maintained and valued. Calls, texts, messenger messages, and email are all utilized for this constant reference to our care providers.

Review of employee personnel file, staff interview, and facility policy review, the facility failed to complete a performance review of nurse aides every 12 months for 2 of 3 Certified Nursing Assistant (CNA) staff reviewed. The facility reported a census of 25 residents. Findings include: Review of Staff G, CNA, personnel file revealed a hire date of 7/07/2023. The personnel file lacked documentation of performance evaluation completed during the last 12 months. Review of Staff A, CNA, personnel file revealed a hire date of 8/10/2020. The personnel file lacked documentation of performance evaluation completed during the last 12 months. During an interview on 7/09/26 at 10:13 AM, the Director of Nursing (DON) stated that performance evaluations had not been done within the past year and reported that the facility would not be able to produce any documentation of nurse aide performance evaluations. During an interview on 7/09/26 at 2:19 PM the DON stated the facility does typically complete nurse aide performance evaluations, but had not completed any over the past 12 months. The facility denied having policies or procedures specific to nurse aide training, evaluation, or performance review.

Based on resident and staff interview, clinical record review, and facility policy review, the facility failed to initiate a timely psychiatric referral for 1 of 1 resident (Resident #8) reviewed for behavioral health services. The facility reported a census of 25 residents. Findings include: Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE], revealed a diagnoses list which included post-traumatic stress disorder, anxiety disorder and Parkinson's disease. The MDS identified Resident #8 prescribed antipsychotic, antianxiety, and antidepressant medications. Resident #8 admitted to the facility on [DATE].Review of the Care Plan, initiated 2/5/26, revealed a Focus area to address I use psychotropic medications (Abilify (antipsychotic), escitalopram (antidepressant), mirtazapine (antidepressant), and venlafaxine (antidepressant) r/t (related to) Depression. Interventions included, in part:a. I have been referred for psychiatric services, initial evaluation pending. Evaluation has been completed. I will continue to see [name redacted] ARNP (Advanced Registered Nurse Practitioner) for routine psychiatric care vis telehealth. Date initiated: 4/16/26. Revision on: 7/07/26.During an interview on 7/09/26 at 1:36 PM, Resident #8 reported meeting a psychiatric provider via video chat as an introductory visit recently. Resident #8 stated she thinks that was within the last 2 weeks. Resident #8 stated it's been hard to have a new diagnosis of Parkinson's Disease but claimed she is doing fine.Review of the electronic health record revealed:a. Nursing Note dated 2/28/26 at 1:25 PM: Resident called this nurse to her room. When nurse arrived at room, resident states she is having a panic attack. She states she feels hot on the inside and her hands are cold and she feels anxious and nervous. This nurse placed a call to on call Primary Care Provider (PCP) and was unable to reach anyone, a message was left, no return call has been received.b. Nursing Note dated 2/28/26 at 9:02 PM: Resident upset that medication frequency and dosage and times have been changed, otherwise pleasant and cooperative with no noted behavioral issues; no noted complaints of prior shift's panic attack; physician never returned call; will continue to monitor. c. Nursing Note on 3/01/26 at 1:03 PM: Resident is having increased pain causing an increase in anxiety following medication changes. Resident also states she is coming to grips with being in a facility for the rest of her life. Resident is concerned and has asked this nurse to reach out to the PCP and ask about changing her medication regimen. This nurse states she will look into it on 3/02/2026. d. Nursing Note, dated 3/09/26 at 12:19 PM: Resident seen by [Name redacted] last week. She says she will put in a referral for resident to see psychiatry for a follow up appointment. 1. Response from [Hospital] referral team: Thank you for the referral of your patient. Unfortunately, the patient is currently under the care of her PCP [Name redacted], for her Psychiatric issues at this time. [Name redacted] aware, awaiting response from [Name redacted]. If [Name redacted] would like a 2nd opinion of the patient, or wishes to transfer her psychiatric care to the department of Psychiatry, [Name redacted] will need to enter a referral for the patient.e. Nursing Note, dated 4/06/26 at 10:17 PM: Resident asked to speak with this nurse. This nurse went in to visit with resident and resident reports feeling increased agitation and anxiety and feels like she wants to lash out at staff and especially her husband. Resident reports feeling exhausted all of the time and having a decreased appetite. Resident states having an increase in jerking movements. Resident is concerned, this nurse states she will reach out to provider regarding concerns f. Nursing Note, dated 4/07/26 at 1:14 PM: Followed up with resident at this time, verifies all these feelings and states she is also feeling more depressed lately, suggested to her that seeing psych might help and explained how we do this. She agrees with this and states she would like to try. 1. Referral sent to [Name redacted] to initiate psychiatric services as requested. g. Nursing Note dated, 7/08/26 at 10:45 PM: This nurse was in with resident administering medications when resident began to cry. Resident states feeling lonely and like she has no who cares about her. Resident then states she wishes she was dead. This nurse asks resident about that statement and resident denies having a plan and states she isn't going to harm herself. Resident states she is more scared of being alone than of her disease. This nurse stays with resident and offers support. This nurse to update facility social worker. During an interview on 7/09/26 at 2:19 PM, the Director of Nursing (DON) stated she sent a referral for Resident #8's psychiatric services right away and due to Resident #8 going out for a lot of different appointments was unable to get psychiatric services scheduled. The DON reported that Resident #8 had initial evaluation with psychiatric provider on 6/30/26. The DON was unable to provide documentation of Resident #8's psychiatric provider visit or provider notes related to initial evaluation visit on 6/30/26. The facility denied having policy or procedures specific to resident behavioral health services.

Based on observation, record review, staff interviews, and facility policy, the facility failed to use Enhanced Barrier Precautions (EBP) for 1 of 2 residents (Resident #3) reviewed for infection control, and failed to utilize standard hand hygiene practices for 1 of 5 residents (Resident #2) observed during medication administration. The facility reported a census of 25 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the resident had a diagnosis of obstructive uropathy (obstruction that does not allow adequate passage of urine) and utilized an indwelling catheter. The Care Plan dated 7/7/26 revealed a Focus area for indwelling catheter due to obstructive uropathy. Interventions dated 7/7/26 included, in part: Maintain enhanced barrier precautions, and a blue dot has been added to the door to identify EBP. During an observation on 7/8/26 at 7:47 AM, Staff A, Certified Nurse Aide (CNA) and Staff B, CNA went into Resident #3 room to change Resident #3 catheter bag to a leg bag. Staff A and Staff B did not gown up while they changed the catheter bags. During an interview on 7/8/26 at 1:45 PM, Staff B, CNA queried on EBP and Staff B stated she should wash her hands and put a gown and gloves on and have everything ready before going into the room to do catheter cares. Staff B confirmed she did not wear a gown while performing catheter cares on Resident #3. Staff B asked when staff used EBP and Staff B stated when doing catheter cares. During an interview on 7/8/26 at 2:15 PM, Staff A, CNA confirmed she use EBP when doing Resident #3 catheter cares. Staff A stated she should have worn a gown. During an interview on 7/9/26 at 10:20 AM, the Infection Preventionist queried on EBP and the Infection Preventionist stated she heard about it and the CNAs should have used EBP because EBP should be used for catheters. During an interview on 7/9/26 at 1:58 PM, the Director of Nursing (DON) stated she preached about EBP and the blue dot on the outside of the door to staff all the time. The DON confirmed the staff should of used EBP while performing catheter cares with Resident #3. Review of the facility policy titled Enhanced Barrier Precautions revised 7/2024 directed, in part: a. EBP are used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.b. Indwelling medical devices include but are not limited to central lines, urinary catheters.2. The MDS assessment dated [DATE] revealed Resident #2 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The list of diagnoses included encounter for orthopedic aftercare following surgical amputation. The MDS indicated Resident #2 prescribed opioid medication. Review of the electronic health record (EHR) revealed Resident #2 had a Physician Order for Pregabalin Oral Capsule 50 milligrams: Give 1 capsule by mouth three times a day for nerve painDuring an observation on 7/8/26 at 8:33 AM, Staff C, Registered Nurse (RN) prepared Resident #2 medications. During the prep a Pregablin capsule fell on the keyboard of the nurses laptop. Staff C picked up the pill with her bare hands and placed the pill into the medication cup. Staff C resumed prepping the remaining medications and administered all medications to Resident #2. During an interview on 7/9/26 at 2:00 PM, the Director of Nursing (DON) stated that staff should have disposed of the Pregablin capsule that had been touched, obtained a replacement from the remaining supply, and ordered a new capsule for the one disposed of. Review of the facilty policy titled Medication Administration revised 4/12/29 directed, in part: If a pill or capsule falls on the floor, it must be discarded, and a new one administered. To replace the capsule or pill, take the appropriate medication from the last tab available in the card. Notify pharmacy to replace the medication. Give them the date used for replacement.

Based on record review, staff interviews, and the facility policy, the facility failed to administer updated pneumococcal vaccines to 2 of 5 (Resident #8, Resident #21) residents who consented to receiving the vaccine. The facility reported a census of 25 residents. Findings include:1. The Review of the Clinical Census revealed Resident #8 admitted on [DATE]. Resident #8 discharged to the hospital on 4/11/26 and returned to the facility on 4/21/26; discharged a second time to the hospital on 4/29/26 and returned on 5/1/26; and discharged a third time to the hospital on 6/6/26 and returned on 6/9/26. The Review of the Immunization Registry Information System (IRIS) revealed Resident #8 received Prevnar 13 (PCV13) on 11/10/2015 and pneumococcal 23 on 1/23/20. Resident #8 signed the Influenza/Pneumococcal consent form on 7/7/26 for a pneumococcal vaccine and the provider gave a verbal order on 7/7/26 at 6:42 PM for the pneumococcal 20 vaccine. 2. The Review of the Clinical Census revealed Resident #21 admitted to the facility on [DATE]. The Review of IRIS revealed Resident #21 had the PCV13 on 12/18/15 and the pneumococcal 23 vaccine on 12/19/16. The Influenza/Pneumococcal consent form signed with verbal consent from the Power of Attorney (POA) on 7/8/26 for the Prevnar 20. During an interview on 7/9/26 at 1:08 PM, the Infection Preventionist (IP) queried on the process with the vaccines and the IP stated the Director of Nursing (DON) was trying to get through them. The IP stated Resident #8 had been out to the hospital and the IP didn't have an answer for Resident #21. The IP stated the facility screened the residents on admission and pulled up IRIS to see what the residents needed. During an interview on 7/9/26 at 2:10 PM, the (DON) stated she was reviewing the immunizations and had been working on it for the last month. The DON stated it wasn't like the residents didn't have their pneumococcal vaccines, this was just the next recommended dose. The DON asked about the process and the DON stated the facility did an admission checklist and the DON had an excel sheet she used to keep up to date. The DON stated Resident #8 came to the facility sick and had been in and out of the hospital. The DON stated consent/declinations not completed until the vaccine would be given. Review of the undated facility policy titled Pneumococcal Vaccine revealed:a. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. b. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendation at the time of the vaccination.

Based on observation, interview, and record review the facility failed to ensure accurate care planning of antipsychotic medication on the comprehensive Care Plan and failed to ensure the comprehensive Care Plan addressed wandering behavior for 1 of 13 residents reviewed for Care Plans (Resident #3). The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 6/25/24 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident took antipsychotic medication and wandered 1 to 3 days during the 7-day look-back period. Review of Resident #3's clinical record revealed an admitted to the facility on [DATE]. a. Review of Resident #3's Care Plan for psychotropic medication use dated 6/4/24 revealed the following: I use psychotropic medications (Haloperidol) r/t (related to) anxiety/Depression and Paranoid Schizophrenia. Review of the resident's Medication Administration Record (MAR) dated May, June, and July 2024 lacked administration of Haloperidol for this resident. Review of the resident's physician orders lacked an order for Haloperidol. b. Review of Resident #3's comprehensive Care Plan lacked a focus area to address wandering/elopement. The Baseline Care Plan Summary dated 5/22/24 revealed, Resident had an elevated risk for wandering and elopement. The Progress Note dated 6/5/24 at 3:18 AM revealed, Before supper last evening, resident was walking in the halls and alarm sounded when she went out of the end door on 200 hall. Resident just made it outside the door a little ways and staff was following her. Returned inside the building. The Progress Note dated 6/6/24 at 1:31 AM revealed, Pt (patient) after dinner went to the front door of the building and was trying to leave. Pt was easily redirected. Will report to oncoming of patient exit seeking The Progress Note dated 6/8/24 at 9:30 PM revealed, Resident attempted to leave facility by exiting doors alone on 400 hall. Resident cooperative as staff assisted her back into facility. Resident voices no c/o and is unable to state why she attempted to leave. The Orders-Administration Note dated 6/24/24 at 3:34 PM revealed, in part, res (resident) is wandering a lot today. will not sit down to allow this writer to change dressing. Review of the Wandering Risk Scale assessments dated 5/27/24 and 6/25/24 identified the resident at high risk to wander with a score of 11, then 12 on the assessment. Observation conducted 7/30/24 at 1:29 PM revealed Resident #3 walked with a walker down the hallway where the resident resided, then turned and walked back. Observation revealed a staff member asked Resident #3 where they were going, and Resident #3 responded, I don't know. On 8/1/24 at 3:52 PM, the MDS Coordinator queried about Haldol (Haloperidol), as was observed on the resident's Care Plan. The MDS Coordinator explained she did see the resident had Risperdal (a different antipsychotic medication). The MDS Coordinator explained she was going to take out the Haldol and put in psychotropic medication so did not happen again. When queried about wandering/elopement, the MDS Coordinator explained she saw the resident had a behavior Care Plan but did not have specifics. The MDS Coordinator explained she would update it. On 8/1/24 at 4:55 PM during an interview with Staff B, Registered Nurse (RN), Staff B explained the resident wandered a little bit, and was easily redirected. On 8/1/24 at 4:19 PM, a Facility Policy which addressed care plans, both comprehensive and revision, was requested from the facility. The policy was not provided prior to the exit of the survey.

Based on interviews, clinical record review, and facility policy review, the facility failed to include person center care needs or identify interventions related to seizure disorders and medications taken to prevent seizures within the Care Plan for 2 of 5 residents (Resident #12 and #26) reviewed for medication regimen. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #12, dated 6/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment. Diagnoses included: Parkinson's Disease, non-Alzheimer's dementia, anxiety disorder, and depression. The Care Plan, revised 7/09/24, lacked identification of seizure disorder or anticonvulsant medications administered on a routine basis. The Medication Administration Record (MAR), dated August 2024, revealed medications ordered included: 1. Levetiracetam 500 milligrams (mg), given one and a half tablets by mouth every day and evening shift for Altered Mental Status (AMS), started on 3/27/24. 2. Carbamazepine 200 mg, given 1 tablet by mouth every day and evening shift for anticonvulsant, started on 3/27/24. A Hospital Inpatient Note, dated 12/22/23, revealed Resident #12's Past Medical History (PMH) had episode concerning for seizure 7/2023. Resident #12 taking Levetiracetam and Carbamazepine. A Hospital Inpatient Note, dated 12/30/23, revealed Resident #12's medical history included seizures. 2. The Minimum Data Set (MDS) for Resident #26, dated 5/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Diagnoses lacked seizure disorder at time of assessment. The Care Plan, revised 7/25/24, lacked identification of seizure disorder or administration of anticonvulsant medications. The Medication Administration Record (MAR), dated July 2024, revealed an order for Levetiracetam 500 milligrams (mg) twice per day for seizure activity, started on 7/12/24 and discontinued on 7/26/24. The Order Summary dated August 2024, revealed an order for Ativan 2 milligrams (mg) per milliliter (mL), give 1 mg as needed intramuscularly for active seizure. The order start date on 6/19/24 with no discontinue date. The Hospital Note, dated 6/12/24, revealed a Principle Diagnosis of subdural hematoma (bleed in the brain membrane) status post fall. Resident #26 had been given Levetiracetam (Keppra) intravenously with recommendation from Neurosurgery to start Keppra 500 mg twice per day. A Nursing Progress Note, dated 6/12/24 at 1:22 PM, revealed nursing received communication from the Hospital that Resident #26 sustained a large subdural hematoma in which family had declined treatment and would discharge back to facility. Resident #26 returned to the facility with new medication order Keppra for seizure activity. On 6/19/24 at 2:00 PM, a Nursing Progress note revealed that the Provider ordered many oral medication to be discontinued per family request, including Keppra, and an as needed order for Ativan Intramuscular injection to be given for active seizure. At 3:24 PM, the facility additionally initiated seizure pads to be placed on Resident #26's bed as safety intervention. On 8/01/24 at 3:52 PM, Staff D, MDS Registered Nurse (RN), revealed that she had recently become responsible for updating the facility's Care Plans and worked offsite, communication regarding changes received from the facility in a weekly meeting and as needed. Staff D informed that if a resident has a diagnosis of seizure disorder whatever the facility's goal and interventions should be included in the resident's Care Plan. On 8/01/24 at 4:55 PM, Staff B, Registered Nurse (RN) revealed she had been responsible for updating fall related interventions in resident Care Plans but believed seizure disorders would be in resident Care Plans. Staff B informed that Resident #26 continued to have the seizure pads on bed intervention in place. On 8/1/24 at 4:19 PM, a Facility Policy which addressed Care Plans, both comprehensive and revision, was requested from the facility. The policy was not provided prior to the exit of the survey.

Based on observations, interviews, and clinical record review, the facility failed to ensure interventions had been effective to prevent recurring falls in 1 of 5 residents reviewed for accidents (Resident #19). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment. The MDS revealed Resident #19 required partial to moderate amount of staff assistance to transfer and ambulate. Diagnoses included Parkinson's Disease, non-Alzheimer's dementia, anxiety disorder, asthma, and muscle weakness. The MDS revealed Resident #19 had 2 or more falls since the last assessment date. The Care Plan, dated 5/08/24, revealed Resident #19 had been at high risk of falls with a history of multiple falls and listed the following dates in which a fall occurred: 2/18/24, 2/25/24, 3/21/24, 4/21/24, 4/22/24, 4/29/24, 5/01/24, 5/24/24, 5/25/24, 5/28/24, 5/30/24, 6/04/24, 6/18/24, 6/21/24, 7/30/24. The Care Plan revealed Resident #19 required the assistance of one staff for transfers, ambulation, and toileting needs using a walker and gait belt. Additionally the Care Plan revealed Resident #19 had impaired cognitive function and impaired thought processes related to delirium with impaired decision making and behavioral problems such as verbal aggression and refusal of cares. Review of Resident #19's Incident Reports, revealed 8 of 18 falls had intervention to remind resident to use call light or call for help. A review of incident reports indicated the following interventions implemented: 1. On 02/16/24 at 3:50 PM, unwitnessed fall in resident's room, reminder for staff to look and make sure belongings are off the floor. 2. On 02/25/24 at 8:30 PM, unwitnessed fall in resident's room, intervention for staff to assist resident to get ready for bed at 8 PM per her request. 3. On 3/23/24 at 3:45 AM, unwitnessed fall in resident's bathroom, intervention for staff to leave her door open or cracked at night. 4. On 4/11/24 at 7:00 PM, unwitnessed fall in resident's room, intervention for staff to frequently check on resident and encourage use of call light. 5. On 4/21/24 at 9:00 PM, unwitnessed fall in resident's room with door closed, intervention for staff to leave door open or cracked for closer supervision. 6. On 4/22/24 at 8:00 AM, unwitnessed fall in resident's room, intervention for staff to open curtains once resident is ready for the day. 7. On 4/29/24 at 2:30 PM, unwitnessed fall in resident's room, intervention to place non slip strips next to the bed. 8. On 4/30/24 at 7:00 PM, unwitnessed fall in resident's room, intervention to encourage resident to use call light and staff continue with frequent checks. 9. On 5/24/24 at 6:06 PM, unwitnessed fall in resident's room, staff to continue to remind resident to not get up without assistance as resident does not remember. 10. On 5/25/24 at 12:50 PM, unwitnessed fall in resident's room, staff remind resident to use controls for recliner and call for help. 11. On 5/28/24 at 8:50 AM, unwitnessed fall in resident's room, staff continuously remind resident to call for help. 12. On 6/04/24 at 8:15 PM, witnessed fall in bathroom when handrail moved, intervention to replace or repair bathroom handrail. 13. On 6/12/24 at 2:00 PM, unwitnessed fall in resident's room, intervention to place bed in lowest position when the bed is made. 14. On 6/12/24 at 3:30 PM, unwitnessed fall in resident's room, intervention to place reminder sign on walker and in room. 15. On 6/18/24 at 1:50 PM, unwitnessed fall in resident's room, staff continue to work with resident to call for help. 16. On 6/21/24 at 9:15 PM, unwitnessed fall in resident's room, staff re-educated on getting resident ready for bed at 8 PM per her request. 17. On 6/26/24 at 5:45 AM, unwitnessed fall in resident's room, shorten oxygen tubing, resident continues to get up without assistance. 18. On 7/17/24 at 9:30 AM, unwitnessed fall in resident's room, Resident #19 found with eyes open, not responding, had a laceration to back of head and pain in right hip. Incident report indicated last time resident toileted is unknown, resident transferred to the hospital and returned without fracture sustained. Intervention for all departments to spend one on one time with resident when able and continue to encourage resident to call for assistance. The Transfer Assessment Form, dated 7/17/24, revealed Resident #19 had been sent to the Hospital due to fall and informed that resident had frequent falls due to resident ambulation in room without assistance. Injuries included left hip pain and head laceration. Head pain rated 7-8 out of 10. A Primary Care Provider Note, dated 7/19/24, revealed Resident #19 had fall on 7/17/24 that required a trip to the Emergency Department as a result of laceration to head, that required 2 staples. On 7/29/24 at 1:29 PM, Resident #19 ambulated in room without walker, noted non gripper socks on her feet, a Certified Nursing Assistant (CNA) passed by and asked Resident #19 to sit back down in her recliner. On 7/29/24 at 1:38 PM, Resident #19 walked around room without walker, attempted to move a wheelchair to get into drawers. Resident #19's gait unsteady as she moved about room. On 7/30/24 at 1:09 PM, Resident #19 walked around in room, CNA passed by and asked to sit down. On 7/30/24 at 1:25 PM, Resident #19 walked around room, Nurse passed by and tried to get Resident #19 to sit down. Resident #19 stated, she is tired of sitting and needed something to do, Nurse called activity director to get resident a puzzle. On 8/01/24 at 10:10 AM, Staff B, Registered Nurse (RN), revealed that Resident #19 is non-complaint with waiting for help and has had repeated falls. Staff B stated the staff try to keep an eye on Resident #19 and try to keep her door open. Staff B informed that interventions in place to prevent falls include one on one with resident, inviting her to activities, and frequent checks. Staff B revealed Resident #19 had confusion and sometimes understood use of call light. On 8/01/24 at 1:22 PM, Staff A, Certified Medication Assistant (CMA) informed that fall interventions for Resident #19 included frequent checks, sign placed on wall to remind her to call, and keep resident items close to her. Staff A revealed that Resident #19 will sometimes push call light but not always. On 8/01/24 at 4:28 PM, Staff C, Registered Nurse (RN), informed that Resident #19 often is non-compliant with calling for help and stated staff constantly help her back to chair. Staff C revealed interventions to prevent Resident #19 falls included give resident her call light, offer a snack, bring to nurses station, and frequent checks.

Based on observation, interview, hospital record review, and clinical record review, the facility failed to include self harm monitoring, triggers, and safety interventions in the plan of care following attempted suicide for 1 of 2 residents reviewed for behavioral health needs (Resident #12). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 6/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS indicated Resident #12 had verbal behaviors directed at others and rejection of cares reported during the review period. Diagnoses included Parkinson's Disease without dyskinesia, non-Alzheimer's dementia, anxiety disorder, depression, and adjustment disorder with depressed mood. The MDS revealed Resident #12 required antidepressant and antipsychotic medications. The Care Plan, revised on 7/09/24, revealed Resident #12 had impaired cognitive function, verbal aggression, and inappropriate behaviors at times with staff. The Care Plan listed the goal that resident's behaviors will not interfere with other residents. Behavioral interventions included: 1. Administration of medications as ordered, monitor for side effects and effectiveness 2. Provide opportunity for positive interaction with resident, stop and talk with him as passing by. 3. Psychiatric services initiated. 4. If reasonable, discuss resident's behavior and explain why it is inappropriate or unacceptable to the resident. 5. Intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. 6. Monitor behavior episodes and attempt to determine underlying cause, document behavior and potential causes. 7. Praise any indication of resident's progress or improvement in behavior. 8. Provide a program of activities of interest and accommodate resident's status. Review of Hospital Adult Psychiatric Inpatient Note, dated 12/22/23, revealed a transfer and admission to the Hospital related to suicide attempt, increasing depressive symptoms, and agitation. The Hospital Note revealed that on 12/20/23, Resident #12 was found at the facility, in his closet, with a belt wrapped around his neck, attempting to tie the belt to the rod in the closet. Resident #12 had stated he was trying to hurt himself and that he does attempt to hurt self everyday. Note revealed accompanying documentation from facility included several communications from Resident #12 to his children that appeared to be suicide notes. Hospital Note additionally revealed past trauma related to abuse. Hospital completed suicide risk assessment, Resident #12 determined to be at moderate to high risk. Review of Nursing Progress Notes, revealed the following entries: a. On 11/27/23 at 4:09 PM, family discussed concern about Resident #12 increase in odd behaviors and requested dementia testing be done. b. On 12/01/23 at 7:10 PM, another call from family regarding concern about increase in Resident #12's odd behaviors, again requesting dementia testing be done. Nursing charted they would notify Director of Nursing and Primary Care Provider. c. On 12/06/23 at 10: 32 AM, nursing staff report increased verbal and sexual behaviors with staff that had not improved since initiation of Sertraline on 10/29/23. Update sent to Psychiatric Provider to report concerns and schedule appointment. d. On 12/18/23 at 1:09 PM, Resident #12 refused to eat, spoke only minimally and appeared upset, quietly declined cares. e. On 12/20/23 at 6:22 PM, Resident #12 sat on footrest of recliner, did not know where he was going or what he was doing. Resident #12 had eyes very wide open and appeared mixed up. Nursing had suggested to day shift to get a hold of Psychiatric Provider to discuss recent behaviors and possible medication change. f. On 12/20/23 at 6:41 PM, Resident #12 requested a sheet of paper and a pen to write a letter, staff gave him a sheet of blank computer paper and a pen. g. On 12/20/23 at 9:51 PM, staff went into Resident #12's room when he was not seen in bed or chair, found Resident #12 in the closet with belt around his neck attempting to hang himself. Nursing noted resident had been in a tormented state all shift, called people constantly and wrote letters. Nurse called Director of Nursing who text Resident #12's Psychiatric Provider, order to transfer Resident #12 to Emergency Department for psychiatric evaluation. h. On 3/27/24 at 2:30 PM, Resident #12 returned to facility from Hospital, mildly aggressive mood during admission assessment, refused to have weight checked. i. On 4/04/24 at 9:17 PM, Nursing noted after evening meal, Resident #12 started verbalizing that he would die tonight, stated he was not going to do anything to cause it, but he just had the feeling. Resident went around to tell other residents that this was his last night. 15 minute checks initiated on Resident #12 through the evening and night. Primary Care Provider at facility, talked to resident and made aware of the situation. DON also made aware. j. On 4/18/24 at 12:04 AM, Resident #12 asked staff if he could have his belt back, belt had been removed from room due to history of suicide attempt. Belt remained at nurses station. k. On 4/21/24 at 5:57 PM, Resident #12 asked if he could have the Certified Nursing Assistant's (CNA) gait belt, CNA told him no. l. On 4/21/24 at 8:38 PM, Resident #12 worked at over bed table all evening writing notes, nursing informed staff would continue to monitor him closely. m. On 7/07/24 at 10:40 AM, Resident #12 in his room taking razor apart and trying to put back together. Resident #12 threw the wheelchair foot pedals at staff's feet who entered room. n. On 7/08/24 at 5:23 PM, Resident #12 found on floor knelt in front of bed with head pressed down in a blanket, told staff he wanted to die and did not want to be here. On 7/29/24 at 1:46 PM, Resident #12 sat in recliner in room, only provided a nod in response, offered no verbal responses. On 8/01/24 at 4:04 PM, Staff D, MDS Registered Nurse (RN), revealed that any self harm or suicide attempts would be included in the Care Plan under the behaviors and safety sections. Staff D worked offsite and received information from the facility through communication with Interdisciplinary Team during weekly meetings. Staff D revealed other disciplines should update their areas such as sections specific to Social Work, Dietary, and Activity staff. On 8/01/24 at 4:28 PM, Staff C, RN, reported Resident #12 would put himself on the floor at times and had agitated behaviors. Staff C recalled Resident #12 recently stated he felt he would die one evening, but informed he wasn't going to do anything to harm self. In response, Staff C stated Resident #12 had been put on suicide watch, notified Director of Nursing, and had staff sit outside resident's door overnight to watch him. Staff C recalled Resident #12's belt had been at the Nurse's Station, unable to recall additional items Resident #12 was not allowed to keep in room for safety reasons. On 8/01/24 at 4:40 PM, Staff E, Social Services staff, revealed Resident #12 often had behaviors such as putting self on the floor, making calls to 911, and destroying phones. Staff E stated Resident #12 had not attempted to harm self since prior suicide attempt at facility. Staff E informed that when Resident #12 had admitted to facility he said he would rather die than stay at facility. Staff E revealed that everything cord like had been taken out of room such as strings and belts. On 8/01/24 at 4:55 PM, Staff B, Registered Nurse (RN) informed that Resident #12 had no additional suicidal ideation since he returned to the facility from hospital. Staff B stated if Resident #12 had indication to harm self, he would tell someone. Staff B reported interventions to prevent harm included removal of the closet bar from Resident #12's room and no gait belts in room. Staff B revealed Resident #12 did still have call light cord in room. Staff B stated Certified Nursing Assistants (CNAs) could check for safety interventions on Resident #12's Care Plan/Kardex. On 8/01/24 at 5:17 PM, Facility Administrator, indicated there had no longer been a concern with Resident #12's safety related to self harm or re-attempted suicide. Administrator reported Resident #12 had changed since hospitalization , and that Resident #12 stated he would not do that again. Administrator informed that staff had in-service training on trauma informed care, but denied use of screening assessment for Post Traumatic Stress Disorder (PTSD).

Based on observation, interview, and record review, and facility policy review the facility failed to ensure residents who received a pureed diet were served all foods included on the menu for four of four residents who received a pureed diet (Resident #3, Resident #7, Resident #19, Resident #22). The facility reported a census of 30 residents. Findings include: On 10/31/23 at approximately 11:15 AM an observation of the puree process was completed with Staff A, Dietary. Observation revealed pureed food items did not include bread for the lunch meal. Review of the general menu at the time of survey revealed the following for Tuesday: country fried steak, mashed potatoes, country gravy, vegetable blend, bread/[NAME], ambrosia dessert, and milk. Review of the pureed menu for Tuesday revealed the meal included 1 serving of puree bread/[NAME]. On 11/1/23 at approximately 1:14 PM, the Dietary Manager notified of the observation with additional information requested. On 11/1/23 at 1:14 PM, the Dietary Manager returned and explained, she said she missed it. The Facility Policy titled Pureed Foods, undated, documented the following per the Supplies section: 1. Menu, 2. Blender, 3. Food items to be pureed and appropriate liquid, 4. Storage containers.

Based on record review, interviews, and facility policy review the facility failed to notify the physician when a resident's weight increased by two pounds in a day per the physician order for 1 of 12 residents reviewed for notification of changes (Resident #2). The facility reported a census of 30. Finding include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented the resident had medical diagnoses including heart failure, unspecified, chronic obstructive pulmonary disease, unspecified, lung transplant status, and Type II diabetes mellitus with hyperglycemia. The MDS documented resident received insulin injections and a diuretic 7 out of 7 days. The Care Plan revealed a focus problem for Congestive Heart Failure (CHF) with initiated date 1/01/22. The Care Plan document an intervention dated 4/6/22 as follows; resident on diuretic therapy for CHF. The interventions dated 3/21/22 directed staff to monitor weight daily and reported concerns of weight gain to the provider. The Electronic Medical Record (EMR) documented the following medical diagnosis: a. heart failure, unspecified The Physician Orders revealed the following orders: a. ordered 12/4/22- Check weight daily ****CALL DR IF UP MORE THAN 2 LB IN ONE DAY**** in the morning for monitoring b. ordered 1/6/22- furosemide tablet 20 mg (milligrams) by mouth every day shift for CHF The Weights Summary Report revealed the following dates that documented dates the weight increased over 2 pounds in one day: a. 7/25/23 at 9:11 AM: 199.0 Lbs (pounds) b. 7/26/23 at 1:28 PM: 202.2 Lbs c. 8/7/23 at 10:16 AM: 193.8 Lbs d. 8/8/23 at 11:03 AM: 196.8 Lbs e. 9/14/23 at 11:22 AM: 191.4 Lbs f. 9/15/23 at 3:29 PM: 194.2 Lbs g. 10/7/23 at 11:39 AM: 183.9 Lbs h. 10/8/23 at 11:54 AM: 190.0 Lbs i. 10/20/23 at 11:26 AM: 178.4 Lbs j. 10/23/23 at 1:11 PM: 181.2 Lbs k. 10/30/23 at 6:57 AM: 176.6 Lbs l. 10/31/23 at 11:35 AM: 179.4 Lbs The EMR lacked documentation of the physician notification for the weight increases on 7/26; 8/8; 9/15; 10/8; 10/23; and 10/31. During an observation on 11/1/23 at 10:24 AM, the resident sat in her recliner with blankets over her. She wore a Nasal Cannula (NC) and the oxygen concentrator set at 3.5 Litters. During an interview on 11/2/23 at 12:07 PM, the Director of Nursing (DON) queried on the check weight order and notification to the provider if resident gained over 2 pounds and she stated if the Medication Administration Record (MAR) didn't document the provider notified she expected a progress note documented of the notification. The Notification of Physician by Facsimile of Non-Emergent Change of Condition Policy dated 9/13/10 revealed the following information: a. Purpose: 1. To provide the facility with another means of communication with attending physician. The use of facsimile for notification of change of condition of a resident's status not intended to circumvent telephone or personal contact between facility staff and attending physician. b. Procedure: 1. When utilizing facsimile to contact a physician, resident condition must be non-emergent, and facsimile intended to inform only. 2. In the event the facility attempted to contact the physician for an urgent or emergent condition change, the facility phoned to consult the physician. The facility won't use facsimile in the event of an emergency.

Based on record review, staff interview, and facility policy review the facility failed to consistently notify the ombudsman of a resident's transfer to the hospital for one of two residents reviewed for hospitalization (Resident #4). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 8/29/23 revealed the resident scored 7 out of 15 on a Brief Interview for Mental Status exam, which indicated severely impaired cognition. The Progress Note for Resident #4 dated 9/20/23 at 4:17 AM documented, in part, Called to 200 hall by staff. Observed resident sitting on floor in front of room [ROOM NUMBER]. Resident in [room number redacted] heard her shout for help and put call light on. Copious amounts of blood was on gown front and back. Hair was covered with blood. Observed hole in back of head about size of nickel. Resident does not remember falling. States she woke up on the floor and scooted out to hall way on her bottom to get help. Back or her gown was wet and a blood trail led to her bathroom. Blood was on radiator. Called 911 for transport to [hospital name redacted]. On-call provider, Dr. [name redacted] notified and gave order to send out. The Progress Note dated 9/20/23 at 11:15 AM documented, in part, Call received from [hospital name redacted] ER (emergency room ) nurse to give report for resident to return to facility. Review of Ombudsman Notification provided by the facility did not include notification for Resident #4's hospitalization described in the resident's progress notes. On 11/02/23 at 11:34 AM when queried who would go on the ombudsman report, the Director of Nursing (DON) explained anyone who transfers would be on that notification. The Facility Policy titled Policy on Transfers reporting to Iowa State Ombudsman's Office, undated, documented the following: Monthly Reporting shall include: Information on Transfers: -hospitalization , 2-Discharge/Home, 3-Transfer to another facility, 4-Theraputic Leave, 5-Other-Including emergency room visits.

Based on observation, interview, and record review the facility failed to revise the Care Plan to address use of antidepressant medication and/or reflect current antidepressant medications ordered, and update following discontinuation of antidepressant medication for three of twelve residents reviewed for care plans (Resident #2, Resident #19, Resident#27). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #27 dated 9/20/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status exam, which indicated severely impaired cognition. Per this assessment, the resident received antidepressant medication for seven of the last seven days. The Physician Order dated 6/24/23 documented, Sertraline HCl Oral Tablet 25 MG (milligram) with directions to give 25 mg by mouth every day shift for dementia. On 11/1/23, review of the Care Plan for Resident #27 did not address receipt of antidepressant medication for Resident #27. Observation on 10/30/23 at 1:09 PM revealed Resident #27 in their room in bed. On 11/2/23 at 11:51 AM, the Director of Nursing (DON) acknowledged antidepressant should be on the care plan, and acknowledged it was missed. The Facility Policy titled Resident Assessment Instrument and Care Planning, undated, docuemnted, Assessments and care plans scheduled will be completed via CMS (Centers for Medicare and Medicaid Services)/RAI (Resident Assessment Instrument) guidelines. 47336 2. The MDS 9/14/23 assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on a BIMS exam, which indicated cognition intact. The MDS revealed medical diagnosis of unspecified mood disorder and generalized anxiety disorder. The MDS documented the resident received an antidepressant 7 out 7 days. The Care Plan revealed a focus area for an order for antidepressant medication citalopram related to depression with an updated upon admission from the hospital on 5/26/23, resident received orders for Mirtazapine also for anxiety and depression initiated on 6/10/21 and revised on 5/26/23. The interventions dated 6/10/21 documented administration of antidepressant medications as ordered by the physician and monitored and documented side effects and effectiveness as needed. The Care Plan lacked documentation that the resident took Trazadone HCL (hydrochloride), and failed to update that Mirtazapine was discontinued one 6/9/23. The Physician Orders revealed the following orders: a. ordered on 7/10/23- Trazadone HCL (hydrochloride) oral tablet- give 25 mg by mouth every evening shift for depression b. ordered 5/26/23 and discontinued on 6/9/23 - Mirtazapine oral tablet 15 mg - give 15 mg by mouth at bedtime for anxiety 3. The MDS assessment dated [DATE] revealed Resident #19 didn't complete a BIMS exam, which indicated severely impaired cognition. The Care Plan revealed a focus area for use of psychotropic medication of olanzapine related to depression, anxiety, and dementia dated 12/1/20. The interventions dated 6/10/21 documented an order for olanzapine related to depression, anxiety, and dementia and administration as ordered by the physician. The Care Plan failed to document that the Olanzapine was discontinued on 7/8/23. The Care Plan revealed a focus area for antidepressant medication of Trazadone related to depression and dementia dated 12/1/20. The interventions dated 2/14/22 administration of antidepressants medications as ordered by provider. The Care Plan failed to document on 7/8/23 that the Trazadone was discontinued. The Physician Orders documented the following orders: a. olanzapine ordered 3/30/23 and discontinued on 7/8/23- olanzapine tablet 10 mg (milligrams)- give 10 tablet by mouth three times a day b. Trazadone HCl (hydrochloride) ordered on 3/30/23 and discontinued on 7/8/23- give 100 mg by mouth three times a day The Progress Note dated 7/10/2023 at 3:26 PM documented a faxed verbal order received from hospice to discontinue all oral non liquid medications. During an observation on 10/30/23 at 1:21 PM, Resident #19 sat in his recliner in his room and rested. A blanket covered his lower half. During an interview on 11/2/23 at 11:53 AM, the MDS Coordinator queried on when a care plan needed to be updated and she stated on a daily basis because things change. She stated at least quarterly. The MDS Coordinator asked what warranted a change and she stated medications, health status, new providers, or anything to follow up to an existing condition. The MDS Coordinator queried on concerns with Resident #2 care plan and she stated she needed to update it and remove the Mirtazapine and citalopram from the care plan. The MDS Coordinator queried on concerns with Resident #19 care plan and she stated his medications were recently discontinued and the care plan needed updated. During an interview on 11/2/23 at 12:07 PM, the Director of Nursing (DON) queried on when care plans needed updated and she stated frequently, minimally quarterly, significant changes, admission, and they always worked on it. The DON queried on Resident #2 care plan and her expectations and she stated she expected the care plan updated by now. The DON asked about Resident #19 care plan and she stated yes, it definitely needed updated on the quarterly.

Based on observation, interview, record review, and facility policy review the facility failed to ensure insulin held per physician ordered parameters and failed to set oxygen at the physician ordered rate for three of twelve residents reviewed for professional standards (Resident #2, Resident #13, Resident #27). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #13 dated 10/14/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Per this assessment, the resident received insulin injections for seven of the last seven days. The Care Plan for Resident #13 dated 5/10/19 documented, I a diagnoses of type 2 Diabetes Mellitus. The Physician Order dated 7/31/23 documented, NovoLOG Solution 100 UNIT/ML (Unit/Milliliter) with directions to inject 10 unit subcutaneously in the evening for DM II Administer with supper. Hold if BS (blood sugar) if below 125. Review of the resident's Medication Administration Record (MAR) dated October 2023 revealed Novalog 10 Units administered on the following dates when blood sugar level outside parameters: a. 10/11/23: BS level 107 b. 10/17/23: BS level 124 c. 10/23/23: BS level 123 The Physician Order dated 8/1/23 documented, NovoLOG Solution 100 UNIT/ML (Insulin Aspart) with directions to inject 12 unit subcutaneously in the morning for DM II related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS .Administer with breakfast. Hold if Blood Sugar is less than 125. Review of the resident's MAR dated October 2023 revealed Novalog 12 Units administered on the following dates when blood sugar level outside parameters: a. 10/16/23: BS level 119 The Physician Order dated 8/1/23 revealed, NovoLOG Solution 100 UNIT/ML (Insulin Aspart) with directions to inject 8 unit subcutaneously in the afternoon for DM II Administer with lunch. Hold if BS if below 125. Review of the resident's MAR revealed Novalog 8 units administered on the following dates when BS levels outside parameters: a. 10/16/23: BS level 122 b. 10/17/23: BS level 122 2. The Minimum Data Set (MDS) assessment for Resident #27 dated 9/20/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status exam, which indicated severely impaired cognition. Per this assessment, the resident received antidepressant medication for seven of the last seven days. The Care Plan dated 6/8/23 documented, I have Diabetes Mellitus II. The Intervention dated 6/8/23 documented, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. The Physician Order dated 9/27/23 documented, Hold Humalog if blood sugar is less than 100. Notify provider if held. with meals for DM (Diabetes Mellitus) II. The Physician Order dated 9/27/23 documented, HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Unit/milliter) with directions to inject 14 unit subcutaneously two times a day for diabetes. Review of documentation on the resident's Medication Administration Record (MAR) dated 10/26/23 documented 14 units of insulin administered on 10/26/23 when blood sugar documented on MAR as 99. Observation on 10/30/23 at 1:09 PM revealed Resident #27 in their room in bed. On 11/2/23 at 11:16 AM upon review of the above information, the Director of Nursing (DON) explained she would add a prompt and acknowledged education needed. The Facility Policy titled Medication Administration dated 1/16/12, revision date 4/12/19, documented, Each Resident will receive the medications and treatments that they and their physician agree are necessary. These medications and treatments require a physician's order or an order from an alternate provider who is legally able to write orders. Medications are administered by licensed nurses or certified medication aides. 47336 3. The MDS 9/14/23 assessment dated [DATE] revealed Resident #2 scored 15 out of 15 on a BIMS exam, which indicated cognition intact. The MDS revealed medical diagnosis for unspecified, chronic obstructive pulmonary disease, unspecified, lung transplant status, and Type II diabetes mellitus with hyperglycemia. The MDS documented resident received insulin injections 7 out of 7 days. The MDS documented the resident wore oxygen while a resident. The Care Plan revealed a focus area for oxygen therapy related to impaired respiratory function initiated on 6/10/21 and revised on 3/20/22. The interventions dated 6/10/21 documented oxygen settings of 2 Liters (L) for comfort or shortness of breath via nasal cannula. The Care Plan revealed a focus area for a diagnosis of Type II Diabetes Mellitus dated 6/10/21. The interventions dated 3/20/22 documented administration of diabetes medication as ordered by the medical providers. The resident had scheduled and sliding scale insulin. Please review the Medication Administration Record (MAR) or order summary for the most up to date orders, and administration as ordered and appropriate. The EMR (Electronic Medical Record) revealed the following medical diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD), unspecified b. shortness of breath c. lung transplant status d. Type II DM (diabetes mellitus) with hyperglycemia The Physician Orders revealed the following orders: a. ordered 6/7/23- Humalog KwikPen solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Lispro (1 Unit Dial))- Inject as per sliding scale: if 150 - 199 = 1; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350+ = 5, subcutaneously before meals and inject 7 unit subcutaneously before meals for diabetes mellitus (DM) II and hold if blood sugar is below 130 b. ordered 6/7/23- Lantus SoloStar subcutaneous solution Pen-injector 100 UNIT/ML (Insulin Glargine)- inject 24 unit subcutaneously at bedtime for DM II c. ordered 7/17/21- blood sugar finger sticks QID (before meals and hs(bedtime)) if unable to use continuous blood sugar monitor.- as needed for DM II check blood sugar, via continuous glucose monitoring device, QID (before meals and at HS), and as needed before meals and at bedtime for DM II. d. ordered 8/2/23- continuous oxygen 2 L per NC (nasal cannula) The MAR/TAR (Medication Administration Record/Treatment Administration Record) for October showed the following dates the resident received the physician scheduled order of Humalog KwikPen 7 units when the blood glucose below 130: a. 10/7/23 at 7:30 AM dose- blood glucose 115 b. 10/8/23 at 4:30 PM dose- blood glucose 125 c. 10/11/23 at 7:30 AM dose- blood glucose 121 d. 10/12/23 at 7:30 AM dose- blood glucose 88 e. 10/15/23 at 4:30 PM dose- blood glucose 86 f. 10/22/23 at 4:30 PM dose - blood glucose 113 g. 10/26/23 at 7:30 AM dose- blood glucose 105 The Progress Note dated 10/4/23 at 3:18 PM documented portable oxygenator delivered for use as requested by resident, following each use the batteries required charging so there will be 5 hours of total use with both batteries next time she wanted to use it. Tubing changes will be required for both the large concentrator and the portable per facility monthly schedule. Resident preferred continuous 2 L versus pulse setting on portable unit. During an observation on 10/30/23 at 1:45 PM, the resident sat in her recliner with a NC in her nostrils and the oxygen concentrator set at 3.5 L. During an observation on 11/1/23 at 10:24 AM, the resident sat in her recliner with blankets over her. She wore a NC and the oxygen concentrator set at 3.5 L. During an observation on 11/1/23 at 12:00 PM, resident sat in her wheelchair in the dining room and had her NC in her nostrils and the portable oxygen set at 3 L. During an observation on 11/2/23 at 8:02 AM, resident sat in her wheelchair in the dining room and ate breakfast. NC in her nostrils and portable oxygen set at 3 L. During an interview on 11/02/23 11:45 AM, Staff B queried on what Resident #2 oxygen needed set at and she stated it currently set at 3 liters and the resident's order could be titrated. She stated 3 liters seemed to hold her at 93% to 94%. Staff B looked up the resident's order and stated she the resident's order wasn't a titrated order. Staff B queried on Resident #2 insulin order and she stated the insulin order documented to hold if blood glucose below 125 mg/dl (milligrams per deciliter) and the resident also had an order for sliding scale. She stated she expected the order held when her blood glucose below 125 mg/dl. Insulin order- unless it below 125 and then sliding scale. Yes, I would expect it to be held. I use 9. During an interview on 11/02/23 at 12:07 PM, the DON (Director of Nursing) queried on Resident #2 insulin order and her expectation of the insulin held if the blood glucose below 130 mg/dl and she stated she expected the insulin held as ordered. The DON queried on Resident #2 oxygen order and the setting on the oxygen concentrators and she stated when the order changed to continuous the nurses needed to follow the order and follow up with the provider if they felt the order not appropriate. She stated they didn't normally have continuous orders and the orders generally documented a titration order.

Based on observation, interview, and record review, the facility failed to ensure care planned diet recommendations from the Registered Dietician were consistently implemented for one of one resident reviewed for nutrition (Resident #6). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The Care Plan dated 6/1/20, revised 10/10/23, documented, I am at risk for nutrition alteration due to: Schizoaffective disorder, ASHD, constipation, depression, hx (history) of TIA (Transient Ischemic Attack), adult failure to thrive. I would like to have a gradual wt (weight) loss. Hx of covid 19. Swallow concerns. I have a mass on thyroid which affects my swallowing. The Intervention dated 6/1/20, revised 10/10/23, documented, I will receive a Gen (general) diet to meet by nutrition needs. I will be offered alternatives as requested and these requests will be honored. I am receiving 206 nutrition drink due to decrease appetite while ill. I am receiving a Mech (mechanical) soft diet with yogurt or magic cup at each meal to assist with swallowing and wt maintenance. The Nutrition/Dietary Note dated 10/25/23 at 5:56 PM documented, in part, Sign (significant) wt change/Sign change Res' wt-165.6#, IBW (ideal body weight)-160-196#, BMI (body mass index)-22.5 (normal) .Res feeds self and consumes 25-100% of the food/meal fluids. Swallowing problem due to mass on thyroid. Mech soft to assist with chewing/swallowing. Also send [Brand Name supplement] or yogurt to follow bites of food to assist with swallow . A: Meet needs for comfort with food/fluids as desired. P: Mech soft with [Brand Name supplement] or yogurt after each bite to assist with swallowing. The Physician Order dated 7/11/23 documented, Regular diet, Minced texture, Regular consistency mechanical soft for diet order. Review of documentation provided with information for the kitchen documented the following diet order for Resident #6: General diet with Mech (mechanical) soft and yogurt or [Brand Name supplement] with meals. Observation of the resident on 11/1/23 at 12:20 PM during the lunch meal revealed the resident did not have yogurt or the supplement present with his food at the table. The resident coughed at time of observation. The Dietary Manager was notified of the observation, went to the container where drinks were located on ice, obtained the missing item, and provided it to the resident. On 11/02/23 at 11:38 AM, the Director of Nursing (DON) explained it should have been on the tray instead of the ice bin. The Facility Policy titled Dietary Policy No. 3.4 dated 12/14/99, revised 2/16/21, documented, in part, It is the policy of [Facility Name Redacted] that resident receive diets as ordered by their attending physicians.

Based on observation, policy review, and staff interview, the facility failed to ensure the dishwasher maintained the minimum required temperature in order to sanitize dishes. The facility reported a census of 29 residents. Findings Include: Observations of the kitchen tour on 5/31/22 revealed the following concerns: a. At 11:31 a.m., the Dietary Manager ran the dishwasher and the temperature on the machine's gauge read 100 degrees Fahrenheit. The Dietary Manager ran it again and it read 100 Degrees Fahrenheit. A plaque on the outside of the machine stated the minimum water temperature should be 120 degrees Fahrenheit and the recommended temperature was 140 degrees Fahrenheit. b. At 12:29 p.m., the Dietary Manager ran the dishwasher again and it was 118.5 degrees Fahrenheit. c. At 12:40 p.m., the Dietary Manager and the Maintenance Supervisor ran the dishwasher again and the gauge on the machine read 120-124 degrees Fahrenheit. The Maintenance Director also obtained a temperature with a manual thermometer submersed in the outer water tank and it read 126 degrees. The Maintenance Supervisor stated he removed air from the water line to correct the problem. The Dietary Manager stated the low temperatures on the May 2022 temperature log such as 80 degrees and 100 degrees Fahrenheit were unacceptable. The untitled May 2022 Dishwasher Temperature Log for breakfasts, lunches, and suppers revealed the following concerns: a. 11 instances of a temperature reading of 80 degrees Fahrenheit. b. 1 instance of a temperature reading of 90 degrees Fahrenheit. c. 21 instances of a temperature reading of 100 degrees Fahrenheit. d. 3 instances of a temperature reading of 110 degrees Fahrenheit. e. 1 instance of a temperature reading of 115 degrees Fahrenheit. The facility Dietary Policy, revised 2/16/21, directed staff to operate the dish machine according to the instructions on the machine.

Based on review of Physician Orders, Medication Records, Facility Policies and staff interviews, the facility failed to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .(Resident #19). The facility reported a census of 29 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident #19, dated 4/13/22 identified the resident as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 2 out of 15. The MDS documented the resident with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also identified the resident to be totally dependent on staff for most activities of daily living. The Care Plan identified the resident with the problem of Type II Diabetes Mellitus on 3/24/19 and directed staff to notify the provider (Physician) of blood glucose results above 400 mg/dl or below 70 mg/dl. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the May 2022 Medication Administration Record (MAR) revealed the following orders which failed to have documentation of the Physician being contacted for blood sugars below 70 and a [MEDICATION(S)] Emergency Kit 1 milligram (MG) administered: a. Inject 1 application subcutaneously as needed for blood sugar below 60 administer or 1 unit application if blood sugar is below 60 and resident is unable to swallow. Doses signed out as given on 5/17/22 at 3:02 AM for a blood sugar of 61 and on 5/21/22 at 2:17 AM for a blood sugar of 52. A review of the May 2022 Medication Administration Record (MAR) revealed the following orders which failed to have documentation of the Physician being contacted for blood sugars below 70 and a Glucose Gel 40%administered: a. Give 1 application by mouth as needed for hypolycemia administer 1 unit application if blood sugar is below 70 and resident is able to swallow. A dose signed out as given on 5/22/22 at 2:49 PM for a blood sugar of 69. A review of the Nurse's Notes revealed the following: a. On 5/17/22 no documentation to show the Physician notified of the blood sugar of 61. b. On 5/21/22 at 10:53 AM, the Physician notified of glucose levels (9 hours after blood sugar of 52 at 2:17 AM) c. On 5/22/22 no documentation to show the Physician notified of the blood sugar of 69 at 2:49 PM. A review of the Nurse Practitioner note dated 5/20/22 failed to have documentation to show she had been notified of the blood sugar on 5/17/22 of 61. During an interview on 6/2/22 9:00 AM, the Director of Nursing (DON) explained the nurse that receives the order is responsible for transcribing to the MAR and those are in the electronic record. The part of the order that addresses calling the doctor for a blood sugar of less than 70 should have been addressed on the MAR. On 6/2/22 9:55 AM, the DON verified the documentation on notification of the Physician is lacking and expected Nursing Staff to have more detailed information for hypoglycemic episodes on 5/17/22 and 5/22/22 documented. The DON also provided a Nurse's Note dated 5/21/22 at 10:53 AM (for the blood sugar of 52 at 2:17 AM) to show the Physician had been notified. A review of the undated policy titled: Diabetic Reactions documented to notify the Physician of severe hypoglycemic reactions, however, it did not include parameters of how low the blood sugar should be before notification.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 29. Findings include: 1. The initial kitchen tour on 12/22/19 at 9:05 a.m. revealed the following concerns: a. The surveyor asked Staff C (Cook) to test the concentration of the liquid in a red bucket labeled Sanitizer Only. Staff C stated there was only water in the bucket. b. Dust particles covered the lights above the stove. c. Clumps of dust approximately 3 millimeters (mm) in size clung to the horizontal pipes located above the stove. d. Clumps of dust approximately 3 mm in size clung to and extended from the horizontal pipes to the vertical pipes at the T section of the pipes above the stove. A facility invoice stated an external company cleaned the kitchen exhaust systems on 10/29/19. The weekly kitchen cleaning schedule directed staff to clean stove vents on Sunday. During an interview on 12/23/19 at 2:25 p.m., the Dietary Manager stated the facility had a regular cleaning schedule staff should follow for the stove hood and stated sanitizer only should be in the red bucket. 2. Observations during the noon meal service in the on 12/23/2019 between 11:30 am to 12:20 p.m. revealed Staff A (Cook) handled the plates and bowls improperly touching the inside of fourteen plates and bowls with her thumb. An observation during the follow-up tour of the kitchen on 12/23/2019 at 12:23 pm revealed an open container of sour cream and an open container of milk without a date. During an interview on 12/23/19 at 1:54 p.m., the Dietary Manager stated her expectation for handling the clean plates prior to serving is to hold them on the edge of bowls and plates. During an interview on 12/23/19 at 12:27 p.m., the Dietary Manager stated the sour cream and milk have expiration dates on them and did not think the items needed an open date. During an interview on 12/23/19 at 12:28 p.m., Staff D stated that the items needed to be labeled.

Based on record review and interview, the facility failed to provide adequate nursing supervison and assistance devices to prevent accidents when staff failed to transfer a resident according to the care plan resulting in a fracture for 1 of 1 residents reviewed with a major injury. Resident #23 required a mechanical lift (Hoyer Lift) for transfers because she had not walked in approximately two years and experienced muscle weakness and [MEDICAL CONDITION]. After a shower, 3 Certified Nursing Assistants (CNAs) transferred her from the shower chair using a standing transfer with assist of 3, rather than the Hoyer Lift as specified in the resident's Plan of Care. This caused the resident pain and resulted in a right ankle fracture which required surgical intervention. The facility reported a census of 26 residents. Findings: 1. The MDS (Minimum Data Set) assessment tool, dated 9/26/18, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene and bathing, extensive assistance of 2 staff for bed mobility and dressing, depended totally on 1 staff for toilet use, and depended totally on 2 staff for transfers. The resident did not walk during the MDS review period. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 15 out of 15, indicating intact cognition. A 10/9/18 3:06 p.m. progress note stated the resident complained of right foot and ankle pain at 1:45 p.m. and requested to see the nurse practitioner. The note stated the resident told the nurse when she was in the shower room, the bath aide and 2 CNAs (Certified Nursing Assistants) stood her up (Attempted to assist her to stand) instead of using the Hoyer (mechanical lift) and stated when they stood her up all of her weight went onto her right foot causing it to hurt. The note stated the nurse reported to the DON (Director of Nursing) staff did not use the Hoyer. The note stated the nurse practitioner gave an order to send the resident to the emergency room for an x-ray and the resident left the facility at 3:03 p.m. A 10/9/18 incident report stated the resident complained of right foot/ankle pain and had bruising and swelling. The report stated the resident informed the nurse 3 staff members stood her up instead of using the Hoyer lift and all of her weight went onto her right ankle causing pain. A 10/9/18 hospital report indicated the resident had an x-ray and listed the [DIAGNOSES REDACTED]. A 10/9/18 6:00 p.m. progress note stated the resident returned to the facility with a boot related to the ankle and the resident was to follow up with orthopedics the next day. A 10/10/18 3:31 a.m. progress note stated the resident was in great pain and staff administered pain medication. A 10/10/18 9:00 a.m. progress note stated the resident had an orthopedic appointment scheduled for 10/12/18 at 8:15 a.m. A 10/10/18 10:52 a.m. progress note stated the resident complained of pain rated at 8 on a scale of 1-10 and staff administered [MEDICATION NAME]/[MEDICATION NAME] (a narcotic pain medication). A 10/10/18 2:00 p.m. progress note stated it was very painful for the resident during repositioning of the right leg and stated the resident became pale and diaphoretic (a state of profuse sweating) during the process. A 10/11/18 11:09 a.m. progress note stated the resident rated pain at a 7 on a scale of 1-10. A 10/12/18 6:40 a.m. progress note stated the resident left the facility to go to her appointment with orthopedic surgery. A 10/12/18 7:22 p.m. progress note stated the resident returned from her appointment with orthopedic surgery. A 10/13/18 11:59 a.m. progress note stated facility staff called orthopedics regarding the resident's appointment as the clinic did not send any paperwork or instructions back with the resident. The note stated the on call physician informed the staff the orthopedic department would call the facility with a date and time for surgery. The note stated the physician directed staff to administer [MEDICATION NAME] and a [MEDICATION NAME] (a narcotic pain medication administered via a patch worn on the skin) for pain control. A 10/15/18 10:50 a.m. progress note stated the hospital scheduled the resident for surgery on 10/16/18 at 8:15 a.m. A 10/16/18 12:38 p.m. surgeon's procedure note listed a pre-op [DIAGNOSES REDACTED]. The note stated the resident sustained [REDACTED]. The note stated the resident underwent [REDACTED]. A 10/18/18 11:33 a.m. progress note stated the resident admitted to the hospital for surgery of right ankle fusion with IM (intramedullary rod-a metal rod inserted in the cavity of the bone to treat fractures) nail. A 10/18/18 12:26 p.m. progress note stated the resident returned to the facility. The Morse Fall Scale (an assessment used to determine a resident's fall risk), dated 9/24/18, listed the resident's fall risk score as 40, indicating a moderate risk for falling. The assessment stated the resident had a history of [REDACTED]. Review of the care plan revealed the following entries: A 6/7/16 entry stated the resident had a fall in her room without injury while she reached for an item and fell out of the wheelchair. A 10/13/16 entry stated the resident had a fall in her room. A 3/31/17 entry stated the resident slid on the floor while trying to take off socks. A 10/24/17 entry stated the resident had an fall without injury when 2 staff assisted her to transfer to the shower chair and her knees buckled and staff had to lower her to the floor. A 1/16/18 entry stated the resident required a Hoyer lift transfer at all times with the assistance of 2 staff. A 1/16/18 entry stated the resident was at high risk for falls related to muscle weakness and general [MEDICAL CONDITION] (inflammation of the bones and joints). An 8/21/18 entry stated the resident would not sustain a serious injury through the review date. A 10/10/18 entry stated the resident sustained [REDACTED]. A 10/10/18 facility disciplinary report listed the following offense for a Staff G CNA: transferred a resident without a Hoyer which was required according to the resident's plan of care. The report stated the resident sustained [REDACTED]. A 10/10/18 facility disciplinary report listed the following offense for Staff B CNA: transferring a resident without a Hoyer which was required per the resident's plan of care. The report stated the resident sustained [REDACTED]. A 10/10/18 facility disciplinary report listed the following offense for Staff C CNA: transferring a resident without a Hoyer which was required per the resident's plan of care. The report stated the resident sustained [REDACTED]. The facility policy Medicare Electric Patient Lift, dated 12/14/11, stated all residents would be assisted to transfer positions in a safe manner and if a resident could no longer safely and reliably bear weight, they would be assisted by staff using a mechanical lift. The policy stated the lift would be used by any resident who met the policy criteria or had a physician's orders [REDACTED]. During an interview on 10/16/18 at 12:07 p.m., Staff B CNA stated they were very rushed the day of the incident. She stated she, Staff G CNA/shower aide, and Staff C CNA decided to stand the resident up from the whirlpool chair to dry her off and pull her pants up instead of using a Hoyer lift to transfer her into her wheelchair. She stated it was a group decision to do this and when they did the resident said ow. She stated after the transfer, it was her impression Staff G would notify the nurse the resident complained of pain and stated after the transfer she and Staff C returned to the floor. She stated they did not use a gait belt as the resident refuses this. She stated later that afternoon when they assisted the resident back to bed the resident stated her ankle hurt. Staff B stated later in the evening, she told the nurse (Staff I) what happened. Staff B stated they made a poor decision to get something done. During an interview on 10/16/18 at 12:24 p.m., Staff C CNA stated the day in question was a terrible day. She stated she, Staff G, and Staff B were in the shower room and Staff G asked if they could just stand the resident up really quickly to save time instead of using the mechanical lift. Staff C stated she was behind the wheelchair and was under the impression Staff G and Staff B were just going to stand the resident up but they ended up turning her (with their arms under the resident's arms) and Staff C placed the resident's wheelchair behind her. She stated the resident said something about her foot but she didn't remember the details. She said the transfer shouldn't have been done using that method). During an interview on 10/17/18 at 9:37 a.m., Staff I LPN (Licensed Practical Nurse) stated on the day of the incident, the resident called her into her room and wanted to see the nurse practitioner who was on rounds that day. Staff I stated the resident told her the staff stood her up in the shower room instead of using a Hoyer. Staff I stated staff were supposed to utilize a Hoyer lift when transferring the resident. Staff I stated at this time there was no bruising and the resident could move the ankle in an up down motion but not in a side to side motion. When she looked at the resident's ankle again toward the end of the shift, there was bruising. Staff I stated the resident subsequently went to the emergency room for evaluation and had sustained a fracture. During an interview on 10/17/18 at 2:55 p.m., Staff G stated on the day of the incident she was the shower aide and used a Hoyer lift to transfer the resident into the shower chair. She stated the resident had an appointment after her bath and Staff G thought they would just stand her to get her back into the wheelchair after her bath. She called Staff B and Staff C into the shower room to help. Staff G stated she was on one side of the resident and Staff B was on the other side. She stated they had the resident hang onto the walker and pivot to the chair while she had her hands underneath the resident's arm. She stated they did not use a gait belt. She stated Staff C pulled the resident's pants up. She stated the resident said something hurt but she didn't remember which part of the body. She stated the resident was to be transferred with a Hoyer lift and it had been a while since the resident had not needed the lift. Staff G stated she felt very guilty and was sorry for all of it. During an interview on 10/18/18 at 11:16 a.m., the DON stated staff should transfer the resident with a Hoyer lift and stated it was not safe for her to be an assist of 2 as she would get weak and could fall. She stated the resident's health had been failing for years and she was inactive. She stated on the afternoon of the incident the resident complained of pain and the nurse practitioner sent her to the hospital for and X-ray and she ended up with a fracture. The DON stated she expected staff to follow the care plan and there was no way to excuse the incident.

Based on observation, record review, staff and resident interviews, the facility failed to assess and provide sufficient interventions to prevent the development of an avoidable pressure ulcer (Resident #1). The sample consisted of 10 residents and 3 of 10 residents had pressure ulcers. The facility reported a census of 29 residents. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment (prior to the development of an avoidable left heel ulcer) with a reference date of 12/05/2016. The MDS indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15. A score of 15 represented the resident had no cognitive impairments. The resident exhibited no rejection of cares per documentation. Daily cares of bed mobility, transfers, dressing, toilet use, personal hygiene, and locomotion in a wheel chair required the extensive assistance of at least 1 staff person to complete. Range of motion included upper extremity impairments only. Resident # 1 rated pain at 7 (1 least and 10 most pain). The MDS did not identify any pressure ulcers, but included a pressure cushion in the wheel chair, a pressure reduction mattress, and ointments/medications to the skin. Nutrition/hydration needs and a turning /repositioning program failed to be a part of treatments for prevention of pressure ulcers. The MDS identified the resident's [DIAGNOSES REDACTED]. The most recent (annual) MDS with an assessment date of 03/02/2017 (post the development of the left heel ulcer), revealed a BIMS of 14 which indicated minimal long or short term memory deficits. The behavior section of the MDS identified the resident demonstrated no rejection of cares. Resident # 1 required the extensive assistance of at least 1 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene cares. A wheel chair with assistance from a staff person provided locomotion around the unit. The resident rated pain as frequent and an 8. The MDS documentation identified this resident as at risk for pressure ulcers with an unstageable pressure ulcer. The MDS documentation failed to provide a turn and reposition program or nutritional/hydration interventions. Prevention measures included a pressure reducing device in the chair, a pressure reducing mattress, pressure ulcer care, and dressings to the feet. The plan of care prior to developing the avoidable left heel ulcer with an initiation date of 07/08/2016, specified Resident # 1 utilized a pressure reduction mattress and a cushion in the recliner and wheel chair. The plan of care noted Resident # 1 needed assistance with personal cares which required the use of the arms due to bad shoulder joints and needed to be monitored for assistance with turning and repositioning at least every 2 hours or less. The intervention directed the staff that the resident's skin should be monitored during baths and other cares, as well as encourage the consumption of fluids. The plans of care edited on 06/13/2017 (post pressure ulcer development), directed staff to provide extensive assistance for repositioning in bed and provide a mechanical lift for transfers. The pressure reduction mattress and a chair cushion plus the monitoring of the skin remained the same. The plan documented Resident # 1 as cognizant. Dietary intervention revisions on 04/27/2017 (2 months after the avoidable pressure ulcer to the heel originated) included fortified shakes and vitamin C and zinc supplements. The heel floating intervention did not start until 07/07/2017 and a wound specialist followed Resident #1's treatment to the left heel ulcer. Education initiated at that time included keeping the feet elevated and using a waffle boot which the resident sometimes refused. Facility staff should encourage and supervise position changes and reposition the resident every 1 to 2 hours and more frequently as needed. The Braden Scale for predicting pressure sore risk dated 12/06/2016 identified Resident #1 as at risk for developing pressure ulcers with a score of 18. The Braden scale scores 15 to 18 as at risk, 13 to 14 as moderate risk, 10 to 12 as high risk, and 9 or below as very high risk. The Braden Scale evaluation of 03/06/2017 as a 16, as at risk for developing a pressure ulcer. The Braden Scale of 06/02/2017 rated Resident # 1 at 18 (still at risk). On 01/25 through 01/27/2017, Resident # 1 received treatment, in the hospital, for a low potassium level. No evidence or assessment of any skin integrity issues upon her/his return to the facility could be located in the medical record. The current Physician order [REDACTED]. Eliquis 2.5 milligrams twice a day (an anticoagulant to prevent blood clots due to limited mobility or circulation) and [MEDICATION NAME] 2.5 milligrams every Sunday (to reduce water build up in the body which causes swelling/[MEDICAL CONDITION] and increasing the risk of skin breakdown. Nursing progress notes from 02/01/2017 through 02/12/2017 failed to contain any information on floating the heels, assisting or supervision of the resident with bed mobility. A nursing note of 02/02/2017 at 03:35 A.M. indicated Resident # 1 also experienced an upper respiratory illness which compromised the resident's overall wellness. Nursing administered an antibiotic. On 02/13/2017 the facility notified the Physician Resident # 1 complained of left heel pain and described the left ankle and foot area as 1 plus (slightly swollen) [MEDICAL CONDITION], red, and cool to touch. No assessment of a pedal pulse (top of foot) or any signs of blanching when touched, or any bogginess to the heel. The Physician responded to monitor the area. The nursing staff did not start a skin assessment sheet for the left heel. The nursing progress notes failed to contain any assessments of the left heel at this time. A Skin/Wound note dated 02/24/2017 speaks of removing a bandage from a puncture site which displayed no drainage, with light purple bruising, and measured 1.3 centimeters long by 3.5 centimeters wide. The note had no explanation as to the location or order for any treatment in the chart. On 02/27/2017 (first entry on pain and soreness was 01/27/2017 a communication with the Physician described the left heel area as a painful, purple intact discoloration, which measured 1.4 centimeters by 3.6 centimeters. Nursing staff covered the area with an Allevyn foam dressing and tape. The Physician responded with an approval for the dressing and to change every third day and as needed. On 01/27/2017, the facility continued to not initiate preventative interventions for the painful left heel. On 02/27/2017 the facility nursing staff started a wound care sheet titled Gentell Fastcare and documented the left heel area as open, 1.4 centimeters by 3.6 centimeters with no depth, no drainage, with [MEDICATION NAME] skin surface, and as a suspected deep tissue injury. The intervention would be to start a turn and reposition program. On 03/01/2017, an assessment of the left heel sent to the Physician descried the area as irregular in shape at 2 centimeters long and 6 centimeters wide with no skin loss or drainage. Nursing staff suggested pressure reduction boots, pain control, weekly monitoring and no dressing with which the physician concurred. On 03/05/2017 at 9:36 P.M., Resident # 1's daughter requested the Physician to see the resident and assess the left heel area which displayed drainage. The note referred to the resident refused to wear blue boots for heel protection. The medical record did not contain information that the physician visited the facility to assess the resident's left heel at this time. On 03/06/2017, the wound sheet described the left heel area as open with [MEDICATION NAME] tissue, no drainage, and measured 1.8 centimeters by 6 centimeters and without depth. The intervention included the application of pressure reduction boots to each foot and to monitor. On 03/29/2017, the physician visited Resident #1 at the facility (55 days after the first mention of the left heel soreness). The physician described the area as a sudden onset of a blood filled blister, deep tissue injury 2 centimeters by 5 centimeters, or a Stage III or IV pressure ulcer covered with eschar (a thick, leathery black/brown area of dead necrotic tissue which can occur with decreased circulation to the skin tissues). Causal factors for Resident # 1 included [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITION], pain, and immobility. The physician ordered staff to keep the heel covered, remove all sources of pressure, and recommended a heel suspension boot. The Director of Nursing verbalized the boot should arrive to the facility that day (03/29/2017). The 04/07/2017 Physician note identified the left heel area as an unstageable pressure injury that measured 5 centimeters by 1.5 centimeters by 0.2 centimeters in depth. A consulting physician assessed the pressure wound and clinically diagnosed it as infected. The physician performed a surgical removal of the infected skin called a debridement. Since the suspension boot felt uncomfortable to the resident, instructions to keep pressure off of the left heel pressure wound however, possible was given. Resident # 1's nursing progress notes on 04/05 and 04/06/2017 documented facility staff encouraged/educated the resident on the importance of wearing the suspension boot without success. The nursing progress notes from 04/07/2017 to present did not address the elevation of the heels, a different boot applied or turning and repositioning the resident. An observation on 07/10/2017 at 10:00 A.M., Staff E (Licensed Practical Nurse) washed her hands, donned gloves, and provided a wound treatment to the resident's left heel. Resident # 1 laid in bed with both legs up on pillows and the heels floated. Staff placed a clean barrier beneath the heels and removed the old dressing to the left heel. Observation of the left heel pressure area noted with no drainage, an area of brown color at the center, with pink granulation tissue surrounding it and the rest of the foot dry and flaky with 1 plus [MEDICAL CONDITION]. Both of the lower legs presented with redness. Resident # 1 cooperated with the procedure and reminded the staff to make sure her/his legs were up on the pillows and the heels not touching before they left. Staff measured the heel ulcer as 0.4 by 1.2 by 0.1 centimeters in depth. On 6/26/2017 the nurse measured the area as 0.6 by 3.2 with 0.2 centimeters in depth. During an interview on 07/10/2017 at 1:20 P.M., Resident # 1 sat in a wheel chair with a pillow on the floor and her/his stocking feet directly on the pillow. The resident was questioned about being turned and repositioned in bed or heels floated. The resident responded and said the staff do keep her/his feet up now and do help her/him turn in bed, but prior to the pressure area on the left heel not so much. On 07/12/2017 at 2:20 P.M. observation identified Resident # 1 seated in a wheel chair with both feet resting on the floor. The resident wore slippers with no backs and cotton socks covering the feet. The staff members did not intervene. On 07/12/2017 at 09:30 A.M., Resident # 1 sat in her/his room. When asked about the suspension boot, she/he answered it did not fit right. The boot came above the knee and was not comfortable. She/he verbalized wearing the boot sometimes, but would rather use the pillows to keep the heels up. Resident # 1 stated she/ he knew the importance of keeping the heels up to prevent sores. An observation of both lower legs noted 1 plus [MEDICAL CONDITION] and redness. The resident expressed being able to move a little in bed, but could not roll from side to side alone or place her/his legs up on the pillows. On 07/11/2017 at 2:03 P.M. and 07/12/2017 at 12:30 P.M., Staff A (Certified Nursing Assistant) worked in hall 3. Staff was questioned about Resident # 1 able to keep the heels elevated. Staff A stated the resident desired to have the heels off the mattress and would remind them. She verbalized that before the left heel pressure ulcer, staff did not help the resident turn or reposition too much. The resident did prefer to stay up during the day. On 07/12/2017 at 9:20 A.M., Staff B and Staff F (Certified Nursing Assistants), both agreed Resident # 1 usually could be talked into agreeing to turn and reposition and the resident would tell staff to float the heels for her/him. On 07/11/2017 at 10:20 A.M., the Administrator provided literature on the mattress and bed Resident # 1 used. This Hill ROM bed and mattress combo could be upgraded to the advances series but did not have the air flow motor on the end of the bed. The Administrator explained the motor could be found under the bed and did work. Observed identified no sound of a motor or airflow noise. With both hands placed on the foot of the bed with pressure downward and in the middle of the bed, no airflow motor could be heard. An observation of the control panel at the end of the bed found the mattress selection to be on comfort and not prevention. Upon switching to prevention, the flow of air could be heard. On 07/12/2017 at 2:20 P.M., observation identified the bed again in the comfort mode and not in prevention and without the use of the airflow. According to the Hill ROM literature, when the mattress is operating, it would redistribute pressure when the resident is placed on it. On 02/13/2017, the physician signed an unavoidable skin/pressure sore sheet for the facility. When contacted on 07/11/2017 at 11:40 A.M., the physician responded she treated the resident for the last 9 years and knew the resident could be uncooperative, would not wear the suspension boot or keep the feet up, and had a history of [REDACTED]. The physician also stated in the past 9 years, she had never seen the resident's feet floated when in bed. On 07/11/2017 at 3:20 P.M., the Director of Nursing stated the facility did not have a policy and procedures for pressure wounds. The Director of Nursing stated the only procedures wound be the one written on the Care Plans.

Based on record review and staff interviews, the facility failed to implement the written care plan intervention and failed to provide adequate supervision to protect one of four residents from hazards (Resident #1). Record review and staff interview revealed staff let go of Resident #1's gait belt during a transfer and Resident #1 fell fracturing his/her hip. The facility reported a census of 30 residents. Findings include: 1. According the Minimum Data Set (MDS) assessment tool with a reference date of 09/15/15, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS identified Resident #1 required physical assistance of one staff member for bed mobility, transfers, ambulation, toilet use, and dressing, personal hygiene. The MDS indicated the resident's balance during transitions and walking as not steady, and only able to stabilize with staff assistance when moving from seated to standing, when walking, when moving on and off the toilet and when transferring from bed to chair (or wheelchair). The MDS documented the resident normally used mobility devices of a walker and wheelchair for mobility. The MDS indicated the resident had no functional limitation in range of motion. The MDS documented the resident had no falls, since prior assessment being completed. The resident's most updated Care Plan dated 11/24/15, identified the resident had limited mobility related to CVA as manifested by muscle weakness. The resident at high risk for falls related to gait and balance problems. The Care Plan listed interventions/approaches that directed staff to: 1. know the resident is weight-bearing for short periods of time, and tires quickly. 2. resident requires assist of one staff member, gait belt, and walker to ambulate short distances. 3. resident requires assist of one staff to push resident wheelchair to meals and activities. 4. In March 2014, the resident totally dependent on staff to push him/her because resident becomes hypoxic with exertion. Resident had an oxygen tank on wheelchair for continuous oxygen management breathing. 5. Staff will transfer resident with oxygen on, resident becomes hypoxic (lack of oxygen in blood) quickly and have become faint (3/18/14). 6. On 9/17/15, the care plan identified Resident #1 required one staff assistance with gait belt and walker to ambulate (a) short distance. The care plan identified Resident #1 had a fall on 10/4/15, and the care plan remained appropriate. The fall report for 10/4/15 documented Resident #1 had been transferring with staff from his/her bathroom to bed when he/she became weak and staff lowered him/her to the floor. Review of the Progress 11/21/15 at 10:13 p.m. Staff A, Certified Nurse Aide (CNA) notified the Nurse Staff B, around 6:45 p.m. that Resident #1 had fallen. Upon entering the resident's room, resident noted to lying on his/her back in bed. Staff A reported that he/she to helping the resident to transfer to bed, resident holding onto walker, when the resident asked Staff A to move his/her clothes to the wheelchair. The resident's knees became weak and resident fell to the floor landing on left side facing the bed. Staff B assessed the resident and noted resident unable to straighten left leg, knee bent, the resident yelled out when moving leg. Staff B notified resident's physician and family member who wanted the resident sent to the emergency room . At 8:10 p.m. the emergency room called the facility and reported the resident diagnosed with [REDACTED]. The hospital summary dated 11/21/15 revealed per the resident's report, he/she had been exiting the bathroom using a walker and once left the bathroom fell to the left side. The resident had no dizziness or light-headedness prior to the fall. The resident had left hip intramedullary nailing completed on the 11/22/15. The report identified an anemic diagnosis (acute on chronic, likely secondary to recent surgery.) Review of the discharge summary dated 11/25/15, revealed Resident #1 admitted to the hospital with [REDACTED]. Discharge instructions and medications given and the resident discharge to facility on 11/22/15. Review of the facility's Fall Report and Post-Fall assessment dated [DATE] at 6:45 p.m. with location in resident's room. The conditions at time of fall included: call light being turned on, floor dry, overhead light on, area clear of objects, resident transferring to bed with assist, gait belt, and walker. Staff person assisting the resident to bed via walker and resident became weak and fell to floor landing on left hip. After resident assessed, family and physician notified and resident transferred to the emergency via ambulance, and then on to another hospital for further treatment of [REDACTED]. Review of a verbal coaching statement dated 11/23/15 to Staff A, revealed coaching done with Staff A regarding resident safety with ambulation. Staff A informed when assisting a resident with ambulation, he/she must have a hand on the gait belt at all times. Staff A is not to perform another task while ambulating a resident; the resident's clothing should have been moved from resident's walker to wheelchair prior to assisting him/her with ambulation. Furthermore, it was discussed with Staff A the dangers of moving a resident that had fallen prior to assessment by charge nurse. Staff A instructed to not move a resident that had fallen and it is the responsibility of the charge nurse to determine whether or not it is safe to move the resident. Interview on 1/14/16 at 5:14 p.m. with Staff A, Certified Nurse Aide (CNA) she stated she's been certified as a CNA for two months. Staff A stated she assisted Resident #1 in the bathroom with night time cares. While Resident #1 sat on the toilet, Staff A placed the resident's clothes over the front of his/her walker and placed a gait belt around him/her. Staff assisted the resident to standing position and held the gait belt as Resident #1 ambulated towards the bed with his/her walker. Staff A stated they were 2 to 3 feet from the side of the bed when the resident stopped and asked Staff A to move the clothes from the walker to the wheelchair. Staff A stated she then took her hands off the resident's gait belt and removed the clothes from the walker, then turned to her left and laid the clothes in the resident's wheelchair when the resident fell . Staff A attempted to grab the gait belt, but could not stop the resident from falling. Staff A stated the resident requested assistance (from the floor) to his/her bed and she told the resident she needed to get a nurse first, however, Resident #1 insisted Staff A to move him/her to his/her bed. Staff A assisted him/her to a standing (position) then transferred the resident to the bed. Staff A stated she should not have taken her hand off the resident's gait belt or moved the resident after the fall, and will not do that again. Staff A stated after incident he/she was educated on safely transferring a resident and not moving the resident after a fall. Interview conducted on 1/15/16 at 8:09 a.m. with Staff B, Registered Nurse (RN). Staff B, stated Staff A informed her the evening on 1121/15 of Resident #1's fall. Staff B stated Staff A said she had been assisting the resident with ambulation from the bathroom to the bed when Staff A turned from the resident to put clothes in the wheelchair, and the resident fell . Staff B stated the resident complained of a lot of pain of the left hip when Staff B assessed the resident. Staff B stated she called the resident's family who wanted the resident sent to the emergency room . Staff B stated the resident had been transported via ambulance to the local hospital and they reported the resident had a fracture of the left hip and would be transferred to another hospital for treatment. Staff B stated she always keeps a hand on a resident during transfers or when ambulating (with residents) and expected staff to follow the facility's practice. Staff B stated no staff should ever move a resident after a fall until assessed by a nurse. An interview conducted on 1/15/16 at 12: 55 p.m. with the Administrator, she stated the facility practice and her expectation is for staff to keep their hands on the gait belt when transferring or ambulating a resident. The Administrator stated if a resident falls, staff are not to move the resident until assessed by a nurse.

This deficiency relates to Complaint -M Based on record review, staff interviews and observations, the facility failed to provide the necessary provisions to ensure residents received adequate supervision with application of hot packs. A staff member placed a hot pack on Resident #2's abdomen. The charge nurse (Staff B) failed to monitor the hot pack treatment and no facility staff checked the dependent resident who sustained a second degree burn from the hot pack. The facility had no hot pack policy/protocol in place until after Resident#2 sustained a burn. The findings constitute an Immediate Jeopardy situation. The facility reported a census of thirty one residents (31), with three residents that utilize hot packs reviewed in the sample. Findings included: According to Resident #2 Minimum Data Set (MDS) assessment with assessment reference date of 8/15/10, Resident #2 had short and long term memory deficits with impaired cognitive skills for daily decision making skills. The MDS identified Resident #2 sometimes made his/her needs known and sometimes had the ability to understand others. The assessment identified Resident #2 required one to two staff physical assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. The MDS identified Resident #2 had full loss of his/her hands including wrist and fingers. Resident #2's [DIAGNOSES REDACTED]. Resident #2 had been receiving hospice care. Resident #2's care plan did not address the problem of abdominal distention or the use of hot pack for therapy to relieve discomfort. A written statement by the DON/(Staff A) dated 8/23/10 documented the following: Staff B/RN (registered nurse) reported on the evening of 8/20/10, she assessed Resident #2 ' s abdomen and determined s(he) would benefit from a warm pack placed on his/her distended abdomen. Staff B instructed Staff C, CMA (certified medication aide) to place the pack on the resident. Staff C had warmed the pack for 2 minutes. Staff D and Staff E reported that when they assisted Resident #2 to bed they noticed his/her abdomen red in color under the (hot) pack. The later assessment revealed a 2.0 by 2.0 cm blister that then ruptured and was treated with Proshield Ointment. Resident did not require further treatment. The interdisciplinary progress notes dated 8/20/10 lacked any documentation of skin issues that developed after staff placed the hot pack on the resident. The progress note identified on 8/26/10 the facility notified the resident's family of the skin issue. A non-pressure skin assessment completed on 8/23/10 identified Resident #2 had a burn that measured 2.0 centimeter (cm) by 2.0 cm. Observation of Resident #2 on 8/26/10, showed the resident sitting in his/her recliner in their bedroom. The surveyor attempted to question the resident about the incident and the resident remained nonverbal and unresponsive to questions. Clinical record review identified that Resident #2's condition declined due to a [DIAGNOSES REDACTED] and passed away on 8/29/10. Staff Interviews: In an interview on 8/26/10 at 1:48 p.m. Staff B (RN), indicated that on August 20th, 2010 at around 5:30 p.m. Resident #2 refused to eat and his/her abdomen had been distended. Staff B indicated she gave Resident #2 Simethicone (gas relief medication) earlier that day but Resident #2 remained bloated. Staff B believed a warm pack placed on Resident #2's abdomen might offer some relief to the abdominal distention and discomfort. Staff B instructed Staff C to warm up the bean bags (hot pack) and place these on Resident #2's upper and lower left abdomen. Staff B admitted she did not obtain a physician's orders [REDACTED].#2's abdomen. Staff B examined Resident #2 and noted reddened areas along Resident #2's abdomen without blistering. Staff B applied Proshield (zinc barrier cream) to the reddened area. Staff B stated she thought the reddened areas would eventually fade. Staff B indicated she did not notify a physician, family member, or supervisor regarding the reddened areas (burn) and the treatment she completed. Staff B also indicated she did not inform the oncoming nurse (Staff F) of the burn. Record review showed no documentation of Staff B's observations or treatment. In an interview on 8/26/10 at 12:45 p.m. Staff C (certified medication aide) indicated on August 20th, 2010 at around 5:00-5:15 p.m. she was instructed by Staff B to heat a couple of bean bags (hot packs) and to place these on Resident #2's abdomen. Staff C heated up two bags in the Hall 2 microwave for two minutes and carried these in the palm of her hand to the dining room. Staff C then places two bags (hot packs) along Resident #2's right and left lower abdomen, over Resident #2's clothing and a sheet. Staff C indicated one bag rolled off and she placed that bag on the table next to the resident. Staff C then returned to her medication passing duties. Staff C stated Staff D remained near the resident. Staff C indicated she had no further involvement with Resident #2 that evening. Staff C stated the bags were not hot enough to cause a burn and she thinks that Staff D may have reheated the bags. Staff C had not observed Staff D reheating the bags and just thought that's what happened but had no evidence of this occurring. In an interview on 8/31/10 at 2:54 p.m. Staff G indicated on August 20th, 2010 she had been in the dining room when Staff C brought in the heated bags and placed them on Resident #2's upper left and right abdomen. One bag immediately rolled off and Staff G caught the bag and positioned it back on Resident #2. Staff G indicated the bag was warm, but not hot enough to cause a burn. Staff G indicated that about 15 minutes later, Resident #2 had been taken to his/her room so staff could assist him/her with cares before bedtime. Staff G indicated that she believed the bags were reheated and then reapplied later to cause the burn. Staff G did not observed any staff reheating the bags or any evidence to support her belief. In an interview on 8/26/10 at 1:23 p.m. Staff D indicated on August 20th, 2010 at around 5:20 p.m. she was bringing residents to the dining room and noticed rice bags on Resident #2's abdomen. Staff D asked why and was told by Staff B and Staff C that they were there to relieve gas. Staff D proceed with getting residents to the dining room for supper. After supper, Staff D and Staff E took Resident #2 back to his/her room to prepare him/her for bed. Staff D indicated she removed the rice bags and took off Resident #2's clothing and noticed his/her upper abdomen was red. After getting Resident #2 to bed, Staff D and Staff E reported their observation to Staff C at around 6:30 p.m. and then resumed with their duties. Staff D indicated that she would refuse, if ever asked to heat up and put a heat bag on a resident. Staff D denied ever reheating the rice bags (hot pack) and placing these back on Resident #2. In an interview on 8/26/10 at 12:15 p.m. Staff E indicated on August 20th, 2010 she was getting Resident #2 ready for bed and noticed a big, bright red area on his/her abdomen. After getting Resident #2 to bed, Staff E reported her observation to Staff C at around 6:15 p.m. Staff E indicated that she had been asked to heat up heat bags and place them on residents in the past. Staff E stated she would heat the bags for 1 minute and 20 seconds and then place the bags on her own skin. Staff E stated then she would wrap the bags in a towel before placing it on a resident. In an interview on 8/26/10 at 3:41 p.m. Staff F indicated he worked the overnight shift on August 20th, 2010. Staff F indicated that in report he was told that Resident #2 had a distended abdomen, but was not informed of the use of a hot pad or redness on Resident #2's abdomen. At around 1:00 a.m. night aides reported to Staff F that Resident #2's abdomen was red. Staff F examined the resident and noticed a reddened area 3 inches by 4 inches on his/her upper right abdomen. Staff F did not notice any blistering at that time and believed the area may be a rash. At around 6:00 a.m. Staff F rechecked the area. This time the reddened area had shrank to 2.5 inches by 3 inches and a blister 1.5 inches by 1 inch had developed. Staff F reports his observations to the oncoming nurse, Staff A (Director of Nursing). Staff F indicated that he use to be a CNA and would sometimes be asked by nursing staff or resident to heat up a bag (hot pack). Staff F noted he would place the bag in the microwave for 1.5 to 2 minutes and place a towel around the bag before applying it onto a resident. In an interview on 8/26/10 at 3:00 p.m. Staff A/DON indicated on August 21st, 2010 at around 6:30 a.m. she had been informed by Staff F that Resident #2 had a rash and he wanted her to look at it. Staff A did not look at the area until 10:30 a.m. at which time Staff B was also present. Staff A immediately assessed the area as a burn and questioned Staff B as to how that could be. Staff B indicated that she instructed Staff C to put a heat pack on Resident #2 the evening before. Staff A/Director of Nursing, stated the grain bags have been available in the facility and periodically used for a long period of time. Staff A was unaware of any other instances in which a resident has been burned when using a grain bag. Two residents use their personal heat bags frequently at night. The facility grain bags (hot packs) appear homemade and are without any manufacturer's instructions. Staff A indicated that at the time of the incident, there was no facility policy/protocol related to cold/hot therapies. Staff A indicated a physician's orders [REDACTED]. In an interview on 9/1/10 at 3:09 p.m. Resident #2's primary physician indicated that Resident #2 had limited functioning and would have been incapable of removing a hot pack. The physician stated the resident was unlikely able to communicate the need to remove a heat pack if it were too hot. The physician stated Resident #2 had been on pain medication. The physician stated he was unaware of the incident in which Resident #2 sustained a burn related to the use of a heat/hot pack. The bean bags (hot packs) consisted of a rice, bean, and or corn mixture and the bags had variations in grain bag sizes. Observation of the hot packs identified the following temperature test: On 8/26/10 at 12:00 p.m. (Trial 1) two grain bags (hot pack) (made of rice and beans) were provided to this surveyor as the ones possibly used on Resident #2 on 8/20/10. Both grain bags were heated in the Hall 2 microwave for two minutes as described by Staff C. Both bags were held in the palm of surveyor's hand and within 10 seconds both bags became too hot and painful for surveyor to continue to hold on too. On 8/26/10 at 12:50 p.m. (Trial 2) two grain bags identified by Staff C as the ones used on Resident #2 on 8/20/10 were heated in the Hall 2 microwave for 2 minutes. The rice bag temperature measured with a kitchen thermometer and indicted at temperature of 140 degree F; and the corn bag hot pack temperature at 130 F. Both bags felt much cooler than the bags in Trial 1. The corn bag is twice as large as the bean bag earlier heated. Surveyor then placed the corn bag and the bean bag in the Hall 2 microwave for 2 additional minutes. This time both bags were too hot to hold. The bean bag temperature was 160 F and the corn bag heated up to 185 F. The temperatures identified in Trial 2 validate the grain bags heated in a microwave for two minutes exceeded a temperature of 120 degrees Fahrenheit (F) a safe standard. The resident's impaired cognition and limited physical mobility limited his/her ability to call for assistance. A staff member placed the hot packs on the resident on 8/20/10 and no facility staff provided any supervision during the treatment. The clinical record lacked any documentation until 8/23/10 of Resident ' s #2 ' s skin assessment. Staff interviews identified no consistency between the staff for how long to warm the hot packs in the microwave or any monitoring after use. The facility failed to provide discretion to staff of when to use a hot pack or any guidelines for the length of time hot pack(s) would remain in place on a resident. The facility failed to set a standard of a safe temperature for hot packs. The facility failed to assess any changes in condition including skin integrity and pain, both during the application of hot packs and after the use. The facility failed to establish a system for how staff would test the temperature of the hot pack and ongoing monitoring of hot packs. The facility abated the immediate jeopardy on 8/26/10 by removing the hot packs. The facility created a policy/protocol for safely administering hot packs therapy and on 8/26/10 to 8/31/10 the facility in-serviced all nursing staff and CNAs of their hot pack therapy policy/protocol. The policy/protocol identified that all hot therapy would be administered under the direction of a physician and with a physician's orders [REDACTED]. The physician's orders [REDACTED]. The policy/protocol identified that licensed nurse would be responsible for applying and removing the hot packs. The policy/protocol identified hot packs will not be placed directly on the resident's skin unless directed by the physician and instead a towel or blanket will be utilized to protect the resident's skin. The facility identified the hot packs temperatures would be no warmer than 115 degrees F. The protocol identified the license nurse will visually assess the resident's skin directly under the pack after 60 seconds, periodically throughout and post treatment. The policy/protocol determined the physician would be notified of any change in skin integrity and monitored on a flow sheet for any compromised areas. The policy/protocol also specified that packs would be personalized for each resident to promote proper infection control. The facility obtained physician's orders [REDACTED]. These actions lowered the deficiency from a scope and severity level J to a G level. At the time of the investigation exit conference, the facility had not educated staff of how to test the temperature of the hot pack. This approach had not been added to the protocol. In addition, the facility had no written directive for routine monitoring of hot packs policy/protocol.