Every finding on record at Pine Acres Rehabilitation and Care Center

Based on observations, clinical record review, facility record review, staff interviews, the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI manual, and facility policy review, the facility failed to develop a personalized, comprehensive care plan for one of the three residents sampled (Resident #3) for care planning. The facility additionally failed to implement multiple fall interventions for one of the three residents reviewed for fall risks (Resident #69). The facility reported a census of 74 residents.Findings include:1. The Minimum Data Set (MDS) of Resident #3 dated 6/29/26 recorded an admission date to the facility of 6/27/26. The MDS documented the resident had a serious mental illness, as determined by the state's Level II Preadmission Screening & Resident Review (PASRR). Diagnoses noted in the MDS included diabetes, non-Alzheimer's dementia, seizure disorder, anxiety disorder, and schizophrenia.The MDS documented the resident received antipsychotic and antidepressant medications during the 7-day lookback period. The Care Area Assessment (CAA) Summary in Section V of the MDS identified the following areas for care planning:-Activities of Daily Living (ADL) Functional/Rehabilitation Potential-Urinary Incontinence and Indwelling Catheter-Falls-Nutritional Status-Dehydration/Fluid Maintenance-Pressure Ulcer-Psychotropic Drug UseThe MDS indicated that all of these categories would be integrated into the resident's comprehensive care plan, dated 7/6/26. The MDS recorded a completion date of 7/7/26. The 2025 RAI manual directs: The RN (Registered Nurse) Coordinator is required to sign and date the Care Area Assessment (CAA) Summary after all triggered CAAs have been reviewed to certify completion of the comprehensive assessment. Facilities have seven days after completing the RAI assessment to develop or revise the resident's care plan. (Due date for Res #3 was 7/14/26). The PASRR Outcome Explanation, dated 7/4/26, mandated that the facility provide ongoing psychiatric medication management overseen by a psychiatrist or a psychiatric Advanced Registered Nurse Practitioner (ARNP). Additionally, it required the facility to develop a PASRR-compliant care plan for all identified services.Facility records indicated that four resident care plans were being audited weekly for Accuracy of Care Plans. Resident #3's care plan was recorded as having been audited on 7/28/29 by Staff K, Registered Nurse. A review of Res #3's care plan, conducted on 8/5/26 revealed the facility failed to incorporate incontinence, nutritional status, dehydration, and psychotropic drug use into the comprehensive care plan. The care plan failed to document the resident's schizophrenia diagnosis, identify the target behaviors justifying psychotropic medication, or specify requirements for monitoring potential side effects. The care plan additionally omitted the resident's PASRR Level II status and his need of required services.On 8/6/26 at 12:00 pm, the Regional Director of Clinical Quality and Compliance stated an outside service company is contracted to complete the MDS Assessments and facility staff complete the care plans. She stated as residents receive new orders or have other changes, the care plans are then updated. She acknowledged the resident's psychotropic medications and other concerns noted on the CAA should have been included in the Care Plan. On 8/12/26 at 3:35 pm, Staff K, RN stated when she completed the care plan audit of Resident #3, she only audited for skin/wound issues and updated his care plan to include current wounds. 2. The MDS of Resident #69 dated 4/9/26 identified a Brief Interview of Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. The MDS documented the resident had experienced two or more falls with no injury and two or more falls with injury (except major) since the prior MDS Assessment period. The MDS dated [DATE] documented an additional fall experienced since the prior MDS Assessment period. The Care Plan of Resident #69 identified a Focus Area of High Risk for Falls, initiated 1/16/25. It directed staff to:-Be sure the resident's call light is within reach, resident needs prompt response - dated 1/16/25-Dycem(a specialized material on the seat of the chair to stop a resident from slipping downward) to wheelchair, dated 1/21/25-Fall mat beside bed while in bed, dated 4/9/25. -Supervision while in wheelchair, please do not leave me unattended in my wheelchair, dated 4/3/26.-Non skid strips placed in front of bed and recliner for safety with transfers, dated 7/15/26. On 8/1/26 at 10:39 am, Resident #69 was observed in his room with no staff present, sleeping in his Broda chair (a specialized medical positioning wheelchair used for individuals with mobility limits). A sign hung on the wall next to his bed directing staff to not leave the resident unattended in his room in a wheelchair. His call light was observed clipped to the curtain separating his side of the room from his roomates side of the room, approximately 3-4 feet out of reach. No recliner was observed in the room. Resident #69 was slouched down in the Broda chair, with the footboard of the Broda chair stopping him from slipping further down. A home health aide (HHA) with a contracted hospice facility entered the room at 10:40 am and looked at the resident and stated he looked very uncomfortable and went to go find assistance from a facility employee. They returned to the room and repositioned Resident #69, pulling him up in the Broda chair to the appropriate position using the sling of the full body mechanical lift underneath him. The HHA stated she had been assigned to Resident #69 since April of 2026 and stated he had always used the Broda chair rather than a standard wheelchair. She stated she had not ever seen dycem in the Broda chair but felt it would be helpful for the resident. Upon the State Surveyor leaving the room on 8/10/26 at 10:45 am, Staff I, Registered Nurse (RN) was standing outside the room and asked if there were questions regarding Resident #69, and the State Surveyor had no questions.On 8/10/26 at 10:50 am, the Director of Nursing and Staff I were walking down the hall and stated they were replacing the Dycem for Resident #69. They stated the Dycem had previously been in place. On 8/10/26 at 2:32 pm, Staff J, Certified Nurse Aide (CNA) stated the normal routine for Resident #69 for the evening shift is to get the resident up for dinner using the full body mechanical lift, and assist him to the dining room for the evening meal. She stated the fall interventions in place for the resident were a blue cushion underneath his mattress for boundary identification and to have his call light in reach. When asked if there were any other fall interventions for the resident, she stated she thought he also had a fall mat. On a second observation of Resident #69 on 8/10/26 at 2:38 pm, Resident #69 was in bed asleep. His call light remained out of reach, still clipped to the curtain, and no fall mat was seen on the floor. On 8/12/26 at 12:55 pm, the Assistant Director of Nursing stated fall interventions for the residents are listed on the Kardex (a less detailed care plan the CNA staff reference for resident care guidelines). She stated as new interventions are placed, the charge nurse is notified who then tells the CNAs. She stated the CNAs are expected to be referencing the Kardex as well. The facility policy titled Comprehensive Care Plans, revision date 5/2026 documented the following:Point 2: The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.Point 3: The comprehensive care plan will describe, at a minimum:Point 3c: Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.

Based on clinical record review, staff interview, observation, and facility policy review, the facility failed to conduct comprehensive, ongoing nursing assessment and interventions for 7 of 7 residents reviewed for significant changes of condition (Resident #2, #7, #93, #71, #41, #83, #94). Resident #2 fell out of bed on [DATE] striking his face on the floor sustaining injury. The resident was sent to the emergency room (ER) where a nose fracture was ruled out and he returned to the facility. The morning of [DATE] the resident complained of pain and transferred back to the ER returning with orders for 5 days of antibiotic medication to treat a diagnosed UTI (Urinary Tract Infection) with hematuria (blood in urine). The facility failed to conduct ongoing neurological nursing assessments following Resident #2's fall with only 1 full set of neurological checks done [DATE] and the last set of full vital sign measurements recorded by nurses ending on [DATE]. Despite staff interviews indicating the resident experienced a significant change in mental condition [DATE] through [DATE], the clinical record lacked any nursing progress note entries from [DATE] at 6:20 AM to [DATE] at 5:54 PM. The resident transferred back to the hospital on [DATE] where he was admitted to the Intensive Care Unit (ICU) due to diagnoses of hyperthermia (low body temperature) and altered mental status, unspecified type. The resident subsequently passed away at the hospital on [DATE] with the cause of death identified as sepsis (life-threatening body reaction to infection) due to possible meningitis infection/swelling of the brain/spinal cord) with other significant conditions of chronic osteomyelitis (bone infection), diabetes, chronic subdural hematoma (swelling in the brain), atrial fibrillation (irregular heart rate), acute kidney injury, and hypertension (high blood pressure). The facility failed to conduct comprehensive nursing assessment and intervention for Resident #7 over a 6 day period from [DATE] through [DATE] while the resident was being treated with an antibiotic for pneumonia.The facility failed to conduct comprehensive nursing assessment and intervention for Resident #93 who experienced nausea and vomiting on [DATE], treated two different times with antinausea medication over a 6 hour period that day, with no documented assessments prior to the resident subsequently experiencing cardiac arrest and initiation of CPR (cardiopulmonary resuscitation). The resident passed away. The facility failed to conduct comprehensive nursing assessment and intervention for Resident #71 prior to and after identification on [DATE] of rib fractures of unknown origin.The facility failed to conduct comprehensive nursing assessment and intervention for Resident #41 on [DATE] after the resident experienced a fall. The facility failed to conduct comprehensive nursing assessment and intervention for Resident #83 on [DATE] through [DATE] while the resident received antibiotic medication to treat pneumonia. The facility failed to conduct comprehensive nursing assessment and intervention for Resident #94 on [DATE] after the resident found falling from a chair and had the presence of a skin injury of unknown origin.The above failures rose to a level of immediate jeopardy and the facility was notified of IJ on [DATE] at 4:52 PM. The failure to conduct nursing assessments began with the first example of failure to assess residents [DATE] for Resident #7, but for Resident #2, the failure began on [DATE]. The facility removed the immediacy on [DATE] after the State Survey Agency (SSA) verified removal actions taken by the facility that included:Immediate Corrective Action for Affected ResidentBecause Resident #2 was no longer in the facility, no further direct corrective action could be completed for that resident. Identification of Other Residents at RiskAll residents were considered at risk for lack of timely assessment and follow-up when there is a fall, hospital return, acute change in condition, mental status change, infection, pain, abnormal vital signs, or staff report of decline. On [DATE], the DON/designee initiated a 100% review of current residents to identify any resident with a fall in the last 7 days, return from hospital or ER in the last 7 days, change in mental status or increased confusion, new infection or antibiotic order, abnormal vital signs, or staff concern of decline/change from baseline. Any resident identified with a change in condition will receive immediate licensed nurse assessment, vital signs, neuro checks if indicated, provider notification as needed, family/responsible party notification as needed, care plan update as needed, and a progress note before the end of the nurse's shift. Systemic Changes to Prevent Recurrence Effective immediately, the facility would use a Change in Condition / Fall Monitoring Checklist for any resident with a fall, ER/hospital return, new or worsening confusion, change from baseline, new infection or antibiotic order, abnormal vital signs, or staff report that something is not right. The licensed nurse would complete and document a full nursing assessment, vital signs, neuro checks when indicated, provider notification for change in condition/abnormal findings/continued decline, family notification, progress note each shift until stable or transferred, and care plan update within 24 hours. For any resident returning from ER/hospital, the licensed nurse would review discharge instructions and new orders before the end of shift and notify the provider of any concern or change. If the resident had a fall with head injury, unwitnessed fall, anticoagulant use, mental status change, or continued confusion, neuro checks would be completed per facility policy and provider direction. CNAs would immediately report any change in condition to the charge nurse, including confusion, lethargy, weakness, pain, abnormal behavior, refusal of meals/fluids, or residents not acting like usual. Staff Education On [DATE], the DON/designee began immediate education with all licensed nurses and CNAs working in the facility. Education included F684 Quality of Care expectations, change in condition reporting, fall follow-up requirements, neuro checks when indicated, vital sign monitoring, provider notification, family notification, required progress note documentation, CNA responsibility to report decline immediately, and nurse responsibility to assess, document, and follow up before end of shift. Any nurse or CNA who had not received education would be educated before working the next scheduled shift. Agency staff, if used, would receive the same education before working the floor. Monitoring / Auditing The DON/designee will audit all falls, ER returns, hospital returns, and change of condition events daily for 5 days per week for 4 weeks, then weekly for 8 weeks. The audit will review for nursing assessment, vital signs, neuro checks when indicated, provider notification when indicated, family/responsible party notification when indicated, progress notes each shift until stable, care plan update, and follow-up for abnormal findings. Any missing item will be corrected immediately when possible and the nurse will be re-educated. QAPI / Ongoing ComplianceAudit results will be reviewed by the Administrator and DON weekly for 4 weeks, then monthly through QAPI for 3 months. The QAPI committee will review trends and determine if additional action is needed. The facility's goal is 100% compliance with change of condition assessment, monitoring, notification, documentation, and follow-up. Responsible Parties The DON is responsible for clinical implementation, staff education, resident review, and audits. The Administrator is responsible for oversight, ensuring completion of the IJ removal plan, and ensuring audit results are reviewed through QAPI. Date of Compliance The facility alleges immediate compliance as of [DATE] after initiation of resident review, staff education, and implementation of the Change in Condition / Fall Monitoring Checklist.The scope and severity of the failure lowered from a K level to an E level on [DATE] after the facility removed the immediacy of the health threat. The facility reported a census of 81 residents. Findings include: 1. Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a readmission date of [DATE]. The MDS identified the resident had clear speech, usually made himself understood, and usually understood others. The MDS recorded a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment without signs or symptoms of delirium or acute change in mental status. The MDS documented the resident exhibited no physical, verbal, or other behavioral symptoms during the 7-day look-back assessment period. The MDS coded the resident's functional abilities with rolling left and right, sit to lying, and lying to sitting on the side of the bed as 01 Dependent, indicating a helper does all of the effort and the resident does none of the effort to complete the activity. The MDS listed diagnoses that included stroke, cancer, hypertension (high blood pressure), neurogenic bladder (loss of bladder control), obstructive uropathy (blockage in the urinary tract), diabetes, aphasia (difficulty speaking), hemiplegia or hemiparesis (paralysis of one side), traumatic brain injury (TBI), cerebral edema (brain swelling), chronic atrial fibrillation (irregular heartbeat), generalized muscle weakness, difficulty in walking, cognitive communication deficit, and need for assistance with personal care. The MDS documented the resident had no falls since the prior MDS assessment. The Discharge Return Anticipated (DRA) MDS assessment dated [DATE] for Resident #2 identified the resident discharged on [DATE] to a short-term general hospital. The MDS documented the resident exhibited no physical, verbal, or other behavioral symptoms during the 7-day look-back assessment period. The MDS coded the resident's functional abilities with rolling left and right, sit to lying, and lying to sitting on the side of the bed as 02 Substantial/maximal assistance, indicating a helper does more than half the effort and lifts or holds the trunk or limbs. The MDS documented the resident had 2 falls with no injury and 1 fall with injury since the prior MDS assessment on [DATE]. The Care Plan focus area initiated [DATE] and revised [DATE] identified the resident at risk for decreased ability to perform ADLs (Activities of Daily Living) in bathing, grooming, dressing and mobility, bathing, transfer, locomotion, toileting related to impaired balance/dizziness. The care plan intervention initiated [DATE] directed staff to provide the resident assistance of 1 for transfers using a FWW (Front Wheeled Walker) and gait belt. The Care Plan focus area initiated [DATE] and revised [DATE] (after the resident discharged and passed away) identified the resident had an ADL self-care performance deficit related to fatigue, impaired balance, difficulty walking, unsteadiness on feet, need for assistance with personal care, muscle wasting, and atrophy. The care plan intervention created [DATE] gave conflicting direction on transfer assistance, instructing staff that the resident required the assistance of 2 persons for toileting and the assistance of 2 persons and the Hoyer (full-body mechanical lift) for transfers. The care plan did not address the resident's bed mobility status. The Care Plan focus area revised [DATE] identified the resident had an actual fall with poor communication, comprehension, and unsteady gait. The care plan recorded the resident had an unwitnessed fall with injury to the nose (nosebleed), and the intervention created [DATE] documented a work order placed to have maintenance assess the brakes on the bed. The care plan intervention created [DATE] identified the resident as a fall risk and directed staff to check toileting, position, pain, personal items in reach, call bell within reach, and proper footwear on. The care plan interventions included another conflicting entry about transfers, instructing on [DATE] to provide assistance of 2 persons for transfers until upgraded by therapy. The care plan intervention revised [DATE] instructed a fall mat added to the floor on the right side of the bed. The Monthly Nursing Summary dated [DATE] at 8:49 PM documented the resident as cognitive and required extensive assistance with 1 person for personal hygiene, total dependence with 1 person for toilet use, and total dependence with a 2-person physical assist for bed mobility and transfers. The summary recorded the resident had no behavior symptoms. The fall incident report on [DATE] at 4:30 PM, recorded by Staff L, Licensed Practical Nurse (LPN), documented she was called to Resident #2's room by a CNA (Certified Nurse Aide) who found the resident on the floor between the bed and the wall. Staff L documented the incident was not witnessed and the resident was unable to communicate what happened. Staff L wrote the resident was on his left side with blood under his head coming from his nose. The resident reported an 8 out of 10 pain to his nose and forehead. The resident was able to follow Staff L's range of motion commands, independently moving his neck, arms, and legs without acute pain in the extremities. Staff L assessed an injury to the bridge of the nose measuring 1.5 centimeters (cm) by 1.0 cm with evident swelling, and the back of the left hand was swollen and discolored, measuring 5 cm by 4 cm. Staff L called the on-call provider, who ordered neurological checks be continued per protocol and a facial bone x-ray. Staff L assessed the resident's mental status as alert and oriented to person and situation, but not place or time. Staff L checked the predisposing environmental factors box for Other (Describe), however she failed to describe what the other factor was. The Neurological Check List with an effective date of [DATE] at 6:05 PM, signed by Staff L, LPN, documented vital sign measurements for Resident #2 of 96.2 Temperature (T), 61 Pulse (P), 18 Respirations (R), 158/90 Blood Pressure (BP), pain an 8 on a 10 pain scale on the bridge of the resident's nose, and no Pulse Ox (Pox) reading (blood oxygen level) taken. Staff L documented the resident was oriented to person and situation, but not oriented to place or time. Staff L assessed the resident's level of consciousness (LOC) as alert, lethargic, and he responded to simple commands appropriately. The Post Fall Skin assessment dated effective [DATE] at 5:52 PM recorded the resident had a swollen open area to the back of his left hand measuring 5 cm by 4 cm and a 1.5 cm by 1.0 cm abrasion to his face. The hospital Emergency Department (ED) note with a Date of Service of [DATE] at 6:18 PM documented the chief complaint of the resident as an unwitnessed fall between the bed and dresser, appeared to have hit his face, took a blood thinner, and had chronic neck and back pain at baseline. At 8:40 PM, the note recorded the resident remained stable through the course of the ED evaluation, the family expressed some concerns about the care that the resident received at the nursing facility that they would address with the facility, and recommended close outpatient follow-up for further evaluation and treatment; the resident was discharged back to the facility. The clinical impression was documented as: ground-level fall; closed head injury, initial encounter; abrasion of nose, initial encounter; and right arm pain. The Change in Condition Evaluation dated [DATE] at 11:46 AM documented the resident had experienced an altered mental status with behavioral symptoms (e.g., agitation, psychosis), a fall, and the change started in the morning. The vital sign section of the assessment was left blank. The nurse documented the resident with increased confusion, acute pain in the neck, and the nurse questioned if there was a possible concussion. The hospital ED note dated [DATE] documented the resident was admitted to the ED at 11:56 AM and discharged at 9:12 PM. The ED note documented the reason for the visit as an unwitnessed fall at the nursing home on [DATE], the resident was alert and oriented times 4 (to person, place, time, situation) but confusion began on [DATE], and the resident complained of right shoulder and neck pain. The ED note recorded diagnosis codes that included primary generalized weakness, anticoagulated, hematuria unspecified type, abrasion of nose without infection, initial encounter injury of head, neck pain, and initial encounter fall. The ED note recorded under the Subjective section that the resident presented after a fall on [DATE] and a chart review showed the resident fell, unwitnessed, between his bed and dresser and had abrasions to the bridge of his nose and his head. The resident reported neck and back pain; radiographs did not show any emergent bony pathology (bone injury). The note recorded the resident had a possible small chronic left subdural (old, type of bleeding inside the head) versus nonspecific dural thickening (swollen or inflamed outer lining) on a computed tomography (CT) of the head, and he was discharged then sent back to the ED on [DATE] after he seemed more confused. The ED note documented under Medical Decision-Making final diagnoses of generalized weakness, anticoagulated, and hematuria (bloody urine) unspecified type. The section documented admission was considered but not pursued based on the ED evaluation. The evaluation did note the resident was given IV (intravenous) fluids, symptoms seemed to improve, and although the resident felt generally somewhat weak, no focal numbness or weakness was noted and symptoms overall were improving. The resident was given cephalexin (antibiotic medication) due to the presence of hematuria noted on the urinalysis for the possibility of a UTI contributing to his symptoms, and a urine culture was sent. The [DATE] Medication Administration Record (MAR) documented the resident received cephalexin 500 milligrams four times a day from [DATE] through [DATE]. The facility EHR for Resident #2 lacked any documentation prior to related to follow-up on the urine culture performed at the hospital on [DATE]. The clinical record reflected only one set of neurological checks was performed at the time of the original fall incident on [DATE] and nothing further, despite the evidence that the resident hit his head during the fall and had obvious injuries to his face. The record lacked comprehensive assessments of the resident post-fall and post-return from the ER on [DATE]. The record lacked assessments of urinary status or characteristics as the resident received the antibiotic treatment. The Vitals tab of the EHR recorded only the following vital sign measurements from [DATE] through [DATE]. No vital signs were recorded on [DATE], [DATE], [DATE], [DATE], or [DATE] except for pain ratings, two of which were assessed when the resident was already discharged . The pain ratings correlate to the same date and times of the April MAR, which asks for ratings per shift: Temperature [DATE] at 6:05 PM - 96.2 degrees F [DATE] at 12:07 PM - 97.3 degrees F [DATE] at 8:58 PM - 97.0 degrees F [DATE] at 5:20 PM - 96.6 degrees F Pulse [DATE] at 6:05 PM - 61 bpm (beats per minute) [DATE] at 12:06 PM - 76 bpm [DATE] at 8:53 PM - 64 bpm [DATE] at 5:20 PM - 51 bpm Respirations [DATE] at 6:06 PM - 18 breaths per minute [DATE] at 12:07 PM - 18 breaths per minute [DATE] at 8:57 PM - 18 breaths per minute [DATE] at 5:20 PM - 18 breaths per minute Blood Pressure [DATE] at 6:24 PM - 127/83 [DATE] at 12:06 PM - 116/63 [DATE] at 8:53 PM - 89/57 (low reading) [DATE] at 7:19 PM - 158/90 (high reading) Pulse Ox [DATE] at 12:07 PM - 95% oxygen level on room air (RA) [DATE] at 8:53 PM - 97% on RA [DATE] at 5:21 PM - 93% on RA Pain Assessment [DATE] at 5:51 PM - 8 [DATE] at 8:04 AM - 10 [DATE] at 8:01 AM - 0 [DATE] at 4:27 PM - 0 [DATE] at 7:35 AM - 0 [DATE] at 8:27 PM - 0 [DATE] at 1:37 AM - 0 [DATE] at 7:50 AM - 0 [DATE] at 6:21 PM - 0 [DATE] at 12:07 AM - 0 [DATE] at 8:11 AM - 0 [DATE] at 5:03 PM - 0 [DATE] at 12:11 AM - 0 [DATE] at 1:06 PM - 0 [DATE] at 6:06 PM - 0 [DATE] at 11:15 PM - 0 [DATE] at 12:39 PM - 0 [DATE] at 9:38 PM - 0 [DATE] at 2:02 AM - 0 [DATE] at 8:02 AM - 0 [DATE] at 11:52 PM - 0 (Resident could not have been assessed due to being hospitalized ) [DATE] at 10:50 PM - 0 (Resident could not have been assessed due to being hospitalized ) Review of the clinical record on [DATE] at 7:38 AM revealed that only the following Progress Notes were recorded in the EHR between [DATE] and [DATE]: [DATE] 9:10 AM - A Medication Administration note recorded the resident was given acetaminophen (Tylenol) for neck pain. 2:23 PM - A note indicated the Tylenol was effective and the resident rated his pain as 0. 4:30 PM - An Incident Note documented the nurse was called to the resident's room by a CNA who found the resident on the floor between the bed and the wall. The progress note contained the same assessment information as noted on the fall incident report. The entry recorded the family was notified and a portable x-ray was set up for the morning. 5:16 PM - A Medication Administration note recorded the resident was given Tylenol. 5:51 PM - An Assessment note recorded a pain level of 8 for severe nose pain. The acute pain was described as pressure, with the resident unable to determine what makes it better or worse. The note documented the resident was not satisfied with the current pain level, with a goal of 2 (mild pain). 5:57 PM - An Assessment Note recorded the pain level at an 8 for severe nose pain. 6:00 PM - A communication with family note recorded the son was coming to visit and the nurse shared the neurological assessment results and that an x-ray was planned. The son expressed that he wanted the resident seen in the emergency room that night, an order was received to send the resident for evaluation, and the resident was sent at that time. 10:03 PM - A Nursing Note documented the resident returned from the hospital with a report of no fractures. The resident was given his nighttime medications, the bed was put in the low position with the call light in reach, and the son was to visit the next afternoon. [DATE] 8:01 AM - A Medication Administration Note documented that staff needed to ask the resident if he needed toileting before and after meals as the resident allows, as the resident was staying in bed due to the fall. 8:04 AM - A Medication Administration note indicated Tylenol was given. 9:44 AM - An IDT (Interdisciplinary Team) Note recorded the team reviewed the resident's fall status. The entry documented the resident fell with no injury on [DATE], the IDT investigated the fall and an abrasion to the bridge of the nose with swelling, the back of the left hand was swollen and discolored, and the root cause of the fall was determined to be self-transferring. The IDT documented the current interventions prevented major injury and a new intervention was implemented for maintenance to service the brakes on the bed. 11:41 AM - A Health Status Note documented the resident was sent to the emergency room (ER) for a change of mental status and neck pain. 12:02 PM - A Transfer Note recorded the reason for the unplanned transfer as a fall and vital signs as BP 89/57, T 97.3, R 18, and pulse ox 95% on room air. 10:46 PM - A General Note recorded the resident had returned from the ER, an antibiotic was ordered for a possible UTI (Urinary Tract Infection), the resident denied pain or discomfort at that time, and he rested in bed. [DATE] 1:49 PM - A Nursing Note recorded the facility received the hospital ER paperwork. 12:00 AM - An encounter note was entered for the Date of Service of [DATE]. The entry documented it was a copy of a signed encounter note documented in another EHR system. The note covered a review of the resident's medication list and recorded vital signs of P: 64, BP: 116/63, O2 Sat: 97% RA, R: 18, and Pain Level: 0. The encounter documented the resident presented for evaluation after a fall out of bed onto his face resulting in a facial injury on [DATE]. The resident was sent to the ER for imaging and no abnormality was reported, with little information in the discharge summary. The resident was started on an antibiotic for 5 days, with the reason not indicated and no access to the lab result at that time. The resident denied pain, chest pain, shortness of breath, or difficulty breathing, and the resident reported he was doing well with no concerns. An examination was documented noting the resident had generalized weakness, sensation was intact, speech was fluent, and he was alert and oriented times 3. The note documented a Signed Date of [DATE] at 5:03 PM, an additional line noted it was e-signed by the Nurse Practitioner on [DATE] at 6:03 PM, and an addendum listing only diagnosis codes was created on [DATE] at 4:22 AM. [DATE] 1:36 AM - A Health Status Note documented the resident was on fall follow-up with neuro (neurological assessments) and an antibiotic for a UTI with no rash or hives from treatment. The clinical record lacked evidence of the completion of a neurological assessment. 4:19 PM - An Activities Participation Note recorded the resident attended a karaoke activity. 8:26 PM - A Medication Administration note documented a question, Was a behavior observed?, and answered YES. No other description of the behavior was documented. Review of the [DATE] MAR revealed the entry linked to the monitoring of anti-depressant medication on the evening shift. The MAR directed to monitor for: behavior/mood/cognition changes; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; no voiding; constipation, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting/diarrhea, dry mouth, dry eyes. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above was observed, select the chart code 'Side Effects Observed' and document. No other documentation was located for the description of the behavior. [DATE] 6:20 AM - A note documented the resident remained on fall follow-up with VSS (vital signs stable), the resident denied pain or discomfort, and no injury at the time. The entry lacked documentation of the vital sign readings or any assessment information either for the fall, behaviors, urinary assessment, or antibiotic medication monitoring. [DATE] through [DATE] No entries were recorded for 3 full days. [DATE] 5:54 PM - A Nursing Note recorded the resident presented with a change in condition that evening with complaints of shortness of breath, breathing through his mouth, and a observed mental status change. The vital signs were recorded as T 96.6, P 51, R 18, BP 127/83, and Pox 93% on RA. The entry noted the resident was seen by the Nurse Practitioner who was in the building at the time, and a new order was received to send the resident out to the ER for evaluation and treatment related to a change in condition. The resident transferred out of the facility at 6:24 PM. 12:00 AM - An encounter note was entered for the Date of Service of [DATE]. The entry documented it was a copy of a signed encounter note documented in another EHR system. The entry indicated it as an acute/follow-up transition of care note, though no transition occurred. The note documented that staff reported the resident had an altered mental status and chest pain, and upon assessment, the resident complained of shortness of breath. The entry noted vital signs of BP 121/83, P 51, R 18, pulse ox 93% on RA, and advised to send the resident to the ER for further evaluation. The note documented a Signed Date of [DATE] at 6:00 PM and an additional line noted it was e-signed by the Nurse Practitioner on [DATE] at 7:00 PM. [DATE] 8:59 AM - A Social Service note documented the writer followed up with the sending hospital regarding the resident's transfer status, as the resident was transferred to another hospital to the Critical Care Unit. The entry recorded that the ED documentation was obtained and uploaded into the medical record. 10:25 AM - A Medication Administration note coded the resident as hospitalized . [DATE] to [DATE] One Medication Administration entry on [DATE], one on [DATE], and two on [DATE] all recorded the resident was hospitalized . One Medication Administration entry on [DATE] recorded the resident as hospitalized . This entry occurred after the resident's passing. No other entries were entered in the progress notes as of [DATE]. The hospital ED note for the Date of Service of [DATE] at 6:47 PM documented a clinical impression that the resident had an altered mental status, unspecified mental status type, and hypothermia, initial encounter. The ED note documented under the Chief Complaint that the resident presented with an altered mental status with the last known normal on Thursday ([DATE]); staff stated he had been altered, alert to self only, and took Eliquis (anticoagulant medication). The ED note documented a chest x-ray completed with the impression of patchy bilateral middle and lower lung zone opacities concerning for a multifocal infectious process (scattered cloudy areas in both lungs with inflammation in multiple areas). The ED note documented a CT (computed tomography) of the abdomen and pelvis with contrast done due to indications of altered mental status, sepsis (life-threatening body reaction to infection), and suspected abdominal infection. The ED Course and Medical Decision-Making section documented that the resident presented to the ED with an altered mental status and staff were unable to obtain a good history from the resident due to his clinical condition. The section documented the resident arrived hypothermic with a temperature of 91.4 degrees F and hypoxic (low oxygen level) with a pulse ox of 88% on room air. He was placed on oxygen with warm blankets applied, showing an improvement of his temperature to 96.1 degrees F. The resident was bradycardic (low heart rate) but not hypotensive (low blood pressure). The resident was noted to have a history of hypothyroidism concerning for myxedema coma (a condition where a low hormone level causes body regulations to slow down), and the Thyroid Stimulating Hormone (TSH) was noted to be within normal limits. The note assessed the resident's venous blood gas (VBG) level as acidotic, which appeared to be hypercapnic (high carbon dioxide level) suspected as a result of a decreased respiratory drive from the hypothermia. The note documented a concern for sepsis versus environmental hypothermia and the CT of the abdomen and pelvis was concerning for cystitis (bladder infection); an antibiotic was ordered. The ED planned to admit him to the hospital for an altered mental status and presumed infection when a recheck of his temperature resulted in 87 degrees F, and the resident was admitted to the ICU for further management. The hospital Critical Care History and Physical dated [DATE] at 9:15 PM documented the resident was admitted for evaluation and management of acute encephalopathy (malfunctioning of brain function due to chemicals, toxins, or systemic illness elsewhere in the body). The note documented that a nurse at the facility had seen the resident the past Thursday ([DATE]) and again on [DATE] and noted the resident was altered, which prompted the evaluation. The Assessment and Plan section included a problem list that featured sepsis with acute hypoxic respiratory failure, and leukopenia with a suspected source of infection being pneumonia or a urinary

Based on clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to implement preventive measures for a resident at risk of developing pressure sores for 4 of 4 residents reviewed for pressure sore prevention and interventions (Resident #73, #83, #85, #94). The facility failed to utilize a pressure reducing wheelchair cushion until after Resident #73 developed an avoidable facility-acquired Stage 4 (full-thickness skin damage) pressure sore to the lower right posterior thigh (which presented with eschar [dead tissue] and treated with antibiotic), failed to maintain pressure relief to the area once developed, and failed to provide major reposition changes and incontinence care over a 7.5 hour period based on a continuous observation. The facility failed to prevent friction and shear when providing incontinence care for Resident #83 who had a facility-acquired Stage 4 Pressure sore to his left hip. The facility also failed to provide physician ordered interventions to prevent pressure ulcers and skin integrity by not providing protective prevalon boots to Resident #83's left foot as ordered. The facility failed to ensure all skin interventions implemented for Resident #83 and #85 who required protective prevalon boots to be worn to the bilateral lower extremities. The facility failed to provide proper care for Resident #94 who had a pressure sore to his left heel and failed to implement measures to prevent the pressure sore to the right heel. The above failures rose to a level of immediate jeopardy and the facility was notified of the immediacy on 5/19/26 at 2:30 PM. The immediacy began based on the first known identification of pressure sore identification for Resident #73 on 3/10/26. The facility removed the immediacy on 5/20/26 after the State Survey Agency (SSA) verified removal actions taken by the facility that included: 1. Immediately removed Resident #73 from any pressure-producing wheelchair surface. Placed resident on ordered pressure redistribution surface/cushion verified to be inflated, intact, and appropriately positioned. If no appropriate cushion was immediately available, the resident would remain off the wheelchair except for medically necessary transfers until safe equipment is obtained. 2. Complete head-to-toe skin assessment for Resident #73, validate wound stage/measurements, obtain wound provider/physician orders, assess for infection, pain, drainage, odor, undermining/tunneling, and update treatment record. 3. Implement individualized pressure-relief schedule for Resident #73: reposition at least every 2 hours in bed, pressure relief at least hourly while up or per wound provider order, offload affected area, float heels, and document each intervention in real time. 4. Provide incontinence care for Resident #73 on rounds and as needed; document toileting/incontinence checks and skin barrier use. 5. Conduct 100% skin sweep for all current residents to identify existing pressure injuries, device-related areas, moisture-associated skin damage, and residents at risk based on immobility, incontinence, nutrition, wound history, chair/bed positioning, and Braden or facility risk tool. 6. Inspect 100% of wheelchair cushions, seating surfaces, beds, mattresses, heel protectors, and offloading devices for residents at risk. Remove broken, deflated, contaminated, missing, or inappropriate equipment from service and replace/rent same day. 7. Complete and document a daily staffing level and staffing pattern assessment by hall, shift, resident census, resident acuity, and care needs. Assign staff for repositioning, incontinence rounds, pressure relief, transfers, meal assistance, wound/skin checks, and supervision by resident and hall. The assessment must determine whether existing staffing is sufficient for facility needs, not merely whether staff completed assigned tasks. If staffing is insufficient, the charge nurse must immediately escalate to DON/Administrator/designee for added staff, reassignment, management assistance, agency request, or other immediate correction. Staffing shortages or assignment imbalance are not acceptable reasons for missed pressure relief, incontinence care, transfers, or skin/wound monitoring. 8. Educate all licensed nurses, CNAs, therapy, activities, and maintenance on F686 expectations, pressure injury prevention, turning/repositioning, offloading, wheelchair cushion integrity, incontinence care, reporting equipment failures, and immediate escalation. 9. Initiate daily leadership wound-risk huddle reviewing Resident #73 and all high-risk residents: wounds, turning compliance, incontinence care, equipment status, nutritional concerns, staffing barriers, physician/wound provider updates, and new skin concerns. 10. Residents with current pressure ulcers/injuries or wounds; immediate review and required intervention:Wound measurements, staging, treatment orders, infection signs, pain, care plan, treatment documentation Update care plan/orders; wound provider/physician notification; offloading; treatment audit; weekly wound review 11. Residents with limited mobility, bed/chair dependence, contractures, paralysis, or poor repositioning ability; immediate review and required intervention:Turning/repositioning orders and actual documentation; seating/bed surface At least every 2 hours bed repositioning or individualized order; pressure redistribution surface; chair pressure relief; staff assignment 12. Residents with incontinence or moisture risk; immediate review and required intervention:Incontinence care documentation; skin barrier orders; briefing/toileting schedule Scheduled and PRN incontinence care; barrier cream; moisture management; CNA assignment verification 13. Residents using wheelchairs, cushions, foot pedals, leg rests, splints, oxygen tubing, catheters, or other pressureproducing devices; immediate review and required intervention: Device fit, inflation, cleanliness, placement, skin contact points Remove/replace defective devices; therapy assessment; device padding/offloading; maintenance work order 14. Residents with nutritional risk, weight loss, low intake, dehydration risk, diabetes, vascular disease, or poor wound healing risk; immediate review and required intervention:Dietary assessment, labs if ordered, supplements, hydration, weights, intake RD consult; supplements/protein/hydration plan; physician notification as indicated The facility leadership team reviewed the current removal plan and added this staffing assessment component to address the concern that survey evidence may indicate insufficient staffing levels or staffing patterns, rather than staff simply failing to complete care-planned tasks. The facility will evaluate staffing based on census, hall location, resident acuity, resident-specific care needs, and the ability to complete required care in real time. Action:Resident #73 was assessed immediately; pressure-producing wheelchair seating was removed from use until safe pressure redistribution equipment was verified; wound provider/physician was notified; wound treatment, infection monitoring, pain assessment, pressure relief, repositioning, offloading, and incontinence interventions were implemented and care planned. All residents were reviewed through a 100% skin sweep and risk review for pressure injury, immobility, incontinence, wheelchair/bed device use, current wounds, nutritional risk, and ineffective/missing pressure relief devices. Any resident identified with risk or skin concern had interventions added to the care plan and orders updated as indicated. Implemented a Pressure Injury Prevention, Equipment Integrity, and Census/Acuity-Based Staffing Assessment process. The facility now completes daily review of staffing levels and patterns by hall, shift, census, and resident acuity to determine whether current staffing is sufficient to meet resident needs. The review includes repositioning, incontinence care, Hoyer and assist x2 transfers, pressure relief, skin/wound monitoring, meal assistance, supervision, hospice/skilled residents, behaviors, admissions/readmissions, equipment needs, and care-completion barriers. Staffing assignments are posted by hall and resident care needs, not merely by total staff count. When staffing is not sufficient, the charge nurse escalates immediately to the DON/Administrator/designee for adjustment, calling support, leadership assistance, agency request, or other immediate correction. Audits include: staffing levels and patterns compared to resident needs; hall assignment appropriateness; turning/repositioning documentation; incontinence care documentation; wound treatment completion; wheelchair cushion/pressure surface integrity; care plan/order match; resident observation for positioning/offloading; staffing escalation log; calllight response concerns; missed showers, meals, weights, treatments, or skin checks; agency use; call-ins; and interviews with CNAs/licensed nurses on assignment awareness. Audit findings, wound trends, new or worsened pressure injuries, equipment concerns, staffing levels/patterns, staffing barriers, census/acuity changes, call-ins, agency use, missed care, corrective actions, and education completion will be reported to QAPI. QAPI will determine additional action, including re-education, counseling, process revision, equipment purchases, staffing pattern modification, schedule revision, recruitment focus, or additional monitoring. Staffing will be based on resident needs and care demands, not census alone. The facility will staff above a basic minimum model while Immediate Jeopardy correction is underway and while SFF-level oversight is required. Daily assignments will be posted by hall and resident care need so that staff accountability is clear and surveyors can validate that the staffing model matches resident needs. Staffing Assessment revealed:Hall 1 - 29 residentsStrong support: hospice, transfer-assist, ADL, incontinence, and skin-risk needs. Assign by resident need; validate repositioning, incontinence care, transfers, pressure relief, hospice support, and skin checks each shift. Hall 2 - 36 residentsHighest priority: high census/occupancy with multiple Hoyer, assist x2, high assist, incontinence, and skin-risk needs. Do not staff as a standard hall. Validate that staff can complete transfers, rounds, incontinence care, meals, repositioning, and pressure relief. Hall 3 - 14 residentsDeceptively heavy: high ADL, transfer, continence, and skin-risk needs despite lower census. Do not treat it as a light assignment. Assign clear accountability and validate care completion and response times. Hall 4 - 3 residentsLow census but still requires assigned rounding responsibility. May combine with Hall 5 only if assigned coverage is clear and rounds are validated. Hall 5 - 3 residentsLow census but still requires assigned rounding responsibility. May combine with Hall 4 only if assigned coverage is clear and rounds are validated. Daily Staffing Level and Pattern Assessment ProcessDON/designee will complete a daily staffing assessment by hall and shift using census, resident acuity, transfer status, incontinence needs, wound/skin risk, hospice/skilled status, behaviors, admissions/readmissions, and care-completion trends. Scheduler/DON/designee will post assignments by hall, including assigned CNA, assigned nurse, high-risk residents, Hoyer/assist x2 transfers, repositioning and incontinence-round responsibilities, meal assistance, showers, skin checks, and supervision needs. Hall 2 will receive the heaviest staffing review. Hall 1 will receive a strong staffing review. Hall 3 will not be treated as a light hall solely because the census is lower. Hall 4 and Hall 5 may be combined only when assigned coverage is clear and rounds are validated. The facility will adjust staffing whenever census or acuity changes, including new admission, hospital return, significant change, new wound/skin concern, new hospice/skilled resident, increased falls/behaviors, increased Hoyer/assist x2 needs, increased incontinence care, call-light concerns, staff call-ins, agency use, or missed care concerns. If staffing is insufficient, the charge nurse must immediately notify DON/Administrator/designee. Corrective action may include adding staff, calling in staff, revising assignments, leadership assistance with resident care within scope, adjusting breaks, shifting staff between halls, or requesting agency support when internal staff are unavailable. Leadership will validate staffing effectiveness against falls, call-light response, showers, meal assistance, weights, wounds/skin checks, incontinence rounds, repositioning, Hoyer/assist x2 transfers, behaviors, admissions/readmissions, care refusals, agency use, and missed or delayed care. The scope and severity lowered from a 'K' level to an 'E' level upon verification the immediacy removed. The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) Resident Assessment Instrument (RAI) manual defines pressure sore stages as: Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Unstageable - Deep tissue injury Upon the start of the survey, the facility provided a Resident Matrix dated 5/11/26 which identified all residents who had a current pressure ulcer and the highest stage and if not present on admission to the facility. The list included: room [ROOM NUMBER]-B - Resident #10 - Stage 3 room [ROOM NUMBER]-B - Resident Random#1 - Stage 4 room [ROOM NUMBER]-B - Resident #35 - Stage 1 room [ROOM NUMBER]-A - Resident #36 - Stage 3 room [ROOM NUMBER]-A - Resident #56 - Suspected Deep Tissue Injury (SDTI) room [ROOM NUMBER]-A - Resident #59 - SDTI room [ROOM NUMBER]-B - Resident #62 - SDTI room [ROOM NUMBER]-A - Resident #73 - Stage 4 room [ROOM NUMBER]-B - Resident #81 - SDTI room [ROOM NUMBER]-A - Resident #83 - Stage 1, Stage 3 As a result of the facilities removal efforts, a list of residents identified with Pressure Ulcer Wounds after a skin inspection completed on all residents. The list documented: Resident #80 - left knee and right heel Resident #54 - right heel Resident #50 - right foot plantar Resident #70 - sacrum Resident #10 - right heel and left heel, sacrum Resident #21 - right buttock Resident #13 - perineum Resident #56 - right knee medial, right knee 'medra asheet' Resident #19 - left heel and peri/open Resident Random#2 - left lateral calf, right shin right medial Resident #73 - left posterior thigh Resident #83 - left hip Resident #11 - left buttock Resident #58 - right lower extremity and right medial knee Resident Random#3 - right foot wound vaccuum Resident Random#4 - toe with eschar Resident #7 - coccyx Resident #4 - buttock Resident #72 - left abdominal fold open The facility also conducted skin assessments on all residents on 5/19/26 and identified: Resident #73 - pressure ulcer posterior left knee, MASD (Moisture Associated Skin Damage) in periarea/buttock region Resident #83 - chronic pressure ulcer left heel, pressure ulcer to left upper hip, scar from previous pressure ulcer right mid hip area, prevlon boot for left heel and skin prep treatment twice a day in place Resident #62 - previous pressure to lateral right ankle area Resident #21 - MASD to coccyx area Resident #13 - left and right armpits with redness, perineum Resident #56 - red testicles Resident #19 - pressure to right lateral ankle area followed by podiatry, small open area 0.2 cm by 0.2 cm in periarea creases red and yeasty, right breast yeasty, abdominal folds red and yeasty Resident Random#2 - preexisting area to back of right calf, periarea pink and yeasty Resident #11 - circled left buttock area, facility did not state what was there Resident #58 - dressing in place on right lower extremity Resident Random#3 - wound vac right foot, rashes to coccyx region Resident #4 - open area to coccyx measured 1.0 centimeters (cm) by 1.3 cm Resident Random#4 - black area on right toe Resident #32 - coccyx area pink Resident #8 - coccyx slightly pink Resident #6 - red coccyx area, redness left great toe Resident Random#5 - coccyx area slightly pink Resident #28 - red/yeast under right breast, right great toe pink Resident #29 - periarea red and itchy, left toes pink Resident #72 - small open area left abdominal fold Resident #41 - periarea red and yeasty, coccyx area MASD Resident #74 - abdominal (abd) folds slightly pink Resident #82 - abdominal fold red and yeasty, coccyx area red, left toe red/pink Resident #27 - right great toe pink Resident #15 - blanchable redness to coccyx region, MASD Resident #12 - coccyx area blanchable MASD with treatment in place Resident #16 - periarea with MASD 1. The Quarterly MDS assessment dated [DATE] for Resident #73 identified a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. The MDS documented the resident did not refuse care and used a wheelchair. The MDS identified the resident's functional self care abilities as requiring partial to moderate assistance with oral care, substantial to maximal assistance with upper/lower body dressing, and totally dependent for assistance with toileting hygiene and personal hygiene. The MDS identified the resident's mobility status as totally dependent for assistance with sit to lying, lying to sitting on side of bed, sit to stand, toilet transfer, and tub/shower transfer. The MDS documented the resident frequently incontinent of urine but always continent with bowels. The MDS listed diagnoses that included debility, cardiorespiratory conditions, heart failure, renal insufficiency/failure, stroke, chronic lung disease and respiratory failure. The MDS recorded a weight of 272 pounds. The MDS recorded the resident at risk of pressure ulcers/injuries with one unhealed Stage 1 pressure injury and moisture associated skin damage (MASD). The Skin and Ulcer/Injury Treatments checked for a pressure reducing device for chair, pressure ulcer/injury care, and application of nonsurgical dressings and ointments/medications. The MDS recorded the resident received hospice care services. The Quarterly MDS assessment dated [DATE] for Resident #73 identified a BIMS score of 08, which indicated moderate cognitive impairment. The MDS documented the resident did not refuse care. The Self Care Functional Abilities identified the resident required supervision or touching assistance for oral care, substantial to maximal assistance with upper/lower body dressing, and totally dependent upon staff for toileting and personal hygiene. The Mobility status identified the resident required substantial to maximal assistance in bed rolling left and right, sit to lying, and lying to sitting on side of bed, and totally dependent for sit to stand, chair-to-bed-to-chair, toilet and tub/shower transfers. The MDS documented the resident frequently incontinent of urine and always incontinent with bowels, which was a major change from the previous assessment. The MDS recorded the resident at risk of pressure ulcers/injuries with one unhealed Stage 1 pressure injury, one new unhealed Stage 4 pressure injury, and moisture associated skin damage (MASD). The Skin and Ulcer/Injury Treatments checked for a pressure reducing device for chair, pressure ulcer/injury care, and application of nonsurgical dressings and ointments/medications. The MDS recorded the resident received hospice care services. The Care Plan dated 1/5/26 documented the following focus areas and care plan interventions: Focus area revised 9/4/25 for potential for skin breakdown related to edema in bilateral lower extremities with two fluid filled intact blistered areas: left lower leg measures 8 cm (centimeters, length) by 6.5 cm (width) and top of left foot 6.3 cm by 4.0 cm. The care plan interventions included on-going assessment of skin conditioning during routine care. a. The interventions lacked identification of interventions to provide pressure relief to the bilateral extremities. Focus area revised 1/5/26 identified a potential for pressure ulcer development related to incontinence and decrease in mobility with a goal to have intact skin, free of redness, blisters, or discoloration by the next review date. The interventions initiated 4/5/23 included education to the resident/family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. The care plan directed staff to follow facility policies/protocols for the prevention/treatment of skin breakdown and to teach resident/family the importance of changing positions for prevention of pressure ulcers with encouragement of small frequent position changes. The interventions lacked identification or instruction in the use of pressure relieving devices in chairs or beds and instructed staff to follow facility policies/protocols for the prevention and treatment of skin breakdown. The care plan dated 4/13/26 that included the following focus areas and care plan interventions: Focus area revised 1/5/26 identified the resident had bladder and bowel incontinence related to impaired mobility and loss of peritoneal tone. The intervention created 4/5/23 instructed staff to clean the peri-area with each incontinence episode. The intervention created 9/2/25 instructed staff to encourage toileting and manage incontinence before/after meals, at AM (morning) and HS (bedtime), and as needed. Focus area revised 1/5/26 identified an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and impaired balance. The interventions revised 94/25 included: encourage the resident to be up in the wheelchair and in the dining room for meals; wheelchair for mobility; transfers with EZ (sit-to-stand) mechanical lift and assistance of 2 persons; and assist of 1 person for dressing, personal hygienic, and toilet use. Focus area revised 3/26/26 identified the resident had an actual skin impairment of a pressure ulcer to the back of her left thigh related to CHF (Congestive Heart Failure), morbid obesity and incontinence of bowel and bladder. The care plan documented on 3/11/26 a Stage 4 pressure sore present on the back of the left thigh. The interventions created 3/11/26 instructed: the use of a pressure reduction equipment and procedures as indicated for preventative measure equipment/procedure; turn and reposition; cushion to the wheelchair and specialty mattress on the bed; and encourage the resident to shift weight, if able, every 2 hours to assist with skin integrity and assist as needed. Focus area revised 3/30/26 identified a potential for pressure ulcer development related to incontinence and decrease in mobility with a note 3/10/26 Stage 4 pressure ulcer present on left rear thigh. Focus area revised 4/13/26 identified impaired cognitive function or impaired thought processes related to short term memory loss. The intervention created 4/3/25 instructed staff to cue, reorient and supervise as needed. The Progress Notes dated 12/30/25 documented a Nurse Practitioner (NP) Encounter visit documenting the resident seen that day for follow up of a new Stage 2 pressure ulcer to buttocks identified first on 12/24/25 and measured 0.5 cm (length) by 1.8 cm (width) by 0.1 cm (depth). The Progress Notes dated 12/31/25 at 2:26 PM documented a wound observation and noted the care plan was reviewed and the wound present after admission. The Progress Notes dated 12/31/25 at 4:33 PM documented an IDT (Interdisciplinary Team) note. The entry recorded the IDT met to review the resident's current Stage 2 pressure ulcer to the right buttock and the care plan updated. The Progress Notes dated 1/5/26 documented a Nurse Practitioner Encounter visit documenting the resident seen that day for follow up of the Stage 2 pressure ulcer to right buttock times 2 and indicated another pressure sore had appeared. The entry noted the resident under hospice care, had Alzheimer's dementia, morbidly obese which further complicated her care. The wounds measured: 1.5 cm by 0.1 cm by 0.1 cm Stage 2 to the right top buttock and 2.5 cm by 2.5 cm by 0.1 cm Stage 2 to the right bottom buttock. The entry documented staff to encourage offloading and turn frequently. The Progress Notes dated 1/7/26 at 3:43 PM documented the IDT met to review the resident's two Stage 2 pressure areas to the right buttock and the resident being followed weekly by the facility wound team and wound nurse. The entry documented a cushion provided by hospice and placed in the recliner and the care plan updated. The Progress Notes dated 1/13/26 documented a Nurse Practitioner Encounter visit documenting the resident seen that day for follow up of Stage 2 pressure ulcer to buttocks and that both ulcers had healed. The entry recorded it was signed by the NP on 1/23/26 at 10:01 AM with an addendum created 1/28/26 at 11:36 AM. The Progress Notes dated 1/13/26 at 8:26 AM documented a late entry noting the pressure ulcers resurfaced. At 4:05 PM, an entry documented the two right buttock wounds resolved. Review of the care plan history and resolved items revealed: RESOLVED focus area dated 1/13/26 of an actual skin breakdown related to edema in bilateral lower extremities and two fluid filled blisters resolved 9/3/25. The area also noted 12/30/25 a Stage 2 pressure ulcer to the right buttock and on 1/6/26 a Stage 2 pressure ulcer to the bottom of the right buttock. The intervention created on 1/7/26 directed the use of a cushion in place in the recliner and on 1/13/26 the intervention was resolved and removed from the active care plan. The Progress Notes dated 1/16/26 at 7:48 PM documented the IDT team reviewed the resident's pressure ulcers and all areas had resurfaced (opened). The entry recorded the IDT would revisit intervention needed from the Registered Dietician at the next risk meeting, the care plan updated, and they would continue to monitor. The Progress Notes dated 1/22/26 recorded an Encounter visit by the physician / Medical Director (MD). The entry lacked documentation pertaining to pressure sores and was signed on 2/3/26 at 12:52 PM. The Progress Notes dated 1/23/26 thru 3/9/26 lacked any documentation of pressure sores. The late entry Progress Notes dated 3/10/26 at 10:48 AM recorded a wound observation. The entry documented a Stage 4 pressure sore present after admission to the left rear thigh that measured 2.7 cm by 7.0 cm by 0.3 cm. The note documented eschar (dead tissue), slough (dead, non-viable tissue that accumulates), and drainage present in the wound bed without odor. The Weekly Wound assessment dated [DATE] recorded a wound summary. The summary documented a Stage 4 pressure sore to the left rear thigh measured 2.7 cm by 7.0 cm x 0.3 cm with 80% eschar, 20% slough, large amount of serosanguineous drainage without odor present, and resident's wound tender to the touch. Noted interventions included pressure reduction mattress, Wheelchair Cushion, Nutritional Supplements, Vitamin Supplements, but did not have Specific Turning/Repositioning Program, Positioning Devices, or Heal Boots marked. The Follow Up Skin assessment dated [DATE] at 2:58 PM documented the resident had an open Stage 4 pressure area to the left rear thigh due to wheelchair seat placement. The Progress Notes dated 3/10/26 at 2:52 PM documented an Incident note for a skin concern on the resident's leg. The entry recorded a wound measurement of 2.7 cm by 7.0 cm by 0.3 cm and that the wound lined up with the wheelchair seat. The entry noted immediate education occurred with staff working to remove the wheelchair cushion from the recliner and place it in the wheelchair when the resident seated. The Progress Notes dated 3/11/26 at 3:15 PM documented the IDT met to review the resident's pressure ulcer to the back of her left thigh. The entry recorded the pressure ulcer was a Stage 4 with large serosanguineous drainage (mixture of clear fluid and small amount of blood). The IDT initiated staff education regarding the recliner cushion being placed in her wheelchair when the recliner was not in use and vice versa and the care plan updated; they would continue to monitor. The Weekly Wound assessment dated [DATE] recorded a wound summary. The summary documented a Stage 4 pressure sore to the left rear thigh measured 5.5 cm by 10.1 cm x 0.1 cm with 50% eschar, 25% slough, 25% granulation, moderate amount of serosanguineous drainage with odor present, the wound surface area enlarged, and the resident reported a pain of 5 out of 10. Noted interventions included pressure reduction mattress, Nutritional Supplements, but did not have wheelchair cushion, Specific Turning/Repositioning Program, Positioning Devices, or Heal Boots marked. The Progress Notes dated 3/19/26 at 10:318 AM recorded a wound observation. The entry documented the Stage 4 pressure sore on the left rear thigh measured 5.5 cm by 10.1 cm by 0.1 cm with eschar, slough, drainage and granulation (formation of new tissue) present in the wound bed. The resident voiced pain present during the wound treatment, a wound odor observed, and the periwound condition fragile with the overall progress of the wound healing documented as declined. The Progress Notes dated 3/20/26 at 4:35 AM documented a new order received for an antibiotic medication to be taken for 7 days for the left thigh wound. The Progress Notes dated 3/20/26 at 4:37 PM documented the IDT team reviewed the resident's pressure ulcer to the back of her left thigh. The entry documented the Stage 4 wound with a large amount of serosanguineous drainage. The IDT educated staff regarding the recliner cushion being placed in the wheelchair when the recliner was not in use and vice versa and the care plan updated; would continue to monitor. The Progress Notes dated 3/24/26 at 5:04 PM documented a Health Status note that the resident was on an antibiotic for wound infection and supplement for wound healing. The Progress Notes dated 3/24/26 at 5:42 PM

Based on grievance forms, clinical record review, family interview, staff interview, and facility policy review, the facility failed to timely and effectively manage resident pain for 1 of 1 residents reviewed for pain management (Resident #94) and for 3 residents via grievance reports (room [ROOM NUMBER]-A, Resident #59, room [ROOM NUMBER]). The facility failed to assess and intervene upon the report of Resident #94 having acute pain and failed to initiate a new order for morphine pain medication in a timely manner on 3/23/26. The resident experienced severe, avoidable pain as evidenced by non-verbal pain indicators and family reports. The facility failed to successfully submit escripts for the acute pain medication to the pharmacy leading to a delay in obtaining and administering the medication. The above failure rose to a level of immediate jeopardy and the facility was notified of IJ on 5/21/26 at 3:35 PM. The failure began 3/23/26 for Resident #94. The facility removed the immediacy on 5/22/26 after the State Survey Agency (SSA) verified removal actions taken by the facility that included: PlanComplete immediate pain and comfort assessment on every current resident, including verbal and non-verbal indicators, hospice/palliative care status, recent falls, wounds, fractures, terminal decline, therapy-related pain, behaviors, anxiety/restlessness, and residents unable to self-report pain. For any resident with pain score 4 or higher, severe nonverbal pain indicators, new/worsening pain, or uncontrolled pain: notify provider/hospice immediately, implement ordered interventions, administer ordered medication timely, and document resident response. Review Resident #94's record for root cause analysis: pain assessment failures, order implementation failure, missed routine tramadol, hospice/provider notification gap, family concern response, near fall/abrasion response, and end-of-life comfort process breakdown. Audit 100% of residents with active pain medication orders, PRN opioids, routine analgesics, hospice comfort medications, recent new orders, and recent pharmacy/hospice recommendations to verify orders are transcribed, available, administered as ordered, and reassessed. Implement pain reassessment requirements: after PRN pain medication, non-pharmacologic intervention, new/worsening pain, fall/injury, therapy treatment, wound care, transfer, hospice symptom change, or resident/family complaint. Establish hospice/palliative care communication protocol: any uncontrolled pain, distress, restlessness, agitation, terminal change, medication issue, family concern, or need to alter the comfort plan requires immediate hospice and/or provider notification. Educate all licensed nurses and CNAs on F697, pain recognition, nonverbal pain signs, end-of-life comfort, timely implementation of new orders, PRN effectiveness documentation, escalation, provider/hospice notification, and family concern response. Implement a Pain Management High-Risk Huddle at least daily, reviewing residents with pain scores 4 or greater, hospice/comfort care, new pain orders, missed/refused pain medications, PRN use, ineffective interventions, family concerns, and provider/hospice follow-up. Add leadership escalation: unresolved severe pain, delayed medication availability, missed pain medication, inability to reach provider/hospice, or concern that staff cannot meet pain management needs must be escalated immediately to DON and Administrator. Action Resident #94 expired prior to the IJ notice. The facility completed an immediate leadership review of the clinical record and survey allegation, including pain assessment, hospice level-of-care transition, morphine order implementation, routine tramadol administration, provider/hospice communication, family concern response, near-fall/abrasion assessment, and overnight monitoring. Findings were used to implement facility-wide corrective action to prevent recurrence. All residents have the potential to be affected by failure to assess and manage pain. The facility completed a 100% pain risk sweep of current residents, prioritizing hospice/comfort care residents, residents with pain orders, residents unable to self-report, residents with recent falls/injuries/wounds, residents receiving therapy/wound care, residents with behaviors that may indicate pain, and residents with new or changed pain medication orders. Implemented Pain Management Immediate Response Process: pain assessment on admission/readmission, change in condition, fall/injury, wound care, therapy concern, family complaint, hospice change, and resident report/nonverbal indicators; timely implementation of pain orders; MAR/order audit; PRN effectiveness reassessment; provider/hospice notification protocol; severe pain escalation; daily pain huddle; staff education and competency validation. Audits include pain assessments, pain score follow-up, nonverbal pain indicators, PRN effectiveness, routine analgesic administration, new-order implementation, hospice/provider notifications, family concern follow-up, MAR/order accuracy, medication availability, and care plan accuracy. Audit findings, pain trends, missed medications, uncontrolled pain episodes, hospice/provider notification concerns, medication availability concerns, staff competency results, and corrective actions will be reported to QAPI. QAPI will determine additional action, including re-education, counseling, pharmacy/provider process revision, hospice communication revision, and staffing/assignment changes if needed. The scope and severity of the failure lowered from a J level to an D level on 5/22/26 after the facility removed the immediacy of the health threat. The facility reported a census of 81 residents. Findings include: The MDS dated [DATE] for Resident #94 revealed diagnoses of fractures of the upper and lower right fibula, fall, chronic obstructive pulmonary disease, heart valve disorder and identified surgical repair of fractures. Resident #94 was dependent on staff for personal hygiene, dressing, and moderate assistance for transfers from bed to chair. Pain was identified that interfered with sleep and therapy. The MDS identified two Stage 1 pressure ulcers, skin tears, a surgical wound that required wound care, the application of dressings and an infection of the foot to include pressure ulcer care. The MDS identified the use of oxygen therapy, an intravenous access site, occupational therapy, physical therapy and speech therapy. The Care Plan for Resident #94 identified a risk for skin tears, bruising and directed staff to apply folded sheet or small pillow between bony surfaces and apply a leg brace. The nursing staff was directed to assess for pain level, effectiveness of the pain medication and inspect skin for bruising or bleeding daily. The Care Plan identified Resident #94 as a fall risk and directed staff to apply the appropriate foot wear when ambulating, utilize the mechanical lift with two staff for transfer, wheelchair for mobility and keep personal items within reach. Staff were to follow all facility protocols related to falls, fall report, investigation, interventions and to inform the physician. During an interview on 5/20/2026 at 9:52 am, Resident #94's wife stated on 3/23/26 she was present in the morning when the Hospice nurse arrived to assess her husband. The wife stated she had left the facility before noon and returned approximately at 2pm to see two staff chatting outside her husband's room and found her husband in a tipped recliner hanging on with fright as the recliner was so far over that his surgical foot and the foot rest was on the floor. She yelled for help and visualized a new wound to her husband's right arm. The nurse told her it was just hair that was removed from his arm. The wife stated, I believe he just was frightened to death as her husband's oxygen level dropped, breathing hard and did not talk much. The wife stated his arm hurt, looked as if the skin was ripped off and his pain was extraordinary. The wife stated she informed the staff and six hours passed with no nurse response. The wife stated, He was so fearful that he did not want me to leave him. The wife stated the two Certified Nurses Aid's (CNA) came in at 8 pm, used the mechanical lift to put him to bed and he curled up facing the wall, he never slept facing the wall. The wife stated he was in terrible pain and the nurse did not respond, assess him or administer pain medication. During an interview on 5/20/2026 at 10:42 am, Resident #94's grandson stated on 3/23/26 he had arrived to visit at approximately 3 pm. The grandson stated his grandfather had a new bruise on his right shoulder and a large area in the middle of his right forearm with no skin, the skin was off, pink but not bleeding. The grandson stated his grandmother requested to speak to a nurse and the nurse did not respond. The grandson stated his grandfather repeatedly said he wanted to go home and asked his grandmother not leave him. The grandson stated his grandfather was in and out of consciousness and staff came in to give him a food tray with pizza that he could not eat it because it was too hard. The grandson stated he was there until 8 pm and only visualized one CNA. The Progress Notes for Resident #94 revealed: a. On 3/21/2026 at 9:47 am Resident #94 was to receive Hospice care. Resident #94 was alert and orientated to person, no change with neuro checks and denied having pain. Resident #94 required assistance with bed mobility, eating, transfers, toilet, and dressing. Resident #94 was incontinent of bowel and bladder. The medications were crushed or given in liquid form. Resident #94 had wounds, skin tears and a surgical wound. b. The assessment on 3/22/26 was not completed c. On 3/23/2026 at 3:19pm, Staff L, Licensed Practical Nurse (LPN) documented she was called to Resident #94's room by a family member. Resident #94 had shifted his weight forward in his chair and had tipped the foot rest to the floor. Resident #94 was still in his chair with his feet on the floor in front of the foot rest. There was no fall nor did the resident leave his seated position. This nurse and therapy assistant tipped the chair back in place and repositioned Resident #94 into the recliner. Resident #94 had been reaching for items on the tray table which was moved closer to the resident. Staff cleaned up the floor where items had spilled. The family members sat with Resident #94 through meal services and Resident #94 was settled, resting comfortably. Resident #94's assessment was completed with no concerns except his oxygen (O2) saturation which was at 88%. Resident #94's family was aware of poor O2 profusion while on 4 Liters of O2, however Resident #94 was converting to Hospice Care tomorrow and requested no additional intervention at this time. Resident #94 eat only a few bits of food and drank 100 milliliters of liquid during meal time. Resident #94 showed no signs or symptoms of shortness of breath. d. On 3/23/2026 at 9:37 pm, Staff L, LPN documented Resident #94 admitted to Hospice Care this date for severe aortic stenosis and severe protein-calorie malnutrition in addition to recent hip and tibial plateau fracture. The blood thinning injection was discontinued and morphine liquid was ordered for difficult breathing and severe pain. Resident #94's daughter was present and in agreement with the new orders. Resident #94 had no discomfort. e. The Progress Notes lacked a follow-up documentation over the night shift. f. On 3/24/2026 at 7:45 am documentation of a call to the wife to report Resident #94 was not doing well and was declining. Blood pressure was 88/42, heart rate 56 and respiration was shallow at 16, difficulty with obtaining an accurate 02 saturation, and there was no sign of discomfort. g. On 3/24/2026 at 7:54 am, Resident #94 expired at 7:50 am, no heart beat or pulse. A call was placed to the wife and reported the information. The wife requested that resident not be moved until her arrival. The hospice nurse was notified. Communication document dated 3/23/26 by Staff SS, Hospice Registered Nurse (RN) documented Resident #94 was admitted to Hospice for severe aortic stenosis, severe malnutrition and recent hip and leg fracture with a request to stop the blood thinner and initiate Morphine for difficult breathing or severe pain. The document was noted by Staff L, Licensed Practical Nurse (LPN). The Hospice Care admission note on 3/23/26, Staff SS, RN documented Resident #94 cried out in pain, scored 8/10 on the PAINAD scale, displayed anxiety and increased agitation with any transfer or movement. Ate small bites of food, drank fluid with heavy assistance and encouragement. Pressure injuries to bilateral heels and was non-blanchable, and pinkness to the skin in the coccyx area. A healing skin tear to the left forearm that the family reported he got when he was combative during his hospitalization. Scattered bruising and scabbed abrasions to both arms. A surgical wound to his rt knee with a dressing and a knee brace. A urinary catheter with yellow urine and was incontinent of bowel. During an interview on 5/20/26 at 9:20 am, Staff SS, RN stated she was the admission nurse for Hospice on 3/23/26 and arrived to the facility around 8 am. The referral came in on Friday late afternoon 3/20/26 as Resident #94 was discontinued from skilled care. Staff SS stated she assessed Resident #94 at 9am with his wife and daughter present. Resident #94 was in bed and the daughter offered him a snack cake; he took a drink. Resident #94 was in pain 8/10 on the PAINAD scale so she ordered Morphine, wrote it on the paper physician's order form provided by Staff BB, LPN, the nurse on duty. Staff SS stated the nursing staff fax the orders to their own pharmacy. Staff SS stated she did not have morphine to give Resident #94 but the facility had an emergency box that contained narcotics and she communicated with Staff BB, LPN who was made aware Resident #94 was experiencing pain. Staff SS stated she would expect Resident #94's pain to be treated. Staff SS stated the booklet with the care plan had not been built yet as she would chart and then the booklet would be brought back by the Hospice RN. Staff SS stated she only did Hospice admissions and the case manager RN will follow up within 24-48 hours. The Medication Administration Record dated March 2026 for Resident #94 revealed: a. Pain level rated at 6/10. b. On 3/23/26 Celecoxib (anti-inflammatory) 200 milligrams (mg) daily administered.c. On 3/23/26 Tylenol 500 mg 2 tablets BID (two times daily) Administered morning and afternoon. d. On 3/23/26 Lidocaine 4% patch, apply to affected area in the morning was applied and removed at bedtime. e. On 3/23/36 Tramadol 50 mg TID (three times daily) was administered am, pm, and lacked documentation for the bedtime dose. Pain levels documented as an X each dose. f. Hydroxyzine (antihistamine) 25 mg take 1 tablet at bedtime as needed for anxiety. Ordered on 3/6/26. No documentation of administration. g. On 3/23/26 Morphine Sulfate Solution 20 mg per 5 milliliter (ml) administer 0.25 ml every 4 hours as needed for dyspnea (difficult breathing) and severe pain. No documentation of administration. A document titled Pain Level Summary for Resident #94 document by nursing staff three times daily. a. Dates 3/17/26 through 3/22/26 revealed 0 for numerical (Resident rates the pain) and 0 for PAINAD (observational tool used to evaluate pain) scale. b. Date 3/23/26 at 8:48 am pain rated as 6/10. c. Date 3/23/26 at 2:07 pm pain rated as 6/10. d. Date 3/23/26 at 7:55 pm through 3/24/26 at 7:16 am pain rated as 0 for numerical. A document dated 3/20/26 at 2:56 pm by Staff Y, Occupational Therapist (OT) as Resident #94's last day of services. Resident #94 had severe dependency on care givers to perform cares, required a mechanical lift for transfers. Resident #94 was alert and oriented during care provided with mild weight bearing to the right lower extremity. Resident #94 displayed increased behaviors that impacted engagement. No complaint of pain but displayed signs and symptoms as restlessness and increased agitation and the nurse was made aware. During an interview on 5/21/26 at 1pm, Staff Y, OT stated Resident #94 declined cognitively and became more agitated to the point that he was not following directives. Staff Y stated Resident #94 was good initially but was not eating. Staff Y stated Resident #94 pulled at the leg brace and the urinary catheter which could be indicators of discomfort. Staff Y stated therapy could not provide further effective treatment for Resident #94. During an interview on 5/21/26 at 11:32 am Staff O, Speech Therapist (ST) Rehabilitation Director stated Resident #94 was admitted to the facility from the hospital for therapy due to a repair of his leg. Staff O stated Resident #94 became agitated and confused during his stay. During an interview on 5/21/26 at 1:26 pm, Staff UU, Physical Therapy Assistant (PTA) stated Resident #94 was admitted for physical therapy. Staff UU stated Resident #94 was never 100% in thought, he required 1 step at a time directions then overtime he became more agitated and combative. Staff UU stated when she had asked Resident #94 if he had pain, he couldn't rate his pain but it was his body language, he rubbed and pulled at everything. Staff UU stated the nurses were aware of his discomfort. Staff UU stated the nurses were notified if a resident can or cannot participate in the therapy, and Resident #94 was to the point that he could not. Staff UU stated she did not remember helping with Resident #94 on 3/23/26. During an interview on 5/21/26 at 12:24 pm, Staff BB, LPN stated at this facility, the certified medication aid (CMA) administers medication but she personally would conduct assessments of a resident if they have pain. Staff BB stated that would trigger a follow up in the computer for the nurse. Staff BB stated the CMA's do not conduct assessments, nurses have to, and there was an automatic order on every resident to assess pain every shift. Staff BB stated she provided care for Resident #94 on 3/23/26, asked if he had pain and used the PAINAD scale, but did not remember if he had pain. Staff BB stated she could not remember if she was notified Resident #94's recliner was tipped forward. Staff BB stated she was aware Resident #94 had a new abrasion on his arm, but unable to remember if she had assessed it. Staff BB stated she had assisted to transfer Resident #94 into the recliner with the mechanical lift. Staff BB stated Resident #94 was in a lot of pain but didn't think it was related to his surgical leg. Staff BB stated she could not remember if she had directed the CMA to administer something for pain. Staff BB stated she was working with the treatment cart and was certain she did not give a pain medication to Resident #94. Staff BB stated she was not aware that the Hospice nurse admitted Resident #94 and wrote an order for Morphine. During an interview on 5/21/2026 at 2:48 pm, Staff L, LPN stated she provided care for Resident #94 on 3/23/26 during the 2-10 pm shift. Staff L stated she was told Resident #94 was falling out of his blue recliner. Staff L stated she found Resident #94 leaning forward with his feet and the recliner foot rest on the floor. Staff L stated she flipped the recliner back but could not recall which staff member assisted to reposition Resident #94 back up and into the recliner. Staff L stated she did not visualize an abrasion on Resident #94's arm. Staff L stated this could have been considered a near fall. Staff L stated she did not see the need to do an assessment. Staff L stated Resident #94 had family present and could not remember if the family reported if he was experiencing pain or if Resident #94 said he had pain. Staff L stated she did not administer pain medication to Resident #94 and could not remember further details. Staff L stated Resident #94 was to be admitted to Hospice care the next day. Staff L stated Resident #94 was only at the facility for a few days. During a follow-up interview on 6/01/2026 at 3:39 pm, Staff L, LPN stated she was informed by the previous nurse on 3/23/26 that the order for Resident #94's pain medication was not received from the Hospice nurse until 2 pm and that nurse (not identified) had looked in the Cubix system for Morphine and it was empty and it would be delivered at 7pm. Staff L stated the unidentified nurse reported the order was e-scripted by hospice and faxed in and the pharmacy entered it into the computer. Staff L stated she called the pharmacy, who said they had not received an e-script from hospice, it had to be entered and that took 15 minutes. Staff L stated she looked in the Cubix and Morphine wasn't in there, it was empty, as it was used the night before for someone who was dying. Staff L stated she called their pharmacy who said on its way out. Staff L stated she had checked on Resident #94 and he was okay. Staff L stated the delivery did not arrive, she called the pharmacy and when asked where the medication was, the pharmacy staff said they did not get a quantity and something was wrong with the script. Staff L stated she had to call the physician on call and stat out an order. Review of the monthly grievance forms revealed the following: The Grievance Form dated 1/21/26 signed by the Administrator recorded a resident who formerly resided in room [ROOM NUMBER]-A reported Staff KK, LPN, would not give her pain medications (meds) when she requested the med when she had pain and Staff KK gave the wrong insulin medication. The Grievance Official Follow-Up section documented education provided to Staff KK that pain medication was to be administered as requested by any resident, the pain assessment should be documented in PCC (Point Click Care aka Electronic Medical Record) and would have a second person with Staff KK while interacting and providing care with the resident. The form lacked any documentation of further interview or follow up with the resident on resolution or efforts to ensure pain managed appropriately and recorded date resolved as 1/23/26. The Grievance Form dated 2/28/26 signed by the Administrator as resolved on 3/2/26 recorded Resident #59 complained call lights took 1 hour to answer, he had a bowel movement in his brief and not changed in a timely manner, and complained of pain meds. The form contained no further elaboration about the pain med concern. The Grievance Official Follow-Up section documented the Administrator educated staff on 2/28/26, spoke to the nurse about pain med, and hung a sign on the door to leave it open. The form lacked any documentation of further follow up or interview with the resident to verify resolution. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 4/16/26 signed by the DON as resolved on 4/17/26 recorded a resident who formerly resided in room [ROOM NUMBER] reported since 3:00 or 4:00 AM he had been asking for his PRN (as needed) pain medication and muscle relaxer but he kept getting told he could not/did not have any. The Grievance Official Follow-Up section documented the staff had been educated on the use of PRNs and giving them in a timely manner and explaining why, if they could not. The form lacked any documentation of further follow up or interview with the resident about his pain or availability of the medications. The form contained no information on whether the grievance was confirmed or not confirmed. Review of Facility provided Change In Resident Condition Policy revised September 2024 stated, our facility shall notify the resident and his or her attending physician of changes in the resident's condition.GUIDELINES: The nurse will notify the resident's attending physician and family when there has been: An accident or incident involving the resident A discovery of injuries of an unknown cause A change in medication/treatment or reaction to a medication A significant change in the resident's physical/emotional/mental condition A need to be seen by a physician for a non-emergent condition A need for a significant alteration in the resident's medical treatment Refusal of treatment or medication per physicians' orders or three consecutive times A need to transfer the resident to a hospital/treatment center A discharge without medical authority Notifications will be made after the nurse assesses the resident and when deemed necessary, except in emergencies, in which case notification will be made immediately. The nurse will inform the resident, or resident representative if indicated, of any changes in his/her medical care or nursing treatments. The nurse will document in the resident's medical record or SBAR in the resident's chart any changes in the resident's condition, who was notified (e.g., physician and family), and any new orders. The resident will be placed on the critical charting board for the next 72 hours after the assessment is completed. Review of Facility provided PRN Medications Policy revised July 2025 stated PRN (as needed) medications are administered by staff who are legally authorized to do so through certifications or licensure, in accordance with a physician's order. Documentation will be provided in the resident's medical record to show adequate indications for a medication's use and the diagnosed condition for which it was prescribed. Orders for medications to be given on an as needed basis shall have clear instructions about how and when to administer them. Examples include, but are not limited to: The symptom or condition for which the medication is to be given (i.e. pain, nausea). When administering a PRN Medication Verify physician's order for the medication. Document the reason by the resident and or assessment findings that show why the resident needs the medication. Document the time of administration. Evaluate the effectiveness of the medication and document the findings.

Based on facility grievance documents, clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to prevent physical abuse for 1 of 2 residents reviewed for abuse (Resident #81). The facility failed to perform assistance with bed mobility and transfers in a manner to prevent the occurrence of physical harm as evidenced by bruising to Resident #81's right elbow and left wrist as a result of staff holding the resident's arms too hard. The facility failed to converse with Resident #81 in a manner to prevent potential intimidation as the resident expressed a desire to shower at a different time than staff wanted. The facility also failed to perform a thorough and accurate investigation with Resident #71, who after an ER visit due to complaints of pain, was found to have rib fractures of unknown cause, putting residents at risk for further injury, abuse, or neglect for not identifying cause of injury. Additionally, the facility failed to prevent patterned issues of neglect as evidenced by: failure to provide assistance with activities of daily living including grooming, oral care, repositioning, and incontinence care spanning an approximate 7.5 hour period for Resident #73. The facility reported a census of 81 residents. Findings include: 1. Review of the Resident Council Meeting Minutes revealed the following: On 3/6/26, the minutes recorded 18 residents attended. The residents reported call light wait times were improving but some wait times are longer. On 4/3/26, the minutes recorded 14 residents attended. The residents reported: they would like staff to check more often on residents who are out in the common areas throughout the evening and nights; residents felt the nursing staff should have a happier disposition when interacting with residents; and call light wait times were getting better, but some days were better than others. 2. Review of the monthly grievance forms revealed the following: The Grievance Form dated 1/14/26 signed by the Director of Nursing (DON) as resolved on 1/21/26 recorded Resident #8 did not like the way the nurse spoke to her and gave an example of the nurse just lifting the resident's foot without the nurse asking the resident to lift the foot. The Grievance Official Follow-Up section documented education was provided to staff on the 2pm to 10pm and 10pm to 6am shifts on professionalism, customer service, abuse neglect and exploitation, and code of conduct. The Grievance Form dated 1/15/26 signed by the Administrator recorded Resident #81 complained he was not getting checked and changed (providing assistance with incontinence care) on the overnight shift. The Grievance Official Follow-Up section documented education was provided to staff on the 10pm to 6 am shift to make sure they were checking and changing the residents every 2 hours. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #49 reported the aides were not friendly, aides did not get her ice water or answer her call light, and she was not getting a shower. The Grievance Official Follow-Up section documented education provided to staff regarding resident dignity and all things that could be considered hindering their dignity, reinforced it was the resident's home, and spoke to staff specifically about the resident's shower schedule. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #44's family member reported the resident's rash treatment was not done, a CNA on the 6am to 2 pm shift went into the room, turned off the call light and then never came back. The Grievance Official Follow-Up section documented there was no treatment to complete for the resident and education completed with staff to leave call light on until the resident need could be completed. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #16 complained a CNA (Certified Nurse Aide) was being rude and called her a stupid bitch in the resident's room. The Grievance Official Follow-Up section documented the CNA was suspended and a report was made to the State Survey Agency. The Grievance Form dated 1/21/26 signed by the Administrator recorded a resident who formerly resided in room [ROOM NUMBER]-A reported Staff KK, Licensed Practical Nurse (LPN), would not give her pain meds when she requested the med when she had pain and Staff KK gave the wrong insulin medication. The Grievance Official Follow-Up section documented education provided to Staff KK that pain medication was to be administered as requested by any resident, the pain assessment should be documented in PCC (Point Click Care aka Electronic Medical Record) and would have a second person with Staff KK while interacting and providing care with the resident. The Grievance Form dated 1/21/26 signed by the Administrator recorded Resident #84 reported the CNA on the 6am to 2pm shift talked rudely to him. The Grievance Official Follow-Up section documented education provided to the CNA on professionalism/customer service, and the resident cares would be provided in pairs. The form documented that the CNA stated she was never rude to the resident, she didn't tell the resident she would come back to check and change them, and the resident didn't request any assistance nor ask for care. The Concern/Recommendation form dated 1/29/26 recorded a resident in room [ROOM NUMBER] reported his call light was not being answered timely and sometimes the light was on for more than an hour. The Staff Response section recorded an inservice with staff done 1/29/26, they would continue to monitor call lights and talk with residents. The Concern/Recommendation form dated 1/29/26 recorded Resident #72 reported her call light was not being answered timely and it usually took 30 minutes. The Staff Response section recorded an inservice with staff done 1/29/26, they would continue to talk with residents and monitor call lights. The Grievance Form dated 1/29/26 signed by the Administrator as resolved on 1/30/26 recorded Resident #8 reported she waited 45 minutes for assistance, she put her light on at 7:10 PM and was very upset and crying. The Grievance Official Follow-Up section documented an inservice done on 1/29/26 with staff, they would continue to monitor call lights. The Grievance Form dated 1/29/26 signed by the Administrator as resolved on 1/30/26 recorded Resident #43 reported the overnight CNAs do not change her brief overnight and she is a complete bed change when that happens. The resident said she already had skin issues and that two staff did a check and change. The Grievance Official Follow-Up section documented an inservice was done on 1/30/26 with staff and they would continue to monitor call lights. The Concern/Recommendation form signed by the DON on 1/29/26 and the Administrator on 1/30/26 recorded Resident #45 reported a concern with a call light not being answered and a nurse trying to give him insulin medication which he did not take. The Grievance Form dated 1/30/26 signed by the Administrator as resolved on 1/31/26 recorded Resident #45 complained of sitting in bowel movement/feces for 14 hours and he did not like it at the facility. The Grievance Official Follow-Up section documented the Administrator asked staff in that hall and they reported they had changed the resident. The form documented an all staff huddle conducted at 2:00 PM, staff were talked with about checking with residents to see if they needed assistance. On 1/31/26 a note was added of a report staff were slow, a bath offered, and the resident refused. A second page Statement Form dated 1/31/26 documented follow up with Resident #45 on the grievance. The resident reported staff taking care of him were slow. The form also recorded staff reported Resident #45 cussed them out and he was very rude and mean. The Grievance Form dated 1/31/26 signed by the Administrator as resolved on 1/31/26 recorded Resident #44 reported a concern with a dietary staff member placing a food tray on her lap and if she could have thrown it at the dietary aide she would have. The form documented the official follow up as the dietary staff member reported the resident requested the tray be placed on her lap, she cussed the staff member out, and education was provided to the staff member about the resident's behaviors. The Grievance Form dated 2/1/26 signed by the Administrator as resolved on 2/1/26 recorded Resident #78 reported a concern with CNAs telling him they could not toilet him because they didn't have an EZ stand (sit-to-stand mechanical lift). The Grievance Official Follow-Up section documented the CNA reported that the EZ stand was not available, she helped the resident to use a urinal, and she found an EZ stand to help him. The Grievance Form dated 2/2/26 signed by the Administrator recorded Resident #84's family member reported the resident stated the CNAs were not treating him well, they just threw things wherever they wanted, and their bedside manner was not good. The Grievance Official Follow-Up section documented the complaint that CNAs put the blankets and bed linens on the floor and the Administrator would talk about it in a huddle. The Grievance Form dated 2/3/26 signed by the Administrator as resolved on 2/7/26 recorded Resident #85's family member reported all the resident's new clothes were missing that included plain t-shirts (a variety of colors), gym shorts, his TV remote, and the family member was supposed to be doing his laundry; the family member wanted the CNAs to stop sending clothes to the laundry room. The Grievance Official Follow-Up section documented a basket was placed in the resident's room, a sign up that family do laundry, the remote was found, and staff informed. The form documented a phone call placed to the family member 2/7/26 but lacked any documentation of follow up to confirm if the clothes were found or if the issue remained resolved. The Grievance Form dated 2/4/26 signed by the Administrator as resolved on 2/4/26 recorded Resident #43 reported not getting checked and changed on the last 3 overnight shifts. The Grievance Official Follow-Up section documented the care need was placed on the TAR (Treatment Administration Record), they would place the resident to get woken up between 3 to 4 AM to be checked and changed. The Grievance Form dated 2/5/26 signed by the DON as resolved on 2/6/26 recorded Resident #88 reported being left in bed due to a broken chair and when she asked to speak to a nurse, the staff member was rude stating she could use the call light, the call light was not in reach at the time, the bed side table was also not in reach, and the nurse would not come to talk to the daughter. The daughter turned on the call light at 3:00 PM, noticed the chair was unplugged, and when staff came in they did not offer to help rearrange to plug in the chair and oxygen, so the daughter did it. Upon leaving the room, the oxygen was not reapplied, the daughter asked the staff member to come back in and reapply the oxygen, and the staff member was rude about doing so. The concern was also reported on 1/19/26, upon return to the facility, EMTs (emergency medical technicians) had to wait 30 minutes for paperwork to be given. The nurse stated she would be back to do an assessment, came back to take vitals, said be back again and did not go back until 7:00 PM. The daughter reported the resident's side of the room not cleaned the entire time the resident was in the hospital and staff told the resident they did not have time to warm up her supper. The Grievance Form dated 2/6/26 signed by the DON as resolved on 2/6/26 recorded a family member of a resident who formerly resided in room [ROOM NUMBER]-A reported a concern that the resident turned on the call light at 6:10 PM while the family member was on the phone with the resident and on the phone until 6:45 PM and no one had been in to help the resident. The Grievance Form dated 2/11/26 signed by the Administrator as resolved on 2/11/26 recorded Resident #8 reported a concern the staff did not have incontinence briefs available for her on the overnight shift. The Grievance Official Follow-Up section documented the Administrator talked with the Staff GG, Certified Medication Aide (CMA), who ordered supplies reported they had large pull ups but extra large would be placed in central supply. The Grievance Form dated 2/15/26 signed by the Administrator as resolved on 2/15/26 recorded Resident #30 complained staff let another resident yell in the hallway while staff were laughing at him and he reported call lights taking an hour and a half on the 200 Hall. The Grievance Official Follow-Up section documented the staff were educated on 2/15/26 about call lights and residents yelling. The Grievance Form dated 2/15/26 signed by the Administrator as resolved on 2/15/26 and 2/16/26 recorded Resident #45 reported missing 4 pairs of blue pants. The Grievance Official Follow-Up section documented the Administrator spoke with laundry and they would find the resident some clothes as he came with no clothes. The form lacked any documentation of further follow up or interview with the resident to confirm resolution or whether the resident actually owned 4 pairs of pants that were missing. The Grievance Form dated 2/16/26 signed by the Administrator as resolved on 2/17/26 recorded Resident #16 reported a concern that Staff HH, CMA, made the comment that the resident better watch her back. The Grievance Official Follow-Up section documented the Administrator Spoke with the CMA and had her write a statement. The statement form dated 2/16/26 recorded the CMA had no knowledge of any conversation of any kind with staff or resident on any day of an abusive nature. The Grievance Form dated 2/16/26 signed by the Administrator as resolved on 2/18/26 recorded Staff II, LPN, reported a concern involving Resident #52. Staff II reported Resident #52 very upset upon return from hospital around 12:00 PM as Staff JJ, CNA, did not do any cares, no pericare (cleansing of perineal area after incontinence), no assistance with any activities of daily living, and the 2pm to 10pm shift called the nurse into the resident's room around 3:00 PM as the resident needed help. Resident #52 reported to Staff II that she had been asking for help since returning from the hospital, the resident still underneath all the hospital linens and draw sheet (transfer sheet), with a brief and all linen saturated with blood and urine from the mid back to mid thigh. The Grievance Official Follow-Up section documented the DON spoke with Staff JJ who would be retrained starting 2/18/26, the facility wanted Staff JJ to do better with her cares, and she would be monitored. The Grievance Form dated 2/24/26 signed by the Administrator as resolved on 2/25/26 recorded Staff II, LPN, reported a concern involving Resident #36 and Resident #78's family member. Staff II reported Resident #36 sat by the med cart in the commons area by the dining room when Resident #78's family member walked by and said 'fuck you' to Resident #36 who became upset and said he wanted it turned in as every time the family member seen Resident #36 he cursed at him due to Resident #36 reporting the family member stealing. The Grievance Official Follow-Up section documented the Administrator spoke with the family member of Resident #78 about calling residents curse names. The family member responded that Resident #36 calls Resident #78 names. The Administrator followed up with Resident #36 about calling Resident #78 names which he acknowledged but stated he had not done for a couple of months. The Administrator documented both residents and the family member were educated about name calling. The Grievance Form dated 2/24/26 signed by the DON as resolved on 2/25/26 recorded Resident #3 reported Staff KK, LPN, stuck her insulin in like a dart, the nurse spoke to her rudely, and refused to push her in the wheelchair on 2/24/26. The form also recorded the resident in a different chair that day, complained to the resident about her hygiene in the hallway, and the resident felt like she was being bullied that day. The Grievance Official Follow-Up section documented the DON spoke with Staff KK regarding the grievance and that they would be making some changes to assignments. The Grievance Form dated 2/27/26 signed by the Administrator as resolved on 2/27/26 recorded Staff LL, Therapy, reported a concern involving a resident who formerly resided in room [ROOM NUMBER]-B. Staff LL reported the resident put his call light on at 6:00 AM, called the front desk twice, a staff member by first name only noted to take the call, and no one went to help the resident until 8:00 AM and the resident almost missed breakfast. The resident reported the staff never cleaned up the room, took laundry, he waited 30 minutes to an hour for the call light to be answered, staff leave call light on for an hour, and it had been recurring for weeks on the 6am to 2pm shift. The resident further reported numerous items including: being left on the toilet for up to one hour; no one empties the urinal; and coming on the wrong shower days. The Grievance Form dated 2/28/26 signed by the Administrator as resolved on 3/2/26 recorded Resident #59 complained call lights took 1 hour to answer, he had a bowel movement in his brief and not changed in a timely manner, and complained of pain meds. The form contained no further elaboration about the pain med concern. The Grievance Official Follow-Up section documented the Administrator educated staff on 2/28/26, spoke to the nurse about pain med, and hung a sign on the door to leave it open. The Concern/Recommendation form dated 3/3/26 signed by the Administrator recorded Resident #44 reported a concern that a resident called Resident #44 a racial slur and threw water on her. The Staff Response section documented staff stated the resident didn't want to go back in the room and explained that was why they had two staff with cares. The response failed to indicate which other resident was involved in the altercation and which needed two staff with care. The form lacked any documentation of further follow up or interview with Resident #44, any other resident or staff who may have witnessed the interaction, or whether an investigation was initiated for resident to resident potential abuse allegation. The Grievance Form dated 3/11/26 signed by the Administrator as resolved on 3/12/26 recorded Resident #5's family member reported a concern that the resident was missing a pink blanket, it went to the laundry and had not been returned, and when going to the bathroom it took a very long time. The Grievance Official Follow-Up section documented staff needed to help the resident in the bathroom and assist her with walking; staff educated at huddle at 2:00 PM on 3/12/26 and the pink blanket found in her closet. A second white page cut off at the top of the form documented for staff to help the resident get cleaned up and they stated, you can walk, that's why we leave you and the family member stated that was true, however, the resident was unable to clean herself after using the bathroom. The Grievance Form dated 3/12/26 signed by the Administrator as resolved on 3/12/26 recorded Resident #51 reported a concern to hospice that Resident #46 tried to pull her pants down and she got away and left the area. The Grievance Official Follow-Up section documented the Administrator spoke with Resident #46 who reported nothing happened and he was confused about the concern. The Administrator spoke with Resident #51 who reported when Resident #46 tried to pull her pants down, she left the area. The Administrator documented both residents educated not to be around each other. The form lacked any documentation of further follow up or interview with other residents, staff, or potential witnesses to the occurrence or whether an abuse investigation was initiated. The Grievance Form dated 3/13/26 signed by the Administrator as resolved on 3/14/26 recorded Resident #43 reported a concern that while attending activity on 3/12/26 Resident #15 threw a bean bag at her making contact with her arm. The Grievance Official Follow-Up section documented at the time of the incident staff told Resident #15 that was not appropriate and he left the area, then returned to activity and the residents were separated as neither wanted to leave. The form documented in the future, the residents would be kept opposite during the activity. On 3/13/26 the DON noted she spoke with Resident #43 whos reported Resident #15 did it on purpose, the DON looked at Resident #43's arm and there were no bruises or marks, and the resident encouraged to continue attending activities. The DON also noted she spoke with Resident #15 and he acted like he didn't know what the DON was talking about. The form lacked any documentation of further follow up or interview with other residents or potential witnesses to the occurrence or whether it was investigated as a potential allegation of abuse. The Grievance Form dated 3/26/26 signed by the Administrator recorded Resident #74 reported a concern that sometimes it took 30 minutes or more to get the call light answered. The Grievance Official Follow-Up section documented 3/27/26 staff educated that day at a huddle about answering call lights in a timely manner. The Grievance Form dated 3/29/26 signed by the Administrator as resolved on 3/31/26 recorded Resident #16 reported a concern that two CNAs helped her roommate, Resident #16 had her call light on needing help in the bathroom, and the staff left her so she did her own cares. The Grievance Official Follow-Up section documented 3/28/26 the resident was unable to tell the Administrator who the two CNAs were and she would educate staff at huddle and no other investigation documented on the form. The Grievance Form dated 3/29/26 signed by the Administrator as resolved on 3/29/26 recorded Resident #58 reported a concern with the way the CNA talked to her, the CNA had a tone, and the resident did not want the CNA back in her room. The Grievance Official Follow-Up section documented 3/29/26 the resident reported she had no other concerns, she still did not want the CNA, and Staff MM, CNA, educated not to go in Resident #58's room. The Grievance Form dated 4/1/26 signed by the Administrator as resolved on 4/1/26 recorded Resident #45 reported a concern that he didn't receive his dinner tray the previous night, he turned on the call light and no one would answer forever. The Grievance Official Follow-Up section documented the Administrator spoke with the resident with the DON and Dietary Manager present, the resident was very rude, they asked the resident to come to the dining room for his meals, and they educated staff at huddle on 4/1/26. An additional note added in different color ink without a date that the CMA stated that no one complained they didn't receive dinner. The Grievance Form dated 4/8/26 signed by the Administrator as resolved on 4/9/26 recorded a hospice CNA reported a concern for Resident #51. The aide reported the resident asked the dietary aide for a peanut butter and jelly sandwich and a drink and the dietary aide informed Resident #51 she could only have so many sandwiches and drinks per day. The Grievance Form dated 4/9/26 signed by the Administrator as resolved on 4/10/26 recorded Resident #21 reported a concern that from 11:30 AM to 2:30 PM, no one answered his call light, he had a hard time getting anyone to change his oxygen tank, and it took 45 minutes at night to get his tray (food). The Grievance Official Follow-Up section documented staff educated at 2:00 PM huddle about answering call lights in a timely manner. The Grievance Form dated 4/13/26 signed by the Administrator as resolved on 4/13/26 recorded Resident #25 reported a concern he had to have a bowel movement at 6:30 AM, he put on his call light, a girl walked in at 8:00 AM, shrugged her shoulders and walked out. The Grievance Official Follow-Up section documented the Administrator spoke with Resident #25 and he reported the CNA went into his room, turned off his light and walked out, and the Administrator let the resident know that they would follow up on his complaint; an investigation was started. The Grievance Form dated 4/14/26 signed by the Administrator as resolved on 4/15/26 recorded Staff Y, Occupational Therapist (OT), reported Resident #64 agitated and yelled in the hallway when the therapist approached at 2:10 PM. Staff Y reported the resident stated he had a wet brief (incontinence) at lunch, he told a CNA who told him they would be right back, and the resident upset they never came back. Staff Y assisted the resident with care. The Grievance Form dated 4/17/26 signed by the Administrator as resolved on 4/17/26 recorded a friend of Resident #35's reported the call light 30 minutes, the room was dirty, changing clothes, and bath, and no other notes to detail the issues in the first section. The Grievance Form dated 4/16/26 signed by the DON as resolved on 4/17/26 recorded a resident who formerly resided in room [ROOM NUMBER] reported since 3:00 or 4:00 AM he had been asking for his PRN (as needed) pain medication and muscle relaxer but he kept getting told he could not/did not have any. The Grievance Official Follow-Up section documented the staff had been educated on the use of PRNs and giving them in a timely manner and explaining why, if they could not. The Grievance Form dated 4/30/26 signed by the Administrator as resolved on 5/1/26 recorded Resident #45 reported the hallway would be noisy, he could hear staff talking, he turned on his call light, and everything went quiet with no one helping him, and it took awhile for anyone to answer his call light. The Grievance Official Follow-Up section documented the Administrator educated (staff) at huddle that day at 2:00 PM. The Grievance Form dated 5/1/26 signed by the Administrator as resolved on 5/1/26 recorded Resident #81 reported a concern of having a bruise to his left wrist and right elbow that happened during care and rolling on 4/30/26, and he did not believe it was purposeful. The Grievance Official Follow-Up section documented the DON and Administrator educated staff verbally on hall to use proper hand placement and a sheet to roll the resident and educated (staff) at huddle on 5/1/26 at 2:00 PM. The form lacked any documentation to indicate an investigation initiated for potential abuse or interviews with staff about the incident. 3. Resident #81 The Minimum Data Set (MDS) assessment dated [DATE] for Resident #81 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented no signs or symptoms of delirium, verbal behaviors directed toward others occurred on 1 to 3 days of the 7-day look back period, and the resident did not refuse care. The MDS coded the resident's functional abilities with mobility and showering self as dependent upon a helper for all effort. The MDS documented diagnoses that included debility, cardiorespiratory conditions. The Care Plan dated 5/3/26 for Resident #81 documented a focus area for assistance needed for Activities of Daily Living (ADL) care related to weakness and decreased mobility. The care plan interventions directed staff to provide assistance of 1 person for bathing and dressing, check and change for toileting, and provide assistance of 2 persons and a hoyer (full body) mechanical lift for transfers. The Care Conference note dated 4/2/26 documented Resident #81 reported to the Director of Nursing and MDS Coordinator who were in attendance that it took a long time for his call light to be answered. The note also recorded Resident #81 felt that nursing staff did not listen to him. The Weekly Skin Review dated 4/24/26 at 5:16 PM recorded skin condition of redness, open area, and pre-existing; it did not check the box for bruises. The review documented description of the skin conditions present as: groin area with redness to folds with treatment in place and right gluteal fold open area with treatment in place. The Incident Report dated 4/30/26 at 9:00 PM documented an incident for Resident #81 recorded by Staff L, Licensed Practical Nurse (LPN). The report documented Staff L was called to the resident's room by Certified Nurse Aide (CNA) due to bruises on left wrist measuring 5 cm x 2 cm (centimeters length by width) and right elbow measuring 10 cm x 7 cm. Staff L wrote the bruises were deep purple, no warmth noted, and no reported pain. Staff L wrote Resident #81 alert, oriented, and reported he was not harmed intentionally. Staff L wrote the resident had limited bed mobility, obesity and use of 10 mg (milligrams) Eliquis (anticoagulant medication aka blood thinner) daily were contributing factors. Under Resident Description, Staff L wrote: It's when they roll me. They hold on too hard. Under Immediate Action Taken, Staff L wrote she reported to the Director of Nursing (DON) for further assessment, monitored CNAs on evening shift with no issues noted during bed mobility. Under Injury Type / Location the report documented bruise to the right antecubital and bruise to left hand palm. The report documented the resident's Mental Status as oriented to person, place, time, and situation. The Progress Notes dated 4/30/2026 at 9:48 PM linked to the Incident Report and recorded the same information. The Follow up Skin assessment dated [DATE] at 9:50 PM documented a skin condition of a bruise. The assessment recorded the right elbow with deep purple bruise measuring 10 cm by 7 cm; left hand palm with deep purple bruises measuring 5 cm by 2 cm. The facility submitted the photographic documentation of Resident #81's bruises which Staff L, LPN, took on 4/30/26 when she first reported them. The photographs depict two areas: 2 deep dark maroon colored thick lines at the base of a hand located on a wrist area, the lines clearly delineated of different lengths that would line up with the length and width of finger marks; and a large area of an elbow region with deep dark maroon and greenish coloring spanning an area which would be greater than the size of a dollar bill. Only upclose pictures were taken so the whole area of the hand/wrist and whole arm was not depicted. The Weekly Skin Review dated 5/1/26 at 2:57 PM recorded skin condition of none, skin intact, despite the photographic evidence and skin assessment the facility had of bruises present on 4/30/26. On 05/11/2026 at 3:00 PM Resident #81 stated he had lived at the facility for about a year, he required a hoyer (full body) mechanical lift for transfers and the staff grab hold of him and yank when helping him. Resident #81 reported the staff grabbed a hold of his arms harshly leaving a bruise when they grabbed to move him. Observation during the interview revealed a fading bruise to the resi

Based on clinical record review, facility document review, observations, staff interviews and policy review, the facility failed to ensure each resident received Safe Smoking Assessments quarterly and/or with change in condition, adequate supervision for smoking and fall prevention safety, and interventions to prevent accidents when smoking and reduce risks for falls for 10 of 14 residents reviewed (Resident #7, #9, #46, #51, #56, #69, #71, #78, #80, #2). Resident #80 sustained injury of a thermal burn when the end of a cigarette fell into his shoe on 5/14/26. Resident #2 sustained facial injury with abrasion to the nose when a staff member moved the bed away from the wall on 4/19/26 leading to the resident landing on his face. The facility reported a census of 81 residents. Findings include: 1. Resident #7's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe impaired cognition. The MDS listed Resident #7 as dependent (helper does all of the effort) for sitting to lying, lying to sit on one side of bed, chair/bed to chair transfers. The MDS also documented Resident #7 is usually understood (difficult communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversation). Resident #7's MDS included diagnoses of stroke, hypertension (high blood pressure), anxiety disorder, schizophrenia and respiratory failure. The facility Incident Reports (IR) revealed Resident #7 fell on 1/2/26, 2/4/26, 2/13/26, 2/22/26, 2/27/26, 2/27/26, 3/2/26, 3/10/26, 3/13/26, 3/16/26, 3/21/26, 3/21/26, 4/3/26. The Care Plan with a target date of 7/8/26 revealed Resident #7 was at risk for falls. The interventions directed the following: 1/1/26 Staff education to answer call lights within 15 minutes. 2/4/26 Encouraged to wear grip socks when in bed. 2/13/26 Dycem to seat of the wheelchair. 2/22/26 Occupational Therapy (OT) will evaluate for another wheelchair. 2/27/26 Physician or Nurse Practitioner will review the medication summary. 2/27/26 OT to review wheelchair positioning 2/4/26 Skid strips added to floor at bedside 3/2/26 Please put my bed in low position while I am in bed 3/9/26 Encourage Resident #7 to participate in activities 3/16/26 Send to the emergency room to be evaluated and treated. 3/21/26 Encourage Resident #7 to be out of room when not in bed 3/21/26 Referral to physical and occupational therapy re-admission and fall 4/3/26 Obtaining labs to rule out pneumonia and upper respiratory infection. An Incident Report (IR) dated 1/2/26 at 3:00 am identified an unwitnessed fall in his room. The IR indicated Resident #7 was found in his room on the floor. The IR stated resident crawled out of bed and scooted himself to the door for assistance. Resident #7 stated I just wanted to get out. Immediate action taken; staff placed a call don't fall sign posted visibly from his bed. An IR dated 2/4/26 at 7:45 pm identified an unwitnessed fall in his room. The IR indicated a certified nursing assistant (CNA) called nurse to Resident #7's room where Resident #7 was on the floor beside his bed sitting on his butt, prior to fall resident was sitting on the side of his bed. Resident #7 denied hitting head and acute pain. Resident #7 was assisted off floor with staff and use of a Hoyer. Resident #7 did not want to go back to bed and wanted to sit in his wheelchair. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 2/5/26 at 9:59 am named Interdisciplinary Team (IDT) reviewed fall on 2/4/26 and determined the root cause was self-transferring. New interventions implemented: skid strips beside bed. An IR dated 2/13/26 at 1:45 pm identified an unwitnessed fall in his room. The IR indicated a staff summoned writer to Resident #7's room, Resident #7 was sitting on the floor on his buttocks, and his wheelchair was in the back of him. The call light was off. Resident #7 voiced he slid off his wheelchair. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 2/16/26 at 9:35 am named IDT note reviewed fall on 2/13/26 and determined the root cause was sliding out of the wheelchair. New interventions implemented: Dycem to seat. An IR dated 2/22/26 at 10:30 am identified an unwitnessed fall in his room. The IR indicated a staff summoned writer to Resident #7's room. Resident #7 was laying, leaning on his left side and resting on his left arm/elbow. Resident #7 denied any pain/discomfort. Resident #7 received an abrasion to his right side of forehead. Resident #7 had one gripper sock on right foot and left foot was bare. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 2/23/26 at 9:31 am named IDT note reviewed fall on 2/22/26 and determined the root cause was self-transferring. New interventions implemented: Occupational Therapy to evaluate for a different wheelchair. An IR dated 2/27/26 at 1:45 am identified an unwitnessed fall in his room. The IR indicated Resident #7 slid out of bed and scooted himself to the door for assistance. Call light was in reach but was off. Resident #7 stated I'm in pain and I need to go to hospital Resident #7 stated pain was 10/10 and everywhere. Resident #7 stated I don't have to explain myself again. Assessment completed before transfer. Resident #7 refused as needed pain medication stated it doesn't work. Resident #7 noted medication he gets at emergency room works. On call physician notified and one time dose order for Hydrocodone 5/325 mg received. Pain medication administered. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 3/2/26 at 10:00 am named IDT note reviewed fall on 2/27/26 and determined the root cause was slid off of bed. New interventions implemented: Bed to be in lowest position. An IR dated 2/27/26 at 6:15 pm identified a witnessed fall in his room. This nurse noted Resident #7 slid off his wheelchair and onto his bottom when this nurse was going to his room to check on him due to a recent fall. Resident #7 assessed for pain and reported pain that he said he had for the last week. Assisted resident off the floor x 2 staff to his bed. Resident #7 educated call staff when he notices he is sitting at the edge of his wheelchair. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 3/2/26 at 10:23 am named IDT note reviewed fall on 2/27/26 and determined the root cause was slid out of wheelchair. New interventions implemented: OT to access. An IR dated 3/2/26 at 5:00 am identified an unwitnessed fall in his room. Resident #7 stated he slid off his bed and hit his head. No visible injuries noted, no redness, swelling, bruising, or open area observed to head or body. Also documented on the IR Resident #7 wanted to transfer to his wheelchair but forgot to call for help. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 3/2/26 at 9:50 am named IDT note reviewed fall on 3/2/26 and determined the root cause was slid off of bed. New interventions implemented: bed to be low position while in bed. An IR dated 3/10/26 at 10:15 am identified an unwitnessed fall in his room. Resident #7 found by CNA sitting on bedroom floor with his back against the bed. Prior to fall CNA stated resident #7 was sitting in his wheelchair in the room. Resident #7 stated I slid off the wheelchair and scooted myself by the bed. Denied hitting his head. No other acute injuries. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 3/11/26 at 9:26 am named IDT note reviewed fall on 3/10/26 and determined the root cause was self-transferring. New interventions implemented: encourage activity participation An IR dated 3/13/26 at 7:15 pm identified an unwitnessed fall in his room. The nurse went to the resident's room and found him sitting on the floor beside his bed. Resident #7 stated that he slid off his bed. Resident #7 assisted x 2 staff to his wheelchair. The IR failed to have an immediate intervention documented. An IR dated 3/16/26 at 10:00 am identified an unwitnessed fall in the hallway. Resident #7 was heard screaming for help in the hallway outside of his room. Resident #7's wheelchair was at the bedside locked with Hoyer pad in wheelchair. Resident #7 denied hitting head. Resident #7 has a skin tear to the right thumb. Resident #7 denied pain/discomfort. Resident #7 able to move extremities at baseline. Resident #7 assisted via Hoyer lift and 2 CNA's and this nurse back into wheelchair. Resident #7 placed visually where he could be monitored continually. Resident #7 stated that he doesn't know what happened or why he was out of the wheelchair. The IR also documented Resident #7 is wheelchair bound, attempting to walk on his own, fell in hall, in front of his room door. Review of the facility Progress Notes on 3/17/26 at 9:50 am named IDT note reviewed fall on 3/15/26 and determined the root cause was self-transferring. New interventions implemented: Send to ER for evaluation. An IR dated 3/21/26 at 9:00 am identified an unwitnessed fall in his room. Resident #7 was found on the floor in front of his wheelchair. Resident #7 stated he slipped out of his wheelchair while watching TV. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes revealed the facility failed to document this fall. Review of the facility Progress Notes on 3/24/26 at 9:16 am noted IDT reviewed fall on 3/21/26 and determined the root cause was reaching. New interventions implemented: Order Physical and Occupational Therapy. An IR dated 3/21/26 at 8:00 pm identified an unwitnessed fall in his room. Resident #7 stated he about to self-transfer to bed when he fell and scooted self to the door for assistance. Call light was within reach but off. Resident #7 noted he doesn't need to transfer to bed. Resident transfers with Hoyer x 2 but refusing to call for assistance requesting in multiple falls recently. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 3/24/26 at 9:23 am named IDT note reviewed fall on 3/21/26 and determined the root cause was self-transferring. New interventions implemented: Encourage resident to be out of room when not in bed. An IR dated 4/3/26 at 7:40 am identified an unwitnessed fall in his room. Resident #7 was trying to get up and fell down. Resident #7 was assessed, vitals taken, got dressed, up and toileted with no injuries. The IR failed to have an immediate intervention documented. Review of the facility Progress Notes on 4/6/26 at 9:32 am named IDT note reviewed fall on 4/3/26 and determined the root cause was self-transferring. New interventions implemented: labs to be requested. Interview with Resident #7 on 6/1/26 at 3:00 pm stated he doesn't have his new wheelchair yet, he stated that he has been waiting for it and has never received it. Observation completed in Resident #7's room on 6/1/26 at 3:00 pm revealed the facility failed to have interventions in place, observed no skid strips on the floor in resident's room, no Dycem to seat of wheelchair, no call light sign stating call don't fall sign and no scoop mattress to his bed to help prevent falls from bed. 2. Resident #69's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severe impaired cognition. The MDS listed Resident #69 as dependent (helper does all of the effort) for roll left and right, sitting to lying, lying to sit on one side of bed, chair/bed to chair transfers. The MDS also documented Resident #69 sometimes understands (responds adequately to simple, direct communication only) and sometimes understood (ability is limited to making concrete requests). Resident #69's MDS included diagnoses of heart failure, hypertension (high blood pressure), aphasia (a neurological disorder caused by brain damage that impairs your ability to speak, write, and understand language), and non-Alzheimer's dementia. Observation completed on 5/12/26 at 8:41 am revealed Resident #69 was observed in his room in his wheelchair. Observed signs on the door to not leave Resident #69 unattended in his room in a wheelchair. No staff were present in the room. The facility IR documented revealed Resident #69 documented a fall on 5/29/26. The Care Plan with a targeted date of 7/10/26 revealed Resident #69 was at high risk for falls related to paralysis, high risk for fracture-low vitamin D, bone density, gait/balance problems, incontinence. The interventions directed the following: 4/2/26 Supervision while in wheelchair. Please do not leave me unattended in my wheelchair. 5/29/26 Encourage Resident #69 to lay down after meals. An IR dated 5/29/26 at 10:15 am identified Resident #69 had an unwitnessed fall in his room. Resident #69 was found on the floor in his room by a hospice CNA. Resident #69 was lying on the floor in front of a wheel chair beside the bed. No skin injuries or head injuries noted. The IR also documented Resident #69 was transferring without assistance. The IR failed to have an immediate intervention documented. Interview with the Director of Nursing (DON) on 6/3/26 at 12:28 pm acknowledged that Resident #69 was in his room in the wheelchair when he fell. The DON also stated the expectation is to have the nurse place an immediate intervention in place after the fall. The DON stated they have a list of interventions they can use and then the Interdisciplinary Team will meet and review the fall and change the intervention if needed. Review of the facility policy named Fall Prevention Program with a revised date of 7/2023 revealed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse will indicate on the care plan/Kardex the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. Low/Moderate Risk Protocols: Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: A clear pathway to the bathroom and bedroom doors. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. Call light and frequently used items are within reach. Adequate lighting. Wheelchairs and assistive devices are in good repair. Implement routine rounding schedule. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. Monitor vital signs in accordance with facility policy. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. High Risk Protocols: The resident will be placed on the facility's Fall Prevention Program. Indicate fall risk on care plan. Place Fall Prevention Indicator on the Kardex Implement interventions from Low/Moderate Risk Protocols. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment, including but not limited to: Assistive devices Increased frequency of rounds Sitter, if indicated Medication regimen review Low bed Alternate call system access Scheduled ambulation or toileting assistance Family/caregiver or resident education Therapy services referral When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. 3. The Minimum Data Set (MDS) dated [DATE] revealed Resident #9's admitted to the facility on [DATE], scored 11 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Diagnoses include cancer, history of stroke, impairment to one side upper extremity, need for substantial/maximal assistance (helper does more than half the effort), and use of wheelchair. Review of Resident #9's Care Plan documented, Resident #9 is a smoker and is not at risk for smoker related injury and may smoke independently per facility assessment. Interventions included complete smoking assessment quarterly and with change in condition. Resident #9 can smoke unsupervised. Review of Resident #9's Electronic Health Record (EHR) revealed most recent Safe Smoking Assessment Form dated 9/23/25 documenting Resident #9 to be safe with independent smoking. The clinical record lacked any other assessments after 9/23/25. 4. Review of the MDS dated [DATE] revealed Resident #46's facility admission on [DATE], BIMS of 11, indicating moderate cognitive impairment. Diagnoses include history of stroke, hemiplegia (paralysis) affecting right dominant side, diabetes mellitus, depression, and need for substantial/maximal assistance for transfers and supervision or touch assistance with use of walker or wheelchair for ambulation. Review of Resident #46's Care Plan documented a focus initiated 9/22/25, Resident #46 likes to smoke and has potential for injury. Resident #46 is to be supervised while smoking due to having burn marks on clothing and shoes. Interventions include assessing resident's ability to smoke independently/safely, close monitoring while smoking in the smoking area, ensure there is no lighter/cigarettes at bedside; staff will provide during smoking time in the smoking room, and observe clothing and skin for signs of cigarette burns. A focus initiated 1/14/25 documented, Resident #46 is supervised with smoking, he is assessed to smoke safely with supervision. Interventions included, encourage resident to wear a smoking apron. Review of Resident #46's most recent Safe Smoking Assessment Form dated 9/22/25, documented Resident #46 is not able to extinguish smoking materials completely in an appropriate receptacle and not able to dispose of ashes or another tobacco-related residue appropriately. Need for adaptive equipment failed to indicate the need for a smoking apron and/or cigarette holder. The Interdisciplinary Team Consultation (IDTC) safety notes stated IDTC reviewed Resident #46's cushion in wheelchair and there were noted cigarette burns to the cushion. There was also noted cigarette butts laying on ground next to Resident #46's wheelchair. Review of Facility provided Smoking: Accidents and Supervision Contract for Resident #46, dated 12/16/25, indicated a current safe smoking assessment had been completed. Resident #46's Care Plan addressed supervision, and protective gear not applicable. 5. Review of MDS dated [DATE] revealed Resident #51's facility admission on [DATE], BIMS of 8, indicating moderate cognitive impairment. Diagnoses include cancer, history of stroke, hemiplegia, heart failure, COPD and need for supervision or touching assistance for transfers with use of a wheelchair. Review of Resident #51's Care Plan initiated 9/9/25 documented, Resident #51 likes to smoke, a smoking assessment was completed and requires supervision for safety with interventions for close monitoring while smoking in the smoking area and encourage Resident #51 to utilize a smoking apron. Review of Resident #51's most recent Safe Smoking Assessment Form dated 9/9/25, documented Resident #51 is not able to light own cigarette safely and need for use of a smoking apron. IDTC safety notes stated, Resident #51 is unable to light her own cigarette and is legally blind. 6. Review of MDS dated [DATE] revealed Resident #56's admission to the facility on 7/18/25, BIMS of 14, indicating cognitively intact. Diagnoses include history of stroke, speech and language deficits following stroke, and muscle wasting requiring substantial/maximal assistance for ambulation with use of a wheelchair. Review of Resident #56's Care Plan initiated 8/11/25 documented, Resident #56 enjoys smoking, currently requiring supervision, and a smoking contract in place 12/16/25. Interventions included Resident #56 requires supervision with smoking. Review of Safe Smoking Assessment Form dated 11/3/25 revealed due to Resident #56's cognitive status, supervised smoking is required. Review of Facility provided Smoking: Accidents and Supervision Contract dated 12/16/25 indicated a current safe smoking assessment had been completed, Resident #56 requires supervision, and protective gear not applicable. 7. Review of MDS dated [DATE] revealed Resident #71's admission to facility on 8/20/25, BIMS of 15, indicating cognitively intact. Diagnoses of metabolic encephalopathy (altered brain function caused by underlying illness), liver cirrhosis (permanent scarring of the liver caused by chronic disease or injury), anxiety, depression, COPD, and partial/moderate transfer assistance with use of wheelchair. Review of Resident #71's Care Plan initiated 9/2/25 documented, Resident #71 has COPD related to smoking with an intervention of utilization of nicotine patch daily to assist with smoking cessation. Care Plan failed to identify Resident #71's current smoking status. Review of facility admission MDS dated [DATE] revealed Resident #71's BIMS of 13, indicating cognitively intact. Review of Resident #71's admission Progress Note dated 8/20/25 documented Resident #71 is a current smoker. Review of Resident #71's January 2026 Medication Administration Record (MAR) documented an order for Nicotine transdermal patch, place one patch to skin daily, removing old patch, had been administered 31 of 31 days. Review of Resident #71's February 2026 MAR documented the Nicotine patch had been administered 23 of 28 days, Resident #71 refused the patch 5 days. Review of Resident #71's March 2026 MAR documented the Nicotine patch had been administered 16 of 31 days, Resident #71 refused the patch 15 days. Review of Resident #71's April 2026 MAR documented the Nicotine patch had been administered 1 of 30 days, Resident #71 refused the patch 29 days. Review of Resident #71's May 2026 MAR documented the Nicotine patch had been administered 2 of 31 days, Resident #71 refused the patch 29 days. Review of Resident #71's Electronic Health Record (EHR) failed to provide a Safe Smoking Assessment Form to indicate an assessment had been completed. On 5/26/26 a Safe Smoking Assessment was requested from Administrative Staff for Resident #71. Review of facility provided Safe Smoking assessment dated [DATE], indicated Resident #71 is able to smoke independently. 8. Review of MDS dated [DATE] revealed Resident #78's admission to the facility on [DATE], BIMS of 15, indicating cognitively intact. Diagnoses of stroke, diabetes mellitus, hemiplegia to left side, contractures of left hand, and dependent assistance for transfers and use of wheelchair for mobility. Review of Resident #78's Care Plan initiated 9/24/25 documented, Resident #78 has chosen to continue to smoke and will need to be supervised for smoking safety as evidence by recent smoking assessment with intervention of need to wear a smoker's apron when smoking due to safety concerns, need for supervision, assure Resident #78 can safely reach the ashtray, assistance to make sure cigarette is fully distinguished each time to prevent burns, and show Resident #78 where the designated smoking area is and assist with getting to and from smoking area during smoking times if assistance is needed. Review of Resident #78's most recent Safe Smoking Assessment Form dated 2/26/26, IDTC safety note documented Resident #79 requires supervision for safety. 9. Review of MDS dated [DATE] revealed Resident #80's admission to facility on 11/2/24, BIMS of 15, indicating cognitively intact. Diagnoses of cancer, heart failure, peripheral vascular disease (disorder of blood circulation), below the knee amputation of left lower leg, kidney failure, diabetes mellitus, Non-Alzheimer's Dementia, and independent with transfers and mobility with use of limb prosthesis and wheelchair. Review of Resident #80's Care Plan initiated 12/18/24 documented, Resident #80 has Peripheral Vascular Disease with interventions of education 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. Keep skin on extremities well lubricated with lotion in order to prevent dry skin and cracking of the skin. Monitor extremities for signs and symptoms of injury, infection or ulcers. Monitor and document for excessive edema and encourage resident to elevate legs. Care Plan revealed on 5/14/26 a cancelled focus, initiated 9/30/24 Resident #80 is a smoker and is independent in smoking. A focus initiated 5/14/26 indicated Resident #80 like to smoke and has an actual injury while smoking with interventions to assess Resident #80's ability to smoke independently and safely and provide close monitoring while smoking in the smoking area. A Wound Observation Progress Note dated 5/14/26 at 10:04 AM documented Resident #80 having a thermal burn to the right heel, 1cm L x 0.8cm W x 0.1 cm D with drainage. A Skin/Wound Progress Note Dated 5/14/26 at 10:15 AM documented, Resident #80 seen by wound care provider, orders received to apply Bacitracin to burn on right heel daily and cover with a band aid until healed. An Interdisciplinary Team (ADT) Note dated 5/15/26 at 7:49 AM documented, Resident #80 currently have thermal burns to the right heel. Current treatment order to cleanse right heel with cleanser of choice, apply bacitracin and cover with band aid until healed. Treatments are effective and wounds are improving, no signs or symptoms of infection and surrounding tissue intact. Review of Resident #80's Electronic Health Record (EHR) provided a Safe Smoking Assessment Form dated 9/29/25 indicating Resident #80 able to smoke independently. Safe Smoking assessment dated [DATE] documented Resident #80 has a burn wound to right foot due to a cigarette cherry falling into his shoe and burning his skin. In order for Resident #80 to be safe and injure himself he will need to be supervised during smoking sessions with use of a smoking apron. Review of Facility Provided Smoking Injury Incident report dated 5/14/26 at 10:15 AM documented Resident #80 seen today by wound care provider; treatment orders received for right heel. Resident #80 stated the cherry from his cigarette fell into his shoe. Review of Facility provided Smoking Times and Smokers document, received on 5/11/26 provided the following. Scheduled smoking times and designated department for supervision. 9:00 AM Dietary, 11:00 AM Housekeeping, 1:00 PM Activities, 3:00 PM 200 hall nursing, 7:00 PM 300 hall nursing CNA. Smoking Residents that must be Supervised: Resident #46 Resident #51 Resident #56 Resident #71 Resident #78 Independent Smokers: Resident #9 Resident #80 During continued observation on 5/20/26 at 12:59 PM to 1:47 PM the following was observed: 12:59 PM Designated smoking supervision staff member, Staff K, Recreation Aid, opens door for Resident #51 to exit into the designated smoking area and courtyard. Staff K assists Resident #51 light her cigarette and fails to provide a smoking apron for protection. Resident #80 observed exiting to the smoking area walking independently with front wheeled walker (FWW). 1:00 PM Staff K enters the building from the smoking area and courtyard, standing in the community room with his back to the exit door. At this time Resident #80 is observed sitting outside on a chair smoking a cigarette without the use of a smoking apron for protection. Staff K, remains in the community room talking with other residents. Resident #51 and Resident #80 continue to smoke outside unsupervised. 1:05 PM Resident #51 re-enters the building after smoking. 1:08 PM Staff K returns outside, with Resident #51 and Resident #56 following. Resident #56 observed smoking without wearing a smoking apron. 1:12 PM Staff K enters the building, talking with residents in the community room. 1:14 PM Resident #9 observed exiting to outside smoking area. 1:17 PM Staff K continues to be inside in community area, unable to supervise residents outside. Staff K paging for assistance via walkie for another staff member to supervise smoker Residents. Staff K asks Staff L, Licensed Practical Nurse (LPN) to supervise as he has to provide activities for other residents. Staff L, LPN responds to Staff K stating I would but I'm helping another resident. During this time Resident #51, Resident #80 and Resident #56, two of three residents require supervision and smoking apron (Resident #51 and Resident #80). 1:20 PM Staff K continues in community area, while Resident #9 attempts to enter facility independently, Resident #9's wheelchair gets caught in the door jam. Both Staff K and Staff L fail to respond and assist Resident #9's get through the door. 1:26 PM Staff M, Certified Nursing Assistant (CNA) responds to Staff K's request for assistance. Staff M, CNA assists Resident #78 outside and follows to the smoking area/courtyard to supervise smoking residents. Resident #78 observed lighting a cigarette and smoking. 1:32 PM Staff M, CNA enters building, leaving Resident #51 and Resident #78 outside, neither resident smoking at this time. 1:36 PM Resident #71 attempts to go ou

Based on observations, family interview, resident interview, and staff interview, the facility failed to maintain an environment free of offensive odors, which were pervasive throughout the building during the majority of the survey period. The facility reported a census of 81 residents. Findings include: Observations and interviews on the following dates and times revealed:May 11, 2026:At 1:27 PM a strong, pungent, foul odor present in the breezeway connecting the back halls to the dining room and in the dining and activity areas on the facility's east end.Immediate observations across all hallways revealed multiple areas of noncompliance:a urine/ammonia smell on the 100 hallway, specifically outside Resident 81's room (118).a strong chemical smell outside rooms 106 (Resident #3 and Resident #43's room); this odor irritated surveyors' eyes and throat.construction occurring at the nurses station, where caution tape and orange cones marked the stripped flooring.a strong, pungent urine/ammonia odor outside rooms [ROOM NUMBERS]; the odor's strength irritated surveyor's throat and required them to plug their nose.a urine odor outside room [ROOM NUMBER] (Resident #83 and Resident #12's room).the urine odor continued down the hall outside rooms 306 (Resident #1 and Resident #16's room) and 307 (Resident #73 and Resident #52's room). At 2:13 PM the strong urine smell continued on the 300 hallway as the surveyor transitioned to the 200 hallway. A moderate aroma of ammonia present outside room [ROOM NUMBER] (Resident #72 and Resident #29's room). A strong urine ammonia odor was present outside room [ROOM NUMBER] (Resident #41 and Resident #26's room). The strong urine odor continued where the hallway turned 90 degrees to connect to the dining room.At 2:35 PM a strong urine odor present outside rooms [ROOM NUMBERS].At 3:10 PM a strong, pungent body odor present throughout the dining room and activity rooms.At 4:36 PM the shower room door on the 100 hall wide open. A staff member transported a resident to the shower room and a very strong urine smell detected as the resident passed. May 12, 2026At 10:45 AM in an interview, Resident #4's family member reported the staff fail to change the resident's incontinence brief often enough leaving the resident frequently wet, sitting in urine. At 12:08 PM a strong urine/ammonia odor present in Resident #73's room [ROOM NUMBER] while the resident was not present. At 12:13 PM a strong ammonia/urine odor identified in Resident #86's room, 308.At 2:23 PM In an interview, Resident #1 reported having to wait long periods of time after incontinence episodes for assistance to the bathroom. Observation revealed the presence of strong urine odor. May 13, 2026At 4:30 AM Immediately upon entering the building, a strong ammonia/urine odor was identified. A half-full trash bag was attached to the outside of a 33 gallon soiled linen yellow barrel on hall 100. An unknown staff member exited room [ROOM NUMBER] with trash after providing care.At 4:35 AM two large trash bags rested on the carpeted floor just outside room [ROOM NUMBER] (Resident #93 and Resident #60's room) on the east end of hall 200; one bag contained trash and the other soiled incontinence linens. A staff member placed items in the bag, picked up both bags, and walked down the hall. A strong ammonia/urine odor present in hall 200 outside rooms [ROOM NUMBERS].At 4:43 AM a strong ammonia/urine smell on hall 300 outside room [ROOM NUMBER] (Resident #83 and Resident #12's room). The odor continued down the hallway to room [ROOM NUMBER] (Resident #73 and Resident #52's room), where an open trash bag containing soiled incontinence briefs was open to the air.At 4:46 AM Staff A, Certified Nurse Aide (CNA), and Staff B, CNA, entered Resident #83's room. Staff performed incomplete incontinence care for Resident #83, who was heavily soiled with urine and feces. Staff A removed the soiled brief and left the room with the soiled bags of trash and linens, then placed the trash in a bag on the floor in hall 300. Staff A placed the soiled linen bag in room [ROOM NUMBER] at the end of the hallway. The urine smell remained in the room after the staff provided incontinence care.At 5:06 AM a strong ammonia smell present throughout Resident #52's room. Staff B and Staff A performed incomplete incontinence care for Resident #52, whose brief was heavily soiled with urine and feces. Staff B left the room with a trash bag, returned, and stated she needed one more bag. At 5:18 AM, Staff B left the room with the soiled linen bag. The urine smell remained in the room after the staff provided incontinence care.At 5:20 AM Staff B took a trash bag into empty room [ROOM NUMBER], which staff used to place garbage bags and soiled linen bags on the tiled floor. Staff B responded during an interview that she noticed the urine odor throughout the building. Staff B acknowledged the smell was down the entire 300 hall and was present on the 100 hallway, speculating it came from the carpet. Staff B responded that she had told leadership about the terrible odor before, and that housekeeping cannot get the smell out. At 5:29 AM Staff C, Registered Nurse (RN), responded during an interview that he had not noticed a urine smell that night or previously, speculating the surveyor smelled it because CNAs had just completed incontinence care rounds or that he was just used to the smell.At 5:31 AM Staff A placed smaller bags of trash into the large bag of trash remaining on the floor of the 100 hallway, then removed it from the hallway.At 5:38 AM the vacant room [ROOM NUMBER] contained two large bags of trash tied shut but placed on the floor; a strong urine odor permeated the room.At 5:43 AM Staff D, CNA, exited room [ROOM NUMBER]. Staff D responded during an interview that she had not noticed an odor, speculating she was used to the building smell since she had worked there for three years.At 5:57 AM the Administrator entered the housekeeping room by the nurses station and told a staff member that a urine smell concern existed on hall 100 and she knew it was the carpet.At 5:58 AM Staff A responded during an interview that she had not really noticed a urine smell in the building, speculating the surveyor smelled it because staff had just completed rounds or that the smell occurred by housekeeping areas. Staff A stated she had never spoken to leadership about the odor.At 6:05 AM an unknown maintenance or housekeeping staff member observed running a carpet cleaner on the central breezeway hallway between the nurses station and the dining room.At 8:56 AM (Cluttered Environment) a pallet full of supplies delivered and dropped in the 300 hallway between rooms [ROOM NUMBERS]. Staff also placed a Hoyer (mechanical) lift on the opposite side of the hallway, reducing the width to less than the space a wheelchair requires to pass. The hallway also contained a nurses treatment cart, a medication cart, several three small drawer containers for Personal Protective Equipment (PPE), and the metal cart for room trays. May 14, 2026At 7:00 AM immediately upon entering the facility a faint odor of ammonia/urine detected in the activity room area near the southeast entrance.At 7:31 AM a quarter of the way down the 300 hall, a strong overwhelming ammonia/urine odor present outside Resident #83's room (302) and continued to Resident #73's room (307). May 18, 2026At 10:54 AM to 12:15 PM a strong pungent urine odor identified on the 300 hallway. No soiled linen bins available in the hallway. The strong odor caused surveyor a scratchy throat with burning sensation to the sinuses and eyes. At 12:50 PM (Sanitary Environment/Hazard) the 100 shower room door wide open, with no staff member present, with the sound of running water. Observation revealed the water trickling out of the shower hose because staff had not completely turned off the water. A single-blade shaving razor laid on the floor of the shower stall, approximately six inches from the drain.At 12:51 PM Staff E, CNA, transported a resident in a shower chair into the shower room. Staff E responded that she left the door open because housekeeping would be delivering items. Staff E donned a glove and picked up the razor after the surveyor pointed it out.At 2:12 PM the Director of Nursing (DON) responded during an interview that Resident #55, who was on a behavioral contract for inappropriate urination and repeated housekeeping issues, likely caused the urine odor on the 300 hall. The DON responded she only occasionally smelled a urine odor on the 200 hallway and not on the 100 hall. The DON believed the maintenance person worked hard to keep up with cleaning the carpet. The DON responded she had not observed soiled linen or trash on the floor or in open garbage bags in hallways. The DON commented she had observed this practice when she started in September 2025, provided education, and expected staff to avoid placing soiled linen and trash bags directly on the floor.On 5/26/26 at 11:02 AM the Administrator responded that when she started in January 2026, she told staff to stop putting bags on the floor and to use the barrels. She procured large bags for staff to take dirty linens and trash back to the laundry in a timely manner, to remove the odor.

Based on facility grievance forms, resident interview, staff interview, and facility policy review, the facility failed to effectively resolve grievances and failed to document written outcomes on whether grievances were confirmed or not confirmed. The Monthly Grievance Logs from January through the beginning of May 2026 revealed a total of 75 grievances filed by 36 different residents, representatives, or staff (Resident #3, #5, #6, #8, #10, #15, #16, #20, #21, #22, #25, #30, #35, #36, #39, #43, #44, #45, #46, #49, #51, #52, #58, #59, #64, #66, #72, #73, #74, #78, #81, #83, #84, #85, #88, #92). The failure has the potential to impact all residents in the building, indicating a widespread issue. The facility reported a census of 81 residents. Findings include:Review of the monthly grievance forms revealed the following:The January 2026 Grievance Log form documented 31 grievances tracked for the month.The log contained a column titled Disposition of Grievance with an *. At the bottom of the form, it noted, * Disposition of Grievance: Confirmed/Not Confirmed, Resolved/Not Resolved. All but two of the entries recorded Resolved in the column and none of the rows indicated Confirmed or Not Confirmed. The Grievance Form dated 1/14/26 signed by the DON as resolved on 1/21/26 recorded Resident #8 did not like the way the nurse spoke to her and gave an example of the nurse just lifting the resident's foot without the nurse asking the resident to lift the foot. The Grievance Official Follow-Up section documented education was provided to staff on the 2pm to 10pm and 10pm to 6am shifts on professionalism, customer service, abuse neglect and exploitation, and code of conduct. The form recorded no other monitoring or follow up and the notification of the representative left blank. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 1/15/26 signed by the Administrator recorded Resident #81 complained he was not getting checked and changed (providing assistance with incontinence care) on the overnight shift. The Grievance Official Follow-Up section documented education was provided to staff on the 10pm to 6 am shift to make sure they were checking and changing the residents every 2 hours. The form recorded no date of resolution but documented it would be ongoing to check with the resident. The form lacked any other monitoring or follow up and the notification of the representative left blank. The form contained no information on whether the grievance was confirmed or not confirmed. The January 2026 Grievance Log documented the disposition of grievance received on 1/15/26 as blank with a date of written decision blank. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #49 reported the aides were not friendly, aides did not get her ice water or answer her call light, and she was not getting a shower. The Grievance Official Follow-Up section documented education provided to staff regarding resident dignity and all things that could be considered hindering their dignity, reinforced it was the resident's home, and spoke to staff specifically about the resident's shower schedule. The form documented the issue resolved on 1/16/26 but lacked any documentation of follow up beyond 1/16/26 with the resident. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #44's family member reported the resident's rash treatment was not done, a CNA on the 6am to 2 pm shift went into the room, turned off the call light and then never came back. The Grievance Official Follow-Up section documented there was no treatment to complete for the resident and education completed with staff to leave call light on until the resident need could be completed. The form documented the issue resolved on 1/16/26 but lacked any documentation of follow up being conducted with the resident or whether the concern regarding a rash treatment was confirmed. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #16 complained a CNA (Certified Nurse Aide) was being rude and called her a stupid bitch in the resident's room. The Grievance Official Follow-Up section documented the CNA was suspended and a report was made to the State Survey Agency. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 1/21/26 signed by the Administrator recorded a resident who formerly resided in room [ROOM NUMBER]-A reported Staff KK, LPN, would not give her pain meds when she requested the med when she had pain and Staff KK gave the wrong insulin medication. The Grievance Official Follow-Up section documented education provided to Staff KK that pain medication was to be administered as requested by any resident, the pain assessment should be documented in PCC (Point Click Care aka Electronic Medical Record) and would have a second person with Staff KK while interacting and providing care with the resident. The form lacked any documentation of further interview or follow up with the resident on resolution or efforts to ensure pain managed appropriately and recorded date resolved as 1/23/26.The Grievance Form dated 1/21/26 signed by the Administrator recorded Resident #84 reported the CNA on the 6am to 2pm shift talked rudely to him. The Grievance Official Follow-Up section documented education provided to the CNA on professionalism/customer service, and the resident cares would be provided in pairs. The form documented that the CNA stated she was never rude to the resident, she didn't tell the resident she would come back to check and change them, and the resident didn't request any assistance nor ask for care. The DON signed the issue as resolved on 1/21/26. The form lacked any documentation of further interview or follow up with the resident on resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The Concern/Recommendation form dated 1/29/26 recorded a resident in room [ROOM NUMBER] reported his call light was not being answered timely and sometimes the light was on for more than an hour. The Staff Response section recorded an inservice with staff done 1/29/26, they would continue to monitor call lights and talk with residents. On 1/30/26 the Administrator noted the resident reported the call light was better. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed.The Concern/Recommendation form dated 1/29/26 recorded Resident #72 reported her call light was not being answered timely and it usually took 30 minutes. The Staff Response section recorded an inservice with staff done 1/29/26, they would continue to talk with residents and monitor call lights. On 1/30/26 the Administrator noted the resident reported the call light was being answered. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 1/29/26 signed by the Administrator as resolved on 1/30/26 recorded Resident #8 reported she waited 45 minutes for assistance, she put her light on at 7:10 PM and was very upset and crying. The Grievance Official Follow-Up section documented an inservice done on 1/29/26 with staff, they would continue to monitor call lights, and she talked with the resident who reported it was better on 1/30/26. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 1/29/26 signed by the Administrator as resolved on 1/30/26 recorded Resident #43 reported the overnight CNAs (Certified Nurse Aides) do not change her brief overnight and she is a complete bed change when that happens. The resident said she already had skin issues and that two staff did a check and change. The Grievance Official Follow-Up section documented an inservice was done on 1/30/26 with staff and they would continue to monitor call lights, they talked with the resident and she was happy with the staff response and the change. The form lacked documentation of any investigation done with specific staff regarding the lack of assistance on the overnight shift. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed.The Concern/Recommendation form signed by the Director of Nursing (DON) on 1/29/26 and the Administrator on 1/30/26 recorded Resident #45 reported a concern with a call light not being answered and a nurse trying to give him insulin medication which he did not take. The staff response section lacked any investigation summary or action taken in regards to the call light concern. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 1/30/26 signed by the Administrator as resolved on 1/31/26 recorded Resident #45 complained of sitting in bowel movement/feces for 14 hours and he did not like it at the facility. The Grievance Official Follow-Up section documented the Administrator asked staff in that hall and they reported they had changed the resident. The form documented an all staff huddle conducted at 2:00 PM, staff were talked with about checking with residents to see if they needed assistance. On 1/31/26 a note was added of a report staff were slow, a bath offered, and the resident refused. A second page Statement Form dated 1/31/26 documented follow up with Resident #45 on the grievance. The resident reported staff taking care of him were slow. The form also recorded staff reported Resident #45 cussed them out and he was very rude and mean. The form lacked any documentation of further follow up or interview with the resident to determine if resolved or report what action was taken to actually resolve his concern. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 1/31/26 signed by the Administrator as resolved on 1/31/26 recorded Resident #44 reported a concern with a dietary staff member placing a food tray on her lap. The form documented the official follow up as the dietary staff member reported the resident requested the tray be placed on her lap, she cussed the staff member out, and education was provided to the staff member about the resident's behaviors. The form lacked any documentation regarding interview or follow up with the resident who reported the concern on the outcome of the grievance and the line for notification of representative and whether it was documented left blank. The form contained no information on whether the grievance was confirmed or not confirmed. The February 2026 Grievance Log form documented 19 grievances tracked for the month.The log contained a column titled Disposition of Grievance with an *. At the bottom of the form, it noted, * Disposition of Grievance: Confirmed/Not Confirmed, Resolved/Not Resolved. All but two of the entries recorded Resolved in the column and none of the rows indicated Confirmed or Not Confirmed. The Grievance Form dated 2/1/26 signed by the Administrator as resolved on 2/1/26 recorded Resident #78 reported a concern with CNAs telling him they could not toilet him because they didn't have an EZ stand (sit-to-stand mechanical lift). The Grievance Official Follow-Up section documented the CNA reported that the EZ stand was not available, she helped the resident to use a urinal, and she found an EZ stand to help him. The form lacked any documentation of further follow up or interview with the resident to confirm resolution. The Grievance Form dated 2/2/26 signed by the Administrator recorded Resident #84's family member reported the resident stated the CNAs were not treating him well, they just threw things wherever they wanted, and their bedside manner was not good. The Grievance Official Follow-Up section documented the complaint that CNAs put the blankets and bed linens on the floor and the Administrator would talk about it in a huddle. The form lacked any documentation of further follow up or interview with the family member or resident regarding the concern of staff treatment and lacked a date of resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/3/26 signed by the Administrator as resolved on 2/7/26 recorded Resident #85's family member reported all the resident's new clothes were missing that included plain t-shirts (a variety of colors), gym shorts, his TV remote, and the family member was supposed to be doing his laundry; the family member wanted the CNAs to stop sending clothes to the laundry room. The Grievance Official Follow-Up section documented a basket was placed in the resident's room, a sign up that family do laundry, the remote was found, and staff informed. The form documented a phone call placed to the family member 2/7/26 but lacked any documentation of follow up to confirm if the clothes were found or if the issue remained resolved. The form contained no information on whether the grievance was confirmed or not confirmed. The February 2026 Grievance Log documented the disposition of grievance received on 2/3/26 for Resident #85 as blank with a date of written decision blank.The Grievance Form dated 2/4/26 signed by the Administrator as resolved on 2/4/26 recorded Resident #43 reported not getting checked and changed on the last 3 overnight shifts. The Grievance Official Follow-Up section documented the care need was placed on the TAR (Treatment Administration Record), they would place the resident to get woken up between 3 to 4 AM to be checked and changed. The form lacked any documentation of further follow up or interview with the resident to confirm resolution. The form contained no information on whether the grievance was confirmed or not confirmed. The February 2026 Grievance Log documented the disposition of grievance received on 2/4/26 for Resident #43 as resolved 2/4/26.The Grievance Form dated 2/5/26 signed by the DON as resolved on 2/6/26 recorded Resident #88 reported being left in bed due to a broken chair and when she asked to speak to a nurse, the staff member was rude stating she could use the call light, the call light was not in reach at the time, the bed side table was also not in reach, and the nurse would not come to talk to the daughter. The daughter turned on the call light at 3:00 PM, noticed the chair was unplugged, and when staff came in they did not offer to help rearrange to plug in the chair and oxygen, so the daughter did it. Upon leaving the room, the oxygen was not reapplied, the daughter asked staff member to come back in and reapply the oxygen, and staff member was rude about doing so. The concern was also reported on 1/19/26, upon return to the facility, EMTs (emergency medical technicians) had to wait 30 minutes for paperwork to be given. The nurse stated she would be back to do an assessment, came back to take vitals, said be back again and did not go back until 7:00 PM. The daughter reported the resident's side of the room not cleaned the entire time the resident was in the hospital and staff told the resident they did not have time to warm up her supper. The Grievance Official Follow-Up section documented the Nurse Practitioner saw the resident on 1/19/26, the nurse and staff nurse listened to the concerns regarding the resident's health status, issues with the recliner and call light, and staff were educated with maintenance actively working on the recliner, labs and x-rays were ordered. The form lacked any documentation of further follow up or interview with the family member or resident to confirm resolution of the call light concern or whether the recliner and oxygen plugged in. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/6/26 signed by the DON as resolved on 2/6/26 recorded a family member of a resident who formerly resided in room [ROOM NUMBER]-A reported a concern that the resident turned on the call light at 6:10 PM while the family member was on the phone with the resident and on the phone until 6:45 PM and no one had been in to help the resident. The Grievance Official Follow-Up section documented it was discussed during huddle the expectations of call lights. The form lacked any documentation of further follow up or interview with the resident, family member, or staff whether the call light response times were corrected. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/11/26 signed by the Administrator as resolved on 2/11/26 recorded Resident #8 reported a concern the staff did not have incontinence briefs available for her on the overnight shift. The Grievance Official Follow-Up section documented the Administrator talked with the Staff GG, Certified Medication Aide (CMA), who ordered supplies reported they had large pull ups but extra large would be placed in central supply. The form lacked any documentation of further follow up or interview with the resident regarding resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/12/26 signed by the Administrator as resolved on 2/18/26 recorded Resident #83's family member reported they would like the staff to groom the resident better and would also like them to do a better job with keeping the room clean. The Grievance Official Follow-Up section documented the Administrator spoke with housekeeping to keep the room cleaned and to the CNAs to keep the resident groomed. The form lacked any documentation of further follow up or interview with the family member to ensure resolution or monitoring of cares to determine if needs met. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/15/26 signed by the Administrator as resolved on 2/15/26 recorded Resident #30 complained staff let another resident yell in the hallway while staff were laughing at him and he reported call lights taking an hour and a half on the 200 Hall. The Grievance Official Follow-Up section documented the staff were educated on 2/15/26 about call lights and residents yelling. The form lacked any documentation of further follow up or interview with the resident or staff about the call light response times. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/15/26 signed by the Administrator as resolved on 2/15/26 and 2/16/26 recorded Resident #45 reported missing 4 pairs of blue pants. The Grievance Official Follow-Up section documented the Administrator spoke with laundry and they would find the resident some clothes as he came with no clothes. The form lacked any documentation of further follow up or interview with the resident to confirm resolution or whether the resident actually owned 4 pairs of pants that were missing. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/16/26 signed by the Administrator as resolved on 2/17/26 recorded Resident #16 reported a concern that Staff HH, Certified Medication Aide (CMA), made the comment that the resident better watch her back. The Grievance Official Follow-Up section documented the Administrator Spoke with the CMA and had her write a statement. The statement form dated 2/16/26 recorded the CMA had no knowledge of any conversation of any kind with staff or resident on any day of an abusive nature. The form lacked any documentation of further follow up or interview to investigate the concern or report back to the resident about resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/16/26 signed by the Administrator as resolved on 2/18/26 recorded Staff II, Licensed Practical Nurse (LPN), reported a concern involving Resident #52. Staff II reported Resident #52 very upset upon return from hospital around 12:00 PM as Staff JJ, CNA, did not do any cares, no pericare (cleansing of perineal area after incontinence), no assistance with any activities of daily living, and the 2pm to 10pm shift called the nurse into the resident's room around 3:00 PM as the resident needed help. Resident #52 reported to Staff II that she had been asking for help since returning from the hospital, the resident still underneath all the hospital linens and draw sheet (transfer sheet), with a brief and all linen saturated with blood and urine from the mid back to mid thigh. The Grievance Official Follow-Up section documented the DON spoke with Staff JJ who would be retrained starting 2/18/26, the facility wanted Staff JJ to do better with her cares, and she would be monitored. The form lacked any documentation of further follow up or interview with the resident regarding resolution or further investigation into the reason why the staff members did not provide care for such an extended period of time. The Grievance Form dated 2/19/26 signed by the Administrator as resolved on 2/19/26 recorded Resident #6's family member reported a concern with the resident's hearing aides not being charged or batteries changed. Additionally the concern included that no one turned the volume up so the resident could hear. The Grievance Official Follow-Up section documented the hearing aides would be in the TARS (Treatment Administration Record) to be charged and batteries changed with staff to turn them on. The form lacked any documentation of further follow up or interview with the family member or resident regarding resolution. The Grievance Form dated 2/19/26 signed by the Administrator as resolved on 2/19/26 recorded Resident #22 reported a concern that she did not get a nightly snack at bedtime, did not get a shower when she was supposed to, her bed was not being made, and the call light timing still took a while. The Grievance Official Follow-Up section documented only evening shift call light, snack to be brought to room, and shower given later that day. The form lacked any documentation of further follow up or interview with the resident regarding resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/24/26 signed by the Administrator as resolved on 2/25/26 recorded Staff II, LPN, reported a concern involving Resident #36 and Resident #78's family member. Staff II reported Resident #36 sat by the med cart in the commons area by the dining room when Resident #78's family member walked by and said 'fuck you' to Resident #36 who became upset and said he wanted it turned in as every time the family member seen Resident #36 he cursed at him due to Resident #36 reporting the family member stealing. The Grievance Official Follow-Up section documented the Administrator spoke with the family member of Resident #78 about calling residents curse names. The family member responded that Resident #36 calls Resident #78 names. The Administrator followed up with Resident #36 about calling Resident #78 names which he acknowledged but stated he had not done for a couple of months. The Administrator documented both residents and the family member were educated about name calling. The form lacked any documentation of further follow up or interview with any one to ensure no further allegations of verbal abuse were occurring. The Grievance Form dated 2/24/26 signed by the DON as resolved on 2/25/26 recorded Resident #3 reported Staff KK, LPN, stuck her insulin in like a dart, the nurse spoke to her rudely, and refused to push her in the wheelchair on 2/24/26. The form also recorded the resident in a different chair that day, complained to the resident about her hygiene in the hallway, and the resident felt like she was being bullied that day. The Grievance Official Follow-Up section documented the DON spoke with Staff KK regarding the grievance and that they would be making some changes to assignments. The form lacked any documentation of further follow up or interview with the resident, other residents, or staff members to rule out abuse or regarding resolution for the resident. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/27/26 signed by the Administrator as resolved on 2/27/26 recorded Staff LL, Therapy, reported a concern involving a resident who formerly resided in room [ROOM NUMBER]-B. Staff LL reported the resident put his call light on at 6:00 AM, called the front desk twice, a staff member by first name only noted to take the call, and no one went to help the resident until 8:00 AM and the resident almost missed breakfast. The resident reported the staff never cleaned up the room, took laundry, he waited 30 minutes to an hour for the call light to be answered, staff leave call light on for an hour, and it had been recurring for weeks on the 6am to 2pm shift. The resident further reported numerous items including: being left on the toilet for up to one hour; no one empties the urinal; coming on wrong shower days; pill left on floor did not know whose pill it was but nurse looked at pill and threw it in the trash so someone ended up missing a pill since it went into the trash; no one hanging clean laundry it is thrown on a chair and gets taken away; no one available to talk to since everyone reported being in training; roommate was needy and he felt like it was being taken out on him being ignored with his roommate; roommate watches TV 24/7 never turning it off at night and tells the tech to close the door at night as he does not feel safe but no one can hear calls for help with the door closed. The Grievance Official Follow-Up section documented the Administrator educated staff at huddle about the resident's concerns, educated the nurses and med aides, and would continue to follow up with the concerns. The form lacked any documentation of further follow up or interview with residents to verify resolution of their concerns. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/23/26 signed by the Administrator as resolved on 3/2/26 recorded Resident #92 complained Staff J, LPN, entered the resident's room to complete a dressing change without waking up the resident and the nurse didn't clean the wound with the hydro blue or cream, she just wrapped it. The Grievance Official Follow-Up section documented the Administrator would follow up with the nurse the next time she worked and she spoke to her on 3/22/26. Staff J did write a statement to document she went into the resident's room, told him she was there to do the treatment, she couldn't find the hydro blue in the treatment cart, so she asked the resident if he had any in his room. The resident indicated the hydroblue in his closet, the nurse let him know it was not enough to cover the wound bed, and the wound was cleansed with wound cleanser prior to applying the dressing. Staff J wrote she wondered if the resident was asleep how could he know that she didn't cleanse his wounds and she questioned if he was talking in his sleep with his eyes open when he told her where the hydro blue was. The form lacked any documentation of further follow up or interview with the resident to verify resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 2/28/26 signed by the Administrator as resolved on 3/2/26 recorded Resident #59 complained call lights took 1 hour to answer, he had a bowel movement in his brief and not changed in a timely manner, and complained of pain meds. The form contained no further elaboration about the pain med concern. The Grievance Official Follow-Up section documented the Administrator educated staff on 2/28/26, spoke to the nurse about pain med, and hung a sign on the door to leave it open. The form lacked any documentation of further follow up or interview with the resident to verify resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The March 2026 Grievance Log form documented 13 grievances tracked for the month.The log contained a column titled Disposition of Grievance with an *. At the bottom of the form, it noted, * Disposition of Grievance: Confirmed/Not Confirmed, Resolved/Not Resolved. All but one of the entries recorded Resolved in the column and none of the rows indicated Confirmed or Not Confirmed. The Concern/Recommendation form dated 3/3/26 signed by the Administrator recorded Resident #44 reported a concern that a resident called Resident #44 a racial slur and threw water on her. The Staff Response section documented staff stated the resident didn't want to go back in the room and explained that was why they had two staff with cares. The response failed to indicate which other resident was involved in the altercation and which needed two staff with care. The form lacked any documentation of further follow up or interview with Resident #44, any other resident or staff who may have witnessed the interaction, or whether an investigation was initiated for resident to resident potential abuse allegation. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 3/11/26 signed by the Administrator as resolved on 3/12/26 recorded Resident #5's family member reported a concern that the resident was missing a pink blanket, it went to the laundry and had not been returned, and when going to the bathroom it took a very long time. The Grievance Official Follow-Up section documented staff needed to help the resident in the bathroom and assist her with walking; staff educated at huddle at 2:00 PM on 3/12/26 and the pink blanket found in her closet. A second white page cut off at the top of the form documented for staff to help the resident get cleaned up and they stated, you can walk, that's why we leave you and the family member stated that was true, however, the resident was unable to clean herself after using the bathroom. The form lacked any documentation of further follow up or interview with the resident or family member on resolution. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 3/12/26 signed by the Administrator as resolved on 3/12/26 recorded Resident #51 reported a concern to hospice that Resident #46 tried to pull her pants down and she got away and left the area. The Grievance Official Follow-Up section documented the Administrator spoke with Resident #46 who reported nothing happened and he was confused about the concern. The Administrator spoke with Resident #51 who reported when Resident #46 tried to pull her pants down, she left the area. The Administrator documented both residents educated not to be around each other. The form lacked any documentation of further follow up or interview with other residents, staff, or potential witnesses to the occurrence or whether an abuse investigation was initiated. The form contained no information on whether the grievance was confirmed or not confirmed.The Grievance Form dated 3/13/26 signed by the Administrator as resolved on 3/14/26 recorded Resident #43 reported a concern that while attending activity on 3/12/26 Resident #15 threw a bean bag at her making contact with her arm. The Grievance Official Follow-Up section documented at the time of the incident staff told Resident #15 that was not appropriate and he left the area, then returned to activity and the residents were separated as neither wanted to leave. The form documented in the future, the residents would be kept opposite during the activity. On 3/13/26 the DON noted she spoke with Resident #43 whos reported Resident #15 did it on purpose, the DON looked at Resident #43's arm and there were no bruises or marks, and the resident encouraged to continue attending activities. The DON also noted she spoke with Resident #15 and he acted like he didn't know what the DON was talking about. The form lacked any documentation of further follow up or interview with other residents or

Based on review of the facility assessment, resident council meeting minutes, facility grievance forms, resident interview, observation, family interview, and staff interview, the facility failed to provide sufficient staffing to meet resident needs in a timely manner in regards to answering call lights, providing incontinence care, and overall assistance with activities of daily living. The evidence identifies staffing concerns reported by 2 resident council meetings that had 18 and 14 attendees respectively and 23 different residents affected (R#1, #4, #8, #9, #12, #13, #21, #22, #25, #30, #35, #43, #44, #45, #49, 52, #59, #64, #72, #73, #74, #78, #81, #85 and 3 discharged residents identified by room numbers 504, 504-A, 205-B), indicating a widespread issue. The facility reported a census of 81 residents. Findings include:1. Review of the Facility Assessment The Facility assessment dated [DATE] documented it was last reviewed May 2026 with no changes needed. The assessment identified 48 residents needed assistance with transfers and 53 assistance with toileting. The assessment documented on page 18 under Administration subsection that staffing patterns were regularly reviewed and adjusted to align with changes in resident acuity and care plans. The assessment documented on page 19 under other subsection that staffing for all other departments and support staff - including maintenance, housekeeping, laundry, administration, and activities- was adequate as evidenced by the facility's ability to maintain a safe, clean, and well-functioning environment that supports resident quality of life and regulatory compliance. The facility provided a resident roster dated 5/18/26 denoting a census of 84 that day and recorded the level of assistance needed for each residents' transfers and whether they had incontinence. The roster documented a total of 64 residents requiring assistance with transfers with 9 requiring an EZ-stand (sit-to-stand mechanical) lift and 20 requiring a Hoyer (full body mechanical) lift. The roster documented 79 residents who had incontinence; only 6 of the 79 residents identified as mixed incontinence meaning sometimes continent, the other 73 marked as fully incontinent. The roster contained the following numbers per hallway: 100 Hall - 29 residents Transfers - 8 independent, 9 assist of 1 person for transfers, 2 assist of 2 persons, 3 EZ stand mechanical lift, 5 Hoyer full body mechanical lift with assist of 2 persons Incontinence - 25 residents incontinent and 4 continent. 200 Hall - 36 residents Transfers - 4 independent, 14 assist of 1 person for transfers, 4 assist of 2 persons, 4 EZ stand mechanical lift, 10 Hoyer full body mechanical lift with assist of 2 persons Incontinence - 25 residents incontinent and 4 continent. 300 Hall - 14 residents Transfers - 3 independent, 3 assist of 1 person for transfers, 2 assist of 2 persons, 2 EZ stand mechanical lift, 4 Hoyer full body mechanical lift with assist of 2 persons Incontinence - 8 residents incontinent, 6 residents mixed incontinence, and 0 continent. 400 Hall - 3 residents Transfers - 3 independent Incontinence - 2 residents incontinent and 1 continent. 500 Hall - 3 residents Transfers - 1 independent, 1 assist of 2 persons, 1 Hoyer full body mechanical lift with assist of 2 persons Incontinence - 3 residents incontinent and 0 continent. The facility assessment failed to reflect the current resident needs for May 2026 or how staffing patterns were reviewed to address the increase in resident care needs. 2. Review of the Resident Council Meeting Minutes revealed the following: On 3/6/26, the minutes recorded 18 residents attended. The residents reported call light wait times were improvising but some wait times are longer. On 4/3/26, the minutes recorded 14 residents attended. The residents reported: they would like staff to check more often on residents who are out in the common areas throughout the evening and nights; residents felt the nursing staff should have a happier disposition when interacting with residents; and call light wait times were getting better, but some days were better than others. 3. Review of the monthly grievance forms revealed the following: The Grievance Form dated 1/15/26 signed by the Administrator recorded Resident #81 complained he was not getting checked and changed (providing assistance with incontinence care) on the overnight shift. The Grievance Official Follow-Up section documented education was provided to staff on the 10pm to 6 am shift to make sure they were checking and changing the residents every 2 hours. The form recorded no date of resolution but documented it would be ongoing to check with the resident. The form lacked any other monitoring or follow up and the notification of the representative left blank. The form contained no information on whether the grievance was confirmed or not confirmed. The January 2026 Grievance Log documented the disposition of grievance received on 1/15/26 as blank with a date of written decision blank. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #49 reported the aides were not friendly, aides did not get her ice water or answer her call light, and she was not getting a shower. The Grievance Official Follow-Up section documented education provided to staff regarding resident dignity and all things that could be considered hindering their dignity, reinforced it was the resident's home, and spoke to staff specifically about the resident's shower schedule. The form documented the issue resolved on 1/16/26 but lacked any documentation of follow up beyond 1/16/26 with the resident. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #44's family member reported the resident's rash treatment was not done, a CNA on the 6am to 2 pm shift went into the room, turned off the call light and then never came back. The Grievance Official Follow-Up section documented there was no treatment to complete for the resident and education completed with staff to leave call light on until the resident need could be completed. The form documented the issue resolved on 1/16/26 but lacked any documentation of follow up being conducted with the resident or whether the concern regarding a rash treatment was confirmed. The Concern/Recommendation form dated 1/29/26 recorded a resident in room [ROOM NUMBER] reported his call light was not being answered timely and sometimes the light was on for more than an hour. The Staff Response section recorded an in-service with staff done 1/29/26, they would continue to monitor call lights and talk with residents. On 1/30/26 the Administrator noted the resident reported the call light was better. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed. The Concern/Recommendation form dated 1/29/26 recorded Resident #72 reported her call light was not being answered timely and it usually took 30 minutes. The Staff Response section recorded an in-service with staff done 1/29/26, they would continue to talk with residents and monitor call lights. On 1/30/26 the Administrator noted the resident reported the call light was being answered. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 1/29/26 signed by the Administrator as resolved on 1/30/26 recorded Resident #8 reported she waited 45 minutes for assistance, she put her light on at 7:10 PM and was very upset and crying. The Grievance Official Follow-Up section documented an in-service done on 1/29/26 with staff, they would continue to monitor call lights, and she talked with the resident who reported it was better on 1/30/26. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 1/29/26 signed by the Administrator as resolved on 1/30/26 recorded Resident #43 reported the overnight CNAs (Certified Nurse Aides) do not change her brief overnight and she is a complete bed change when that happens. The resident said she already had skin issues and that two staff did a check and change. The Grievance Official Follow-Up section documented an in-service was done on 1/30/26 with staff and they would continue to monitor call lights, they talked with the resident and she was happy with the staff response and the change. The form lacked documentation of any investigation done with specific staff regarding the lack of assistance on the overnight shift. The form recorded no other monitoring or follow up on call light response times. The form contained no information on whether the grievance was confirmed or not confirmed. The Concern/Recommendation form signed by the Director of Nursing (DON) on 1/29/26 and the Administrator on 1/30/26 recorded Resident #45 reported a concern with a call light not being answered and a nurse trying to give him insulin medication which he did not take. The staff response section lacked any investigation summary or action taken in regards to the call light concern. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 1/30/26 signed by the Administrator as resolved on 1/31/26 recorded Resident #45 complained of sitting bowel movement/feces for 14 hours and he did not like it at the facility. The Grievance Official Follow-Up section documented the Administrator asked staff in that hall and they reported they had changed the resident. The form documented an all-staff huddle conducted at 2:00 PM, staff were talked with about checking with residents to see if they needed assistance. On 1/31/26 a note was added of a report staff were slow, a bath offered, and the resident refused. A second page Statement Form dated 1/31/26 documented follow up with Resident #45 on the grievance. The resident reported staff taking care of him were slow. The form also recorded staff reported Resident #45 cussed them out and he was very rude and mean. The form lacked any documentation of further follow up or interview with the resident to determine if resolved or report what action was taken to actually resolve his concern. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 2/1/26 signed by the Administrator as resolved on 2/1/26 recorded Resident #78 reported a concern with CNAs telling him they could not toilet him because they didn't have an EZ stand (sit-to-stand mechanical lift). The Grievance Official Follow-Up section documented the CNA reported that the EZ stand was not available, she helped the resident to use a urinal, and she found an EZ stand to help him. The form lacked any documentation of further follow up or interview with the resident to confirm resolution. The Grievance Form dated 2/4/26 signed by the Administrator as resolved on 2/4/26 recorded Resident #43 reported not getting checked and changed on the last 3 overnight shifts. The Grievance Official Follow-Up section documented the care need was placed on the TAR (Treatment Administration Record), they would place the resident to get woken up between 3 to 4 AM to be checked and changed. The form lacked any documentation of further follow up or interview with the resident to confirm resolution. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 2/6/26 signed by the DON as resolved on 2/6/26 recorded a family member of a resident who formerly resided in room [ROOM NUMBER]-A reported a concern that the resident turned on the call light at 6:10 PM while the family member was on the phone with the resident and on the phone until 6:45 PM and no one had been in to help the resident. The Grievance Official Follow-Up section documented it was discussed during huddle the expectations of call lights. The form lacked any documentation of further follow up or interview with the resident, family member, or staff whether the call light response times were corrected. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 2/15/26 signed by the Administrator as resolved on 2/15/26 recorded Resident #30 complained staff let another resident yell in the hallway while staff were laughing at him and he reported call lights taking an hour and a half on the 200 Hall. The Grievance Official Follow-Up section documented the staff were educated on 2/15/26 about call lights and residents yelling. The form lacked any documentation of further follow up or interview with the resident or staff about the call light response times. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 2/16/26 signed by the Administrator as resolved on 2/18/26 recorded Staff II, Licensed Practical Nurse (LPN), reported a concern involving Resident #52. Staff II reported Resident #52 very upset upon return from hospital around 12:00 PM as Staff JJ, CNA, did not do any cares, no peri care (cleansing of perineal area after incontinence), no assistance with any activities of daily living, and the 2pm to 10pm shift called the nurse into the resident's room around 3:00 PM as the resident needed help. Resident #52 reported to Staff II that she had been asking for help since returning from the hospital, the resident still underneath all the hospital linens and draw sheet (transfer sheet), with a brief and all linen saturated with blood and urine from the mid back to mid-thigh. The Grievance Official Follow-Up section documented the DON spoke with Staff JJ who would be retrained starting 2/18/26, the facility wanted Staff JJ to do better with her cares, and she would be monitored. The form lacked any documentation of further follow up or interview with the resident regarding resolution or further investigation into the reason why the staff members did not provide care for such an extended period of time. The Grievance Form dated 2/19/26 signed by the Administrator as resolved on 2/19/26 recorded Resident #22 reported a concern that she did not get a nightly snack at bedtime, did not get a shower when she was supposed to, her bed was not being made, and the call light timing still took a while. The Grievance Official Follow-Up section documented only evening shift call light, snack to be brought to room, and shower given later that day. The form lacked any documentation of further follow up or interview with the resident regarding resolution. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 2/27/26 signed by the Administrator as resolved on 2/27/26 recorded Staff LL, Therapy, reported a concern involving a resident who formerly resided in room [ROOM NUMBER]-B. Staff LL reported the resident put his call light on at 6:00 AM, called the front desk twice, a staff member by first name only noted to take the call, and no one went to help the resident until 8:00 AM and the resident almost missed breakfast. The resident reported the staff never cleaned up the room, took laundry, he waited 30 minutes to an hour for the call light to be answered, staff leave call light on for an hour, and it had been recurring for weeks on the 6am to 2pm shift. The resident further reported numerous items including: being left on the toilet for up to one hour; no one empties the urinal; coming on wrong shower days; pill left on floor did not know whose pill it was but nurse looked at pill and threw it in the trash so someone ended up missing a pill since it went into the trash; no one hanging clean laundry it is thrown on a chair and gets taken away; no one available to talk to since everyone reported being in training; roommate was needy and he felt like it was being taken out on him being ignored with his roommate; roommate watches TV 24/7 never turning it off at night and tells the tech to close the door at night as he does not feel safe but no one can hear calls for help with the door closed. The Grievance Official Follow-Up section documented the Administrator educated staff at huddle about the resident's concerns, educated the nurses and med aides, and would continue to follow up with the concerns. The form lacked any documentation of further follow up or interview with residents to verify resolution of their concerns. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 2/28/26 signed by the Administrator as resolved on 3/2/26 recorded Resident #59 complained call lights took 1 hour to answer, he had a bowel movement in his brief and not changed in a timely manner, and complained of pain meds. The form contained no further elaboration about the pain med concern. The Grievance Official Follow-Up section documented the Administrator educated staff on 2/28/26, spoke to the nurse about pain med, and hung a sign on the door to leave it open. The form lacked any documentation of further follow up or interview with the resident to verify resolution. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 3/26/26 signed by the Administrator recorded Resident #74 reported a concern that sometimes it took 30 minutes or more to get the call light answered. The Grievance Official Follow-Up section documented 3/27/26 staff educated that day at a huddle about answering call lights in a timely manner. The form lacked any documentation of date of resolution or further follow up or interview with the resident about their concern. The form contained no information on whether the grievance was confirmed or not confirmed. The March 2026 Grievance Log documented the disposition of grievance as resolved with a date of written decision 3/27/26. The Grievance Form dated 4/1/26 signed by the Administrator as resolved on 4/1/26 recorded Resident #45 reported a concern that he didn't receive his dinner tray the previous night, he turned on the call light and no one would answer forever. The Grievance Official Follow-Up section documented the Administrator spoke with the resident with the DON and Dietary Manager present, the resident was very rude, they asked the resident to come to the dining room for his meals, and they educated staff at huddle on 4/1/26. An additional note added in different color ink without a date that the CMA stated that no one complained they didn't receive dinner. The form lacked any documentation of further follow up regarding the lack of call light response or lengthy response time. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 4/9/26 signed by the Administrator as resolved on 4/10/26 recorded Resident #21 reported a concern that from 11:30 AM to 2:30 PM, no one answered his call light, he had a hard time getting anyone to change his oxygen tank, and it took 45 minutes at night to get his tray (food). The Grievance Official Follow-Up section documented staff educated at 2:00 PM huddle about answering call lights in a timely manner. The form lacked any documentation of further follow up or interview with the resident. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 4/13/26 signed by the Administrator as resolved on 4/13/26 recorded Resident #25 reported a concern he had to have a bowel movement at 6:30 AM, he put on his call light, a girl walked in at 8:00 AM, shrugged her shoulders and walked out. The Grievance Official Follow-Up section documented the Administrator spoke with Resident #25 and he reported the CNA went into his room, turned off his light and walked out, and the Administrator let the resident know that they would follow up on his complaint; an investigation started. The form lacked any documentation of further follow up or interview with the resident. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 4/14/26 signed by the Administrator as resolved on 4/15/26 recorded Staff Y, Occupational Therapist (OT), reported Resident #64 agitated and yelled in the hallway when the therapist approached at 2:10 PM. Staff Y reported the resident stated he had a wet brief (incontinence) at lunch, he told a CNA who told him they would be right back, and the resident upset they never came back. Staff Y assisted the resident with care. The Grievance Official Follow-Up section documented education at huddle done on 4/15/26 at 2:00 PM and the Administrator would follow up. The form lacked any documentation of further follow up or interview with the resident. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 4/17/26 signed by the Administrator as resolved on 4/17/26 recorded a friend of Resident #35's reported the call light 30 minutes, the room was dirty, changing clothes, and bath, and no other notes to detail the issues in the first section. The Grievance Official Follow-Up section documented the Administrator spoke with the resident and he reported baths were being given, clothes were being changed, and staff educated on the concerns at huddle that day at 2:00 PM. The form contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 4/30/26 signed by the Administrator as resolved on 5/1/26 recorded Resident #45 reported the hallway would be noisy, he could hear staff talking, he turned on his call light, and everything went quiet with no one helping him, and it took a while for anyone to answer his call light. The Grievance Official Follow-Up section documented the Administrator educated (staff) at huddle that day at 2:00 PM. The form lacked any documentation of further follow up or interview with the resident or monitoring of call light response times. The form contained no information on whether the grievance was confirmed or not confirmed. 4. Resident #25's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of heart attack, stroke (blood clot or bleed in the brain), congestive heart failure (CHF; heart pumping weakness), and pulmonary disease (lung disease). The Brief Interview for Mental Status (BIMS) score showed a score of 14, indicating intact cognition. Resident #25 depended on staff for toileting and required total assistance from two staff members for bed-to-chair transfers. The Incident Summary from 4/13/26 reflected a nurse asked Staff EEE, Certified Nursing Assistant (CNA), to help Resident #25 go to the restroom. Staff EEE responded, shut Resident #25's call light off, shrugged her shoulders to the resident who asked to be taken to the restroom, walked out of the room without assisting, and refused to acknowledge the nurse requesting assistance. On 5/19/26 at 1:22 PM, Resident #25 stated he'd discharged to home. Resident #25 stated during his stay at the facility he told the nurse, as she administered his medication, that he needed to use the bathroom. Resident #25 stated the nurse told him she'd get someone and left his room without returning. Resident #25 stated a CNA came in, turned the call light off, and left him because she had to get someone else. Resident #25 stated he waited for over 2 hours to have a bowel movement. Resident #25 stated a therapist entered his room to answer his call light and helped him. Resident #25 stated he felt abandoned due to the shortness of staff. Resident #25 stated that at the facility, it was hurry up and wait, and wait, and wait. Resident #25 stated he felt that he was to learn a lesson in patience due to not enough staff to provide proper care for him. A document titled Statement Form signed by Staff FFF, Licensed Practical Nurse (LPN), revealed: On 4/13/26 at 6:30 AM, Staff FFF assessed Resident #25 during a medication pass. Resident #25 requested to be assisted to the toilet. Staff FFF left to find additional staff. On 4/13/26 at 8:00 AM, Resident #25's call light was on. Staff FFF observed Staff EEE exiting Resident #25's room. Staff FFF responded and asked Resident #25 what she could do to help. Resident #25 said Staff EEE came in to answer the call light and when Resident #25 requested to go to the toilet, Staff EEE shrugged her shoulders and walked out. On 4/13/26 at 9:30 AM, Resident #25's son was present and requested to talk to administrative staff. The son expressed concern about the quality of care. On 4/13/26 at 10:15 AM, the Director of Nursing (DON) and Staff F, MDS Coordinator, responded. On 4/13/26 at 11:30 AM, the Administrator spoke with Resident #25 and his family. 5. On 5/11/26 at 3:00 PM, Resident #81 stated the call lights take forever and the staff claim they're short staffed. Resident #81 said when the staff do come in to help, they run in and right back out, which he believes is due to how he voices his opinion. Resident #81 stated he won't be silenced about his concerns and the staff can't stand it. Resident #81 commented he'd spoken to the last several administrators who all say they're working on it but he still sees the same stuff over and over. Resident #81 stated there was a Resident Council, but he quit going to the meetings as they didn't see any changes. Resident #81 said he'd waited up to 2 hours before and he checked his phone to know the amount of time; that only happened one time, otherwise he frequently waits over a half hour on all 3 shifts for help. Resident #81 commented he felt the 3rd shift was lazy and didn't give a damn. Resident #81 reported he eats in his room because the staff leave him in his wheelchair for over an hour when they bring him back to his room. 6. On 5/11/26 at 5:25 PM, Resident #21 responded he usually waited a half hour for his call light to be answered. 7. On 5/12/26 at 9:22 AM, a confidential family member reported concerns with staffing. The family member stated they received so many different answers from different people, no one had a clue what was going on, and most times when they visited, they can't find anyone to talk to or determine who was assigned to work. They commented there needed to be more communication with families and someone available to talk to. 8. On 5/12/26 at 10:40 AM, Resident #72 responded the staff were very slow at answering call lights on all shifts and she felt the facility didn't have enough staff. 9. On 5/12/26 at 10:45 AM, Resident #4 responded it's hard to get a hold of anyone at the facility, the staff didn't come in often to change her incontinence (lack of bladder or bowel control) brief, and she frequently experienced being wet which led to sores on her bottom from sitting in her own urine and not being changed like she should be. Resident #4 reported she sat in her wheelchair one day with blood on her face and hands. She pushed the button for help, the staff came in, shut the light off, and didn't come back. 10. On 5/12/26 at 11:32 AM, Resident #9 stated the staff tell him to wait for help but no one ever comes. Resident #9 had a fall with a fracture that occurred in March 2026 from attempting to get to the restroom independently. 11. On 5/12/26 at 12:57 PM, Resident #13 stated trying to talk to staff can be difficult and he can never find anyone who knows what's going on. Resident #13 complained about having to wait on staff, he can't get up on his own, and he depended on staff. 12. On 5/12/26 at 2:16 PM, Resident #1 indicated there weren't enough staff on the 300 wing and there were times she sat waiting more than an hour. Resident #1 said the staff said they can't put her to bed as they've to find someone to help transfer her to the chair and it took forever to answer the call light to be put in the chair. Resident #1 stated she knew the facility was working on hiring staff. Resident #1 reported she'd pooped her pants one time, it was upsetting, and she waited for the staff but they didn't come right away. Resident #1 reported after supper was the worst time and hard to get someone to help due to the number of residents who were totally dependent for care. Resident #1 commented the facility was short staffed a lot on the weekends. Resident #1 responded she times the wait by the clock on her wall and the residents had brought their concerns up in Resident Council which is how she knew the facility was trying to hire more people. 13. On 5/12/26 at an unrecorded time, a resident's Family Member stated concerns related to staffing. The Family Member stated she'll get so many different answers from different nursing staff. No one has a clue what's going on and most times she's not able to find anyone to talk to and isn't able to determine who the nurses or CNAs are that are assigned to care for her loved one. The communication with family's needs to be better. Nurses are rude, when Family Member asked about a wound care recommendation for a wheelchair cushion, the nurse's response was sharp and rude saying I don't know why they tell people they need that. 14. On 5/13/26 at 9:11 AM when asked if Resident #73 didn't get up for breakfast it was because Resident #73 wouldn't get out of the bed, Staff H responded Resident #73 would get out of bed, but the staff took longer than usual that morning in other resident rooms providing care. Staff H reported normally they had a float between 300 and 400 hall and she'd to wait for the second aide to come and help her. Staff H stated what made 300 hall difficult was that Resident #73 was an aspiration risk (danger of breathing foreign materials into the lungs) and needed to be supervised; the 100-hall aide got sent home the day before, and the 300 hall was heavier with residents who require assistance of 2 people. Staff H answered she'd worked for the facility for 2 months, she was a newer aide, and she'd mentioned to leadership that it was hard and they tried to get a float but census a factor. Staff H said mainly it was difficult getting people up as if she didn't have the residents up by 7:30 AM to get to the dining room and they had no float or running behind like that morning because Resident #83's care took a long time, then it was difficult to get those residents who required assistance of 2 and mechanical lift up out of bed. Staff H indicated Resident #83 and Resident #12 took the longest to assist as they were both heavy care; Resident #85 needed a Hoyer mechanical lift, and Resident #1 only one person assists but it can be harder at times as her ability fluctuates. Staff H voiced she felt bad because she'd to assist the nurse with wound care and it took an hour to do that. Staff H stated the nurses have to be available to supervise the dining room so if they do not take residents to the dining room before 7:30 AM, they need to eat in their rooms. On 5/13/26 at 9:20 AM, an observation revealed Resident #73 remained dressed in a hospital gown positioned in a semi-Fowler's position (head of bed raised 30-45 degrees) on her back. A continuous observation on 5/13/26 from 4:20 AM to 12:00 PM revealed staff failed to provide assistance with grooming, dressing, oral care, major position changes, or incontinence care for Resident #73. Staff H assigned to the 300 hall on 5/13/26 responded in an interview the reason she can't provide care for that timeframe was directly related to only having 1 ded

Based on filed grievances, recertification survey outcomes, resident interviews, observations, family interview, and staff interviews, the facility failed to provide effective leadership and administration of resources to ensure a safe, clean environment, free from abuse and neglect, with quality of care services provided by sufficient and competent staff. This failure was a widespread systemic failure affecting all residents in the building. The facility reported a census of 81 residents. Findings include: Review of the monthly grievance forms:The Monthly Grievance Logs from January through the beginning of May 2026 revealed a total of 75 grievances filed by 36 different residents, representatives, or staff:The January 2026 Grievance Log form documented 31 grievances tracked.The February 2026 Grievance Log form documented 19 grievances tracked.The March 2026 Grievance Log form documented 13 grievances tracked.The April 2026 Grievance Log form documented 11 grievances tracked.The May 2026 Grievance Log form documented 1 grievances tracked.The logs contained a column titled Disposition of Grievance with an *. At the bottom of the form, it noted, * Disposition of Grievance: Confirmed/Not Confirmed, Resolved/Not Resolved. All but two of the entries recorded Resolved in the column and none of the rows indicated Confirmed or Not Confirmed. The individual grievance forms contained no information on whether the grievance was confirmed or not confirmed.Proof of repeat deficiencies and higher scopes and severities for survey ending 1/8/26 cited the following 12 tags:F550 - D level - Resident Rights/Exercise of RightsF656 - D level - Develop/Implement Comprehensive Care PlanF658 - D level - Services Provided Meet Professional StandardsF689 - D level - Free of Accident Hazards/Supervision/DevicesF725 - D level - Sufficient Nursing StaffF755 - E level - Pharmacy Svcs/Procedures/Pharmacist/RecordsF760 - D level - Residents are Free of Significant Med ErrorsF804 - E level - Nutritive Value/Appear, Palatable/Prefer TempF842 - E level - Resident Records - Identifiable InformationF880 - D level - Infection Prevention & ControlF883 - D level - Influenza and Pneumococcal ImmunizationsF887 - D level - COVID Immunizations The current survey cited the follow 33 tags:F550 - D level - Resident Rights/Exercise of RightsF561 - D level - Self DeterminationF584 - F level Substandard Quality of Care (SQOC) - Safe/Clean EnvironmentF585 - F level - GrievancesF600 - H level SQOC - Freedom from Abuse/NeglectF609 - D level - Reporting of Alleged ViolationsF610 - D level - Investigate/Prevent/Correct Alleged ViolationF627 - D level - Inappropriate DischargeF628 - E level - Discharge ProcessF641 - D level - Accuracy of Assessments F656 - D level - Develop/Implement Comprehensive Care PlanF657 - E level - Care Plan Timing and RevisionF677 - E level - Activities of Daily Living Care Provided for Dependent ResidentsF684 - K level SQOC - Quality of Care (Nursing Assessment and Intervention)F686 - K level SQOC - Treatment/Services to Prevent/Heal Pressure UlcerF688 - E level - Increase/Prevent Decrease in Range of Motion/MobilityF689 - H level SQOC - Free of Accident Hazards/Supervision/DevicesF693 - D level - Tube Feeding Management/Restore Eating SkillsF695 - D level - Respiratory/Tracheostomy Care and SuctioningF697 - J level SQOC - Pain ManagementF725 - F level - Sufficient Nursing StaffF726 - E level - Competent Nursing StaffF732 - C level - Posted Nurse Staffing InformationF760 - D level - Residents are Free of Significant Med ErrorsF761 - D level - Label/Store Drugs and BiologicalsF812 - E level - Food Procurement, Store/Prepare/Serve-SanitaryF835 - F level - AdministrationF838 - F level - Facility AssessmentF842 - D level - Resident Records - Identifiable InformationF865 - F level - QAPI, Disclosure/Good Faith AttemptF880 - F level - Infection Prevention & ControlF908 - E level - Essential Equipment, Safe Operating Condition The facility had 7 repeat deficiencies that include: F550, F656, F760F725 and F880 at higher scopesF689 at a higher severity levelThe facility had 3 newly cited areas that rose to the level of immediate jeopardy: F684 lack of comprehensive nursing assessment and intervention for 7 residentsF686 lack of pressure sore interventions and care for 4 residentsF697 inadequate pain management for 1 resident. The current survey identified 6 deficient practices as SQOC. The facility should have been aware of the systemic concerns well before the current survey started. The survey outcomes point to the ineffective QAPI program. F561 Resident Choices and failure of leadership to follow up on concerns: The current survey cited issues under F561 as the facility failed to honor a resident's choice of bathing time for Resident #81.The quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #81 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. In an interview on Monday 05/11/2026 at 3:00 PM, Resident #81 stated the call lights take forever to be answered, the staff claim they are short staffed and when the staff come to assist him, they run in and right back out. Resident #81 stated he voices his opinion, he will not be silenced, and the staff cannot stand that. Resident #81 said he talked to the last several administrators about his concerns and they tell him they are working on it, but he still sees the same stuff over and over and he doesn't see any changes. Resident #81 commented he doesn't go to resident council as it is a joke and he doesn't see any changes being made when concerns are voiced. F584 Environmental concern with odors and leadership awareness:The current survey cited issues under F584 as the facility failed to maintain an environment free of offensive odors, which were pervasive throughout the building during the majority of the survey period. Observations on multiple dates and times revealed the presence of urine/ammonia odors throughout the building. On 5/11/26 between 1:27 PM and 4:36 PM, observation revealed an ammonia/urine odor present on 100, 200, and 300 hallways. On 5/12/26 from 2:13 PM to 3:10 PM, observation revealed odors present in the 200 hallway and dining room/activity room. On 5/13/26 from 4:30 AM to 5:58 AM, observation revealed odors present in the 100, 200, and 300 hallways. In an interview at 5:20 AM, Staff B, Certified Nurse Aide (CNA), Staff B acknowledged the smell was down the entire 300 hall and was present on the 100 hallway, speculating it came from the carpet. Staff B responded that she had told leadership about the terrible odor before, and that housekeeping cannot get the smell out. In an interview at 5:57 AM, the Administrator entered the housekeeping room by the nurses station and told a staff member that a urine smell concern existed on hall 100 and she knew it was the carpet.On 5/14/26 from 7:00 AM to 7:31 AM, observation revealed immediately upon entering the facility a faint odor of ammonia/urine detected in the activity room area near the southeast entrance. Later observation revealed a quarter of the way down the 300 hall, a strong overwhelming ammonia/urine odor present outside Resident #83's room (302) and continued to Resident #73's room (307).On 5/18/26 from 10:54 AM to 12:15 PM observation revealed a strong pungent urine odor identified on the 300 hallway. No soiled linen bins available in the hallway. The strong odor caused surveyor a scratchy throat with burning sensation to the sinuses and eyes. At 2:12 PM the Director of Nursing (DON) responded during an interview she had not observed soiled linen or trash on the floor or in open garbage bags in hallways, however, she had observed this practice when she started in September 2025. The Director of Nursing (DON) stated she provided education and expected staff to avoid placing soiled linen and trash bags directly on the floor.On 5/26/26 at 11:02 AM, the Administrator stated that when she started in January 2026, she told staff to stop putting bags on the floor and to use the barrels. She procured large bags for staff to take dirty linens and trash back to the laundry in a timely manner, to remove the odor.F600, F607, F609, F610 Freedom of Abuse / Neglect:The current survey cited issues under several abuse regulatory tags as the facility failed to prevent physical abuse in the form of bruises left during provision of cares for Resident #81; failed to identify and report the bruises on Resident #81 as potential abuse and to identify fractured ribs as injury of unknown origin for Resident #71 as potential abuse; failed to fully investigate both of those situations, and failed to ensure implementation of their abuse policies and procedures which covered the protocols on how to prevent, report, and investigate allegations of abuse. The failures were evidenced by leadership awareness of staff treatment to residents via 45 grievance forms submitted January thru May 2026 that reported dignity, respect, and lack of providing care when assistance requested. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #81 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Incident Report dated 4/30/26 at 9:00 PM documented an incident for Resident #81 recorded by Staff L, Licensed Practical Nurse (LPN). The report documented Staff L was called to the resident's room by CNA due to bruises on left wrist measuring 5 cm x 2 cm (centimeters length by width) and right elbow measuring 10 cm x 7 cm. Under Resident Description, Staff L wrote: It's when they roll me. They hold on too hard. On 05/11/2026 at 3:00 PM Resident #81 stated he had lived at the facility for about a year, he required a hoyer (full body) mechanical lift for transfers and the staff grab hold of him and yank when helping him. Resident #81 reported the staff grabbed a hold of his arms harshly leaving a bruise when they grabbed to move him. Observation during the interview revealed a fading bruise to the resident's left wrist and a large bruise located on the resident's right forearm near the elbow. Resident #81 voiced the staff know they cannot do that, they ignore him like he is an idiot, and bottom line it should not be going on. Resident #81 stated he wore incontinence briefs and call lights took forever with staff claiming they are short staffed. Resident #81 said the staff ran in then right back out and he thought it was personal because he voices his opinion, he will not be silenced, and the staff cannot stand that. Resident #81 reported he had talked to the last several administrators who responded they were working on it but he continued to see the same stuff over and over; he doesn't see changes. As of 06/01/2026 at 7:34 AM no abuse investigation file was received related to the bruises on the right elbow and left wrist and the facility failed to report the allegation of abuse to the State Survey Agency. Review of MDS dated [DATE] revealed Resident #71 BIMS of 15, indicating cognitively intact.Provider Encounter Note dated 3/17/26 documented for Resident #71, chief complaint: abdominal pain. Resident #71 seen and examined today for follow-up acute abdominal pains onset 3/14/26, status post ER (Emergency Room) visit and return to facility on 3/15/26 with diagnosis of right 11th rib fracture, UTI (Urinary Tract Infection), and right sided abdominal pains and given prescription for Cefdinier (antibiotic medication) 300mg (milligram) by mouth every 12 hours for 5 days. Today Resident #71 is resting in a wheelchair in room. Resident #71 complaints of right sided rib and abdominal pains for 2 weeks. Resident #71 reports cracked right rib. Denies falling or recent injury, denies shortness of breath, dyspnea on exertion, cough, congestion, fever, chills, nausea, vomiting. In email communication dated 5/28/26, Facility's Regional Director of Operations, clarified Resident #71's rib fracture of unknown origin had not been reported by the Facility to the Regional Director of Operations or DIAL. F677 Assistance with Activities of Daily Living:The current survey cited issues under F584 as the facility failed to provide timely and complete assistance to residents who needed help with toileting / incontinence care, grooming, oral care, and transferring for 6 residents reviewed for assistance with personal cares (Resident #81, #73, #83, #53, #85, #86) and 14 residents identified via grievance forms (Resident #81, #49, #43, #45, #78, #8, #83, #52, #22, #59, #25, #64, #66, formerly room [ROOM NUMBER]-B). The failures were evidenced by leadership awareness of staff treatment to residents via 16 grievance forms submitted to leadership from January thru April 2026 which complained of concerns with staff not providing assistance with resident needs which included answering call lights, toileting assistance, incontinence care, and getting showers.Resident #73's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 8, indicating moderately impaired cognition. The MDS documented Resident #73 didn't refuse care. The Self-Care Functional Abilities section identified Resident #73 required supervision or touching assistance for oral care, substantial to maximal assistance with upper and lower body dressing, and total dependency on staff for toileting and personal hygiene. The Mobility status section identified Resident #73 required substantial to maximal assistance in bed rolling left and right, moving from sitting to lying, and moving from lying to sitting on the side of the bed, and total dependency for sitting to standing, chair-to-bed-to-chair, toilet, and tub or shower transfers. The MDS documented Resident #73 experienced frequent urinary incontinence and constant bowel incontinence. On 5/13/26 from 4:15 AM to 11:41 AM staff failed to provide Resident #73 with any major position changes, incontinence care, grooming, or oral care during a continuous observation. At 11:41 AM staff finally assisted Resident #73 with morning care. F838 Facility Assessment:The current survey cited issues under F584 as the facility failed to revise the facility assessment as needed to identify the changes to the leadership team, the high number of residents who required assistance with transfers and incontinence care, and how those changes directly impacted the assessment and determination of how many staff were needed to meet resident needs. The Facility Assessment identified 48 residents needed assistance with transfers and 53 assistance with toileting. The facility provided a resident roster dated 5/18/26 denoting a census of 84 that day and recorded each residents' level of assistance needed for transfers and whether they had incontinence. The roster documented a total of 64 residents requiring assistance with transfers and 9 required an EZ sit-to-stand mechanical lift and 20 required a Hoyer full body mechanical lift. The roster documented 79 residents had experienced incontinence. The facility assessment failed to reflect the current resident needs for May 2026 or how staffing patterns were reviewed to address the increase in resident care needs. The current survey identified F725 failure to have sufficient nursing staff to provide for resident needs. On 6/1/26 at 3:25 PM the Administrator confirmed she signed the May 2026 review and that the Facility Assessment needed no changes. After reviewing the failure of the Facility Assessment to reflect the recent leadership changes, inaccurately reflect the vast number of residents who required transfer and toileting assistance, and the high number of residents on Enhanced Barrier Precautions, the Administrator was asked to respond to why the assessment was signed as needing no changes. The Administrator responded she would need to find the assessment to look at it before answering. The Administrator failed to provide any further response during the survey.

Based on facility document review, observation, staff interview, and facility policy review, the facility failed to revise the facility assessment as needed to identify the changes to the leadership team, the high number of residents who required assistance with transfers and incontinence care, and how those changes directly impacted the assessment and determination of how many staff were needed to meet resident needs. The facility assessment affects all residents in the building and the facility reported a census of 81 residents. Findings include: The Facility assessment dated [DATE] documented it was last reviewed May 2026 with no changes needed. The assessment failed to contain updates in recent leadership changes which included a new Director of Nursing (DON), MDS (Minimum Data Set) Coordinator, and Administrator in September 2025, October 2025, and January 2026 respectively. The assessment contained names of leaders no longer employed by the facility. The Facility Assessment identified 48 residents needed assistance with transfers and 53 assistance with toileting. The assessment documented on page 18 under Administration subsection that staffing patterns were regularly reviewed and adjusted to align with changes in resident acuity and care plans. The assessment documented on page 19 under other subsection that staffing for all other departments and support staff - including maintenance, housekeeping, laundry, administration, and activities- was adequate as evidenced by the facility's ability to maintain a safe, clean, and well-functioning environment that supports resident quality of life and regulatory compliance. The facility assessment documented on page 8 under Diseases/Conditions & Physical/Cognitive Disabilities for Which We Provide Care, the Infectious Disease row in the table identified 11 residents who were on EBP (Enhanced Barrier Precautions) and 1 acute infection. Observation and initial tour of the facility on 5/11/26 at 1:50 PM revealed 19 rooms had signs outside the doorways identifying a resident in the room required Enhanced Barrier Precautions. The signs did not contain which side of the room impacted, if one or both residents were on precautions. The facility provided a resident roster dated 5/18/26 denoting a census of 84 that day and recorded each residents' level of assistance needed for transfers and whether they had incontinence. The roster documented a total of 64 residents requiring assistance with transfers and 9 required an EZ sit-to-stand mechanical lift and 20 required a Hoyer full body mechanical lift. The roster documented 79 residents had experienced incontinence; only 6 of the 79 residents identified as mixed incontinence meaning sometimes continent, the other 73 marked as fully incontinent. The roster contained the following numbers per hallway: 100 Hall - 29 residentsTransfers - 8 independent, 9 assist of 1 person for transfers, 2 assist of 2 persons, 3 EZ stand mechanical lift, 5 Hoyer full body mechanical lift with assist of 2 personsIncontinence - 25 residents incontinent and 4 continent.200 Hall - 36 residentsTransfers - 4 independent, 14 assist of 1 person for transfers, 4 assist of 2 persons, 4 EZ stand mechanical lift, 10 Hoyer full body mechanical lift with assist of 2 personsIncontinence - 25 residents incontinent and 4 continent.300 Hall - 14 residentsTransfers - 3 independent, 3 assist of 1 person for transfers, 2 assist of 2 persons, 2 EZ stand mechanical lift, 4 Hoyer full body mechanical lift with assist of 2 personsIncontinence - 8 residents incontinent, 6 residents mixed incontinence, and 0 continent.400 Hall - 3 residentsTransfers - 3 independentIncontinence - 2 residents incontinent and 1 continent.500 Hall - 3 residentsTransfers - 1 independent, 1 assist of 2 persons, 1 Hoyer full body mechanical lift with assist of 2 personsIncontinence - 3 residents incontinent and 0 continent. The facility assessment failed to reflect the current resident needs for May 2026 or how staffing patterns were reviewed to address the increase in resident care needs. The current survey identified F725 failure to have sufficient nursing staff to provide for resident needs. On 6/1/26 at 3:25 PM the Administrator confirmed she signed the May 2026 review and that the Facility Assessment needed no changes. After reviewing the failure of the Facility Assessment to reflect the recent leadership changes, inaccurately reflect the vast number of residents who required transfer and toileting assistance, and the high number of residents on Enhanced Barrier Precautions, the Administrator was asked to respond to why the assessment was signed as needing no changes. The Administrator responded she would need to find the assessment to look at it before answering. The Administrator failed to provide any further response during the survey. The facility policy titled Facility Assessment revised July 2025 included the following documentation: Policy: This facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. Policy Explanation and Compliance Guidelines: .3. The facility will use the facility assessment to: a. Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. b. Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population. c. Consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to its resident population. d. Develop and maintain a plan to maximize recruitment and retention of direct care staff. e. Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care. 4. The Administrator is responsible for ensuring the completion of the facility assessment and maintaining all documents that pertain to the assessment. The Administrator serves as the leader of the facility assessment process, or may designate someone to lead the process.8. Based on the assessment of resident characteristics, the facility will determine what care/services, staff competencies, and staffing needs are required to meet the needs of our residents. This will be compared to the specific care/services, including by contract, and training that we provide. Action plans will be implemented as necessary.10. The facility assessment will be reviewed and updated as necessary and at least annually, whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment. Additionally, the facility will consider specific staffing needs for each shift (e.g., day, evening, night, weekend shifts) and for each resident unit in the facility based on changes to resident population. Any changes to the assessment will be documented, along with a revision history.

Based on previously imposed Directed Plan of Correction monitoring, filed grievances, current survey outcomes with repeat deficiencies and identification of 6 Substandard Quality of Care tags with 3 rising to the level of immediate jeopardy, staff interview, and facility policy review, the facility failed to effectively monitor and improve the quality of care residents received. The failure represented a systemic, widespread failure with potential to impact all residents who resided in the facility. The facility reported a census of 81 residents. Findings include: Previous Directed Plan of Correction (DPOC) Monitoring The facility operated under a DPOC (Directed Plan of Correction) with monthly reports received by the SSA (State Survey Agency) from the facility's consultant and biweekly calls conducted with the facility. On 1/26/26 at 7:40 AM, an email from the consultant provided the monthly review of the facility. Areas reviewed included accidents and supervision, active performance improvement plans through the facility's QAPI (Quality Assurance Performance Improvement) plan, and progress notes including key clinical systems. The report documented that the facility continued to identify root causes and appropriate interventions for falls. The report also documented a review of recent survey tags and a review of treatments and dressings with wound documentation supporting positive trending. On 2/17/26 during the biweekly call with facility management and the consultant, the facility reported overall improvement with wounds but could not identify the cause except for the use of consistent staffing and a highly involved wound nurse. The facility held citations for significant medication errors at its last three surveys. To address the issue, staff performed medication pass audits and medication cart audits and attended a biweekly pharmacy meeting. On 3/3/26 at 2:18 PM, an email from the consultant provided the monthly review of the facility. The report documented a decreased number of falls in February related to terminal agitation (restlessness before death). She encouraged the community to evaluate transfer training and the anticipation of needs. Fall trends remained higher than community goals. On the 3/3/26 biweekly call with facility management and the consultant, the facility reported that management and nurses performed rounds. Through tracking, they identified a trend of falls with new admissions and falls with terminal agitation. Since identifying these trends and implementing interventions, the number of falls decreased in those two areas but remained above the facility goal. Staff completed a facility-wide medication cart audit. Cycle medication refills were scheduled to begin on 3/27/26. The facility self-identified a concern for smoking as more residents smoked, and management thought the visibility of the smoking area and a higher incidence of residents with behaviors served as contributing factors. They considered moving the designated smoking area. The consultant reported that the nursing management team took more proactive measures with daily reviews, which decreased the need for the consultant to identify and correct issues. On 3/25/26 at 9:53 PM, an email from the consultant provided the monthly review of the facility. The report documented that she encouraged more details in the IDT (Interdisciplinary Team) portion of the risk assessment to include painting a picture of everything the team evaluated during a fall. The report noted that nursing staff notes and risk management improved with details about what staff observed when entering the area of a fall. Nursing implemented immediate interventions. Wounds reviewed showed positive trends, and staff resolved some difficult wounds. On the 3/31/26 monthly call with facility management and the consultant, the facility reported plans to move the smoking area due to issues with residents who smoke and behaviors. Falls continued to trend but dropped lower than the previous month. The facility conducted a daily huddle at the change of shift to discuss falls and obtain details. Management reported no new issues when asked. On 4/26/26 at 10:22 PM, an email from the consultant provided the monthly report. She reported an overall decrease in the number of falls along with a decrease in the number of recommendations needed from the consultant. On the 4/28/26 monthly call with facility management and the consultant, management reported that the facility responded to issues and trends in a proactive way. The facility involved its aides in falls meetings to help identify root causes and implement interventions. Staff then brought the new interventions to the daily huddle at the 2:00 PM change of shift. The process helped show a 53% reduction in falls. Clinical staff across all shifts just completed the skills fair. Pressure ulcers (bedsores) remained low, but staff noted an increase in non-pressure wounds. The facility hired a new ARNP (Advanced Registered Nurse Practitioner) for wound management who visits weekly. On 5/28/26 at 5:25 PM, an email from the consultant provided the monthly report. She continued to review progress notes weekly to identify systemic concerns. The report documented that appropriate team members identified and addressed systemic concerns, with the team demonstrating consistency. The IDT team continued to embrace opportunities to support floor staff with education, identified needs, and process improvement. Staff completed a facility skin sweep during the survey presence, which identified several new areas. The facility and external consultant reported that fall incident occurrences decreased and that residents did not have pressure sores. The leadership failed to identify current issues with staffing levels, a lack of provision of cares such as repositioning, and a failure to ensure pressure sore interventions stayed in place to prevent Stage 3 and 4 pressure sores. Leadership also failed to ensure that staff performed pain assessments to avoid severe pain, lacked adequate incontinence care, and failed to maintain an environment free of urine odor. Based on the previous recertification survey having 12 deficiencies and the current survey identifying 33 deficient practices, the facility failed to provide effective Quality Assurance. Grievances Review of the monthly grievance forms The Monthly Grievance Logs from January through the beginning of May 2026 revealed a total of 75 grievances filed by 26 different residents, representatives, or staff: The January 2026 Grievance Log form documented 31 grievances tracked. The February 2026 Grievance Log form documented 19 grievances tracked. The March 2026 Grievance Log form documented 13 grievances tracked. The April 2026 Grievance Log form documented 11 grievances tracked. The May 2026 Grievance Log form documented 1 grievance tracked. Survey Outcomes Survey ending 1/8/26 cited the following 12 tags: F550 - D level - Resident Rights/Exercise of Rights F656 - D level - Develop/Implement Comprehensive Care Plan F658 - D level - Services Provided Meet Professional Standards F689 - D level - Free of Accident Hazards/Supervision/Devices F725 - D level - Sufficient Nursing Staff F755 - E level - Pharmacy Svcs/Procedures/Pharmacist/Records F760 - D level - Residents are Free of Significant Med Errors F804 - E level - Nutritive Value/Appear, Palatable/Prefer Temp F842 - E level - Resident Records - Identifiable Information F880 - D level - Infection Prevention & Control F883 - D level - Influenza and Pneumococcal Immunizations F887 - D level - COVID Immunizations The current survey cited the follow 33 tags: F550 - D level - Resident Rights/Exercise of Rights F561 - D level - Self Determination F584 - F level Substandard Quality of Care (SQOC) - Safe/Clean Environment F585 - F level - Grievances F600 - H level SQOC - Freedom from Abuse/Neglect F609 - D level - Reporting of Alleged Violations F610 - D level - Investigate/Prevent/Correct Alleged Violation F627 - D level - Inappropriate Discharge F628 - E level - Discharge Process F641 - D level - Accuracy of Assessments F656 - D level - Develop/Implement Comprehensive Care Plan F657 - E level - Care Plan Timing and Revision F677 - D level - Activities of Daily Living Care Provided for Dependent Residents F684 - K level SQOC - Quality of Care (Nursing Assessment and Intervention) F686 - K level SQOC - Treatment/Services to Prevent/Heal Pressure Ulcer F688 - E level - Increase/Prevent Decrease in Range of Motion/Mobility F689 - H level SQOC - Free of Accident Hazards/Supervision/Devices F693 - D level - Tube Feeding Management/Restore Eating Skills F695 - D level - Respiratory/Tracheostomy Care and Suctioning F697 - J level SQOC - Pain Management F725 - F level - Sufficient Nursing Staff F726 - E level - Competent Nursing Staff F732 - C level - Posted Nurse Staffing Information F760 - D level - Residents are Free of Significant Med Errors F761 - D level - Label/Store Drugs and Biologicals F812 - E level - Food Procurement, Store/Prepare/Serve-Sanitary F835 - F level - Administration F838 - F level - Facility Assessment F842 - D level - Resident Records - Identifiable Information F865 - F level - QAPI, Disclosure/Good Faith Attempt F880 - F level - Infection Prevention & Control F908 - E level - Essential Equipment, Safe Operating Condition The facility had 7 repeat deficiencies that include: F550, F656, F760, F842 F725 and F880 at higher scopes F689 at a higher severity level The facility had 3 newly cited areas that rose to the level of immediate jeopardy: F684 lack of comprehensive nursing assessment and intervention for 7 residents F686 lack of pressure sore interventions and care for 4 residents F697 inadequate pain management for 1 resident. The current survey identified 6 deficient practices as SQOC. An interview on 6/3/26 at 2:39 PM with the Administrator revealed the process of the grievance forms is that anyone can write up a grievance form, and depending on what the grievance is about determines who follows up with it. She stated if they relate to more nursing and staffing concerns, the Director of Nursing or the MDS (Minimum Data Set) Coordinator should address it. If the grievance relates to the kitchen, the kitchen manager should address it, just like if it relates to therapy, the director of rehab (rehabilitation) should address it. The Administrator stated that she likes to follow up with them and sometimes will call the family depending on what it is and if she feels the family needs involvement. The Administrator stated that she takes them to huddle and talks with the staff. The Administrator stated that if the grievance regards call lights or the way staff talk to residents, she always asks the resident what time of day it occurred, figures out who worked that day, and depending on the situation will educate that person with a witness. She stated they would do a whole group education with whoever works in the building. She noted if it is widespread, she'd send the staff person home and investigate the situation. She stated that she likes to follow up with the resident within 24 hours. The Administrator also stated the reason they hadn't identified the problems with several residents identified as having MASD (Moisture Associated Skin Damage) and other residents with skin interventions not being used or not in place is because staff left, they had a change in leadership, and they are getting the right people into those positions. The Quality Assurance and Performance Improvement Plan policy dated April 2025 instructed that the program is designed to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility. The policy noted this is a living document that'll continue to be refined and revisited, written in accordance with the facility's vision and mission statement. Objectives of the QAPI plan include: a. Establish a facility-wide process to identify opportunities for improvement through continuous attention to quality of care, quality of life, and resident safety. b. Address gaps in systems or processes. c. Ensure adequate provision of staffing, time, equipment, and technical training resources. d. Establish clear expectations around safety, quality, rights, choice, and respect. e. Continually improve the quality of care and services provided to their residents. The facility designed their QAPI program to be ongoing and comprehensive. The scope of services encompasses all systems of care and services provided (including complexities and unique care) that impact clinical care, quality of life, resident choice, and care transitions with participation from all departments. The aim is safety and high quality with all clinical interventions, while emphasizing autonomy and choice in daily life for residents or resident's agents. It utilizes the best available evidence (such as data, national benchmarks, published best practices, and clinical guidelines) to determine appropriate care and define and measure goals. The policy section named Administration instructed that staff conduct all business practices to ensure every resident receives individualized care, and work to support providers with the resources and equipment to meet the care goals of their residents. The policy section named Clinical Care instructed that the facility provides comprehensive clinical care to residents with acute and chronic diseases, rehabilitative needs, as well as end-of-life care. All care is resident-centered and focuses on choice and individualized plans of care. Staff strive to meet each resident's goals of care, including developing and executing a transitional plan for discharge back to the community. Staff monitor existing quality indicator and quality measure results, post-fall assessments, medication errors, pressure injuries, incident reports, and infection reports. The Quality Assurance and Assessment Committee meets monthly with the Medical Director and others to address any care concerns. The policy section named Person Center Care instructed that the facility provides person-centered care services that focus on resident choice, resident strengths and interests, physical ability, and cognitive status. The policy section named Dietary instructed that the facility provides nutritious meals under the services of a registered dietitian and a certified dietary manager based on each resident's choices and preferences by providing options for meals. The policy section named Pharmacy Services instructed that the facility contracts with a licensed pharmacist to review medications monthly, participate in antipsychotic reduction efforts, and assist with monitoring and effectiveness to ensure therapeutic goals are maintained for each and every resident. The policy section named Housekeeping instructed that the facility provides housekeeping services to ensure an environment that meets the requirements of the Occupational Safety and Health Administration through regular cleaning, disinfection, and sanitation of all aspects of the facility. The policy section named Maintenance and Engineering instructed that the facility provides a comprehensive maintenance program that maintains building safety, conducts repairs when needed, and performs safety inspections in accordance with State and Federal regulations to ensure the safety and well-being of all residents, visitors, and staff members. The policy section named Quality of Life instructed that their purpose is to provide excellent quality care and services for their residents. Staff will monitor existing data available through, but not limited to, resident and family satisfaction surveys, concerns brought up at Resident or Family Council meetings, concerns brought up at care conferences, and individual discussions with residents and family members. The policy section named QAPI Methodology instructed that the facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of change. The facility uses a thorough and highly organized approach to determine the root cause of identified problems. The facility will utilize a variety of tools to describe the current process we use, and to identify any area of breakdown or weakness in the current process. Each Performance Improvement Project subcommittee will identify areas for improvement. Data will be collected during the process and then analyzed to determine the effectiveness of change. The PIP subcommittee will provide the QAA Committee with a summary report, analysis of activities, and recommendations. Root Cause Analysis is a method of problem solving used to break down the current process and identify areas in need of improvement. Tools available to identify the cause of the problem include: Five Whys, Fishbone Diagram, Flowcharting, and Failure Mode and Effect Analysis. The policy section named Governing Body instructed that the Governing Body and facility administration shall provide general oversight for QAPI activities related to resident care and services throughout the facility. The Governing Body is responsible and accountable for ensuring that an ongoing QAPI program is defined, implemented, maintained, and addresses identified priorities; policies are established to ensure the QAPI program is sustained during leadership transitions and staff turnover; the QAPI program is adequately resourced, including ensuring staff, time, equipment, and technical training resources as needed; the QAPI program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services to residents based on performance indicator data, resident and staff input, and other information; corrective actions address gaps in systems and are evaluated for effectiveness; clear expectations are set around safety, quality, rights, choice, and respect; one or more persons are designated to be accountable for QAPI; leadership and facility-wide training is conducted on QAPI; and an atmosphere exists in which staff members are encouraged to identify and report on quality problems and opportunities for improvement. The policy section named QAA Committee instructed that the QAA Committee provides the backbone and structure for QAPI. The core members are the Medical Director or his/her designee, the DON, the Infection Preventionist, and at least three other staff members, one who is the Administrator, Owner, or Board Member. Additional representatives may include nursing, dietary, social services, therapy, housekeeping, laundry, maintenance, medical records, activities, and business office staff, and representatives may be asked to sit on a PIP subcommittee. The Committee's overall responsibility is to develop and modify the plan, analyze information, and set priorities for PIPs, giving priority to issues identified as high risk, high volume, and those that fall within problem-prone areas. The Committee [NAME] teams to work on PIPs, and team members will have specific knowledge or skills to address the issue. The QAA Committee ensures that corrective action and tracking is undertaken in cases of physical or sexual abuse and will help define how staff communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation. Committee meetings are held monthly at a minimum, and the committee shall maintain written meeting agendas, minutes, attendance records, and QAPI program progress reports. Communication about QAPI activities is shared through staff meetings, training, and resident or family council meetings, and the Committee will complete an annual review of the QAPI program. The policy section named Feedback, Data systems, and Monitoring instructed that the facility has systems in place to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others. Data sources may include grievance logs, medical record reviews, skilled care claims, fall logs, pressure injury logs, treatment logs, staffing trends, incident and accident reports, quality measures, resident council meetings, family council meetings, and regulatory survey outcomes. The facility uses performance indicators to monitor a wide range of care processes and outcomes, and findings are reviewed against established benchmarks or targets for improvement. It also includes tracking, investigating, and monitoring Adverse Events, to include developing action plans to prevent recurrences. Monitoring systems may include incident reports, worker's compensation claims, safety rounds, environmental rounds, leadership rounds, clinical rounds, focused clinical rounds, clinical observation, competency validation, as well as committee and organizational reports. Benchmarking sources may include CMS [NAME] reports, Nursing Home Compare, and Organizational scorecards or dashboards. A scorecard or dashboard for individual performance improvement projects is used to communicate progress and outcomes of individual QAPI projects, the information is compared against the benchmark set by the QAA Committee, and results are listed and graphed. The QAPI Lead or Coordinator is responsible for cataloging and maintaining these reports. The facility leadership will communicate performance improvement data as appropriate to the governing body, staff, residents, and family members, and education and training will be offered during regularly scheduled meetings, new hire orientation, PIP development, and as needed. The policy section named PIP and PIP Team Members instructed that the facility conducts PIPs to examine and improve care and services in specifically identified areas. PIPs are chosen based upon their importance and meaningfulness in relation to the scope of services provided, focusing on preventing problems and improving current systems and services. The facility seeks to prioritize projects in high-risk, high-frequency, and problem-prone areas that impact quality of care and quality of life for their residents, and conducts one improvement project annually based on these areas. PIP Team members are appointed by the QAA Committee based on the problem and the expertise needed, and a qualified staff member is selected as Project Leader for each project. The PIP Team's mission is to examine the problem area and come up with plans of correction or improvement to be implemented, and team members will receive the training and resources needed. PIPs are reported by the project lead to the monthly QAA Committee meeting and documented in the meeting minutes. Clinical data elements to monitor may include falls, medication errors, polypharmacy, pressure injuries, infections, vaccination compliance, nutrition, physical or chemical restraints, unplanned hospitalizations, unexpected deaths, dementia care, abuse or neglect, and decline in functional status. Organizational data elements to monitor may include safety-related events, employee illnesses, functional status of alarms, staff retention, regulatory survey outcomes, laundry services, dietary services, environmental services, recreational programming, staff education or training, employee immunization, and criminal background checks. The policy section named Systematic Analysis and Systemic Action instructed that when a change is made, it has the potential to have a broader impact than originally intended. The impact of change on specific systems or processes is reviewed and assessed for both intended and unintended consequences or outcomes, and education will be provided regarding the substantial changes. The QAA Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements. The policy section named Communications instructed that communications from the QAA Committee and PIP subcommittees will be communicated based on the audience. The policy section named Evaluation of the QAPI Program instructed that the QAA Committee will review the key elements of the program to ensure they are occurring, that the program is efficient, and that results are communicated to the appropriate audience. The QAA Committee will utilize a QAPI self-assessment tool to analyze the facility's performance improvement culture, and performance indicators will be reviewed to ensure they are still relevant and that the frequency of monitoring is appropriate. Gaps in systems and processes will be identified and addressed in the coming year's QAPI Plan. Other factors that may be considered are current trends in the long-term care industry as well as strategic goals for the facility, and the QAPI program will be reviewed annually and as needed. The purpose of the evaluation is to help their organization expand their QAPI skills and increase the impact of QAPI within their organization.

Based on observations, record review, resident and staff interviews and policy review, the facility failed to implement and practice infection control policies and practice Enhanced Barrier Precautions (EBP) according to resident care plans for 6 of 6 residents reviewed (Residents #19, #6, #83, #52, #85, and #73). The facility failed to practice appropriate infection control measures with soiled laundry and the delivery of clean laundry. The facility failed to implement an effective infection control program due to the lack of tracking records for the entire facility and antibiotic stewardship program from January 2026 to June 2026. The facility reported a census of 81 residents. Findings include:1.The Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed the diagnosis of a non-pressure chronic (long term) ulcer of the left foot and contained a Multidrug-Resistant Organism (MDRO) that required surgical wound care. The Brief Interview for Mental Status (BIMS) score was a 15 that suggested an intact cognition. The Care Plan for Resident #19 initiated on 4/15/25 directed staff to follow enhanced barrier precautions (EBP), physician treatment orders and complete weekly wound assessments. During an observation on 5/12/2026 at 12:34 pm, Resident #19 had a white dressing to her left leg. There was no evidence of personal protective equipment (PPE) at Resident #19's door and the lack of a sign to notify staff to EBP guidelines. During an interview on 5/12/2026 at12:31 pm, Resident #19 stated she was admitted on [DATE] after she fell at home, found after she was on the floor for multiple days. Resident #19 stated she had been going to the wound clinic. Resident #19 stated in October 2025, she had to be treated at the hospital for sepsis from the skin infection in her lower left leg and in December 2025 she had a wound graft surgery with a wound vac in January 2026. Resident #19 stated it was improving and the concern was they only wear gloves when they change the dressing. When inquired about handwashing and a gown, Resident #19 stated no. Resident #19 stated the wound clinic ordered a new dressing and the pharmacy had not delivered it yet so the nurse put on gloves and wrapped it in the white dressing. The Physician Order for Resident #19 revealed: Start on 5/11/26, Left Foot- Cleanse leg with soap and water, apply Hydrofera Blue, cut to size of wound bed, and cover with an ABD pad or small super absorber, wrap from toes to knee with Colfex Calamine every Monday and Thursday for wound care. On 5/13/26 EBP was ordered. The Progress Notes for Resident #19 revealed:On 5/14/2026 at 12:42 the wound observation and care was completed.The Resident #19 denied pain during treatment.Care plan was reviewed and resident education was provided.Wound 1: Left heel - Pressure: Length = 0.9, Width = 1.8, Depth = 0.2, - Stage IVWound in unresolvedThe wound had drainage present without an odor.The overall progress of wound healing: Improved During an interview on 5/28/2026 at 4:02 pm, The Director of Nursing (DON) stated for Resident #19 the new treatment dressings were delivered before the next dressing change. The DON stated the initial application was completed by the wound clinic. The DON stated her expectation was that the nursing staff would follow EBP with treatment dressing changes. The DON stated the new Infection Preventionist (IP) had EBP set up immediately after the interview with the surveyor. 2. The MDS dated [DATE] for Resident #6 revealed a diagnosis of MDRO and identified a urinary catheter. Resident #6 was able to make herself understood and usually understood others. Resident #6 required maximal to dependency on staff for care. The Care Plan revised on 12/12/24 for Resident #6 directed staff to follow EBP as it relates to urinary output, incontinence and history of ESBL (Extended-spectrum beta-lactamases (ESBLs) are enzymes produced by bacteria that make them resistant to many common antibiotics, including penicillin and cephalosporins. These resistant bacteria (commonly E. coli or Klebsiella) cause infections—often urinary tract infections—that are harder to treat and require specialized antibiotics. They are a significant global public health concern, particularly in hospitals, and require strict infection control). During an observation on 5/12/2026 at 11:00 am, Resident #6 was in her room, sitting in a wheelchair. Resident #6 had a urinary catheter tubing that led to a urinary bag that was placed into a dignity bag attached to her wheelchair. There was no evidence of PPE at her door and no sign to notify staff to EBP guidelines. During an interview on 5/13/2026 at 11:40 am, Staff YY, Registered Nurse (RN) Infection Control Nurse stated her employment began 5/12/26 and was reviewing the infection control history at this facility. Staff YY was unaware that Resident #6 had an MDRO. During an interview on 5/13/2026 at 11:47 am, Staff ZZ, Certified Nursing Assistant (CNA) stated she was made aware of infection control directions with a resident by the sign on the door and the personal protective equipment placed at the resident door. Staff ZZ stated the facility provided plenty of gloves and gowns. When inquired about access to the care plan, Staff ZZ stated yes, she had access to the care plans. Staff ZZ stated she was unaware that Resident #6 required EBP due to the urinary catheter as there was no sign on her door or PPE. During an interview on 5/13/2026 at 12:48, Staff AAA, RN stated she had worked on the unit with Resident #6 for a month and denied knowledge that she required EBP. During an interview on 5/14/2026 at 10:18 am, Staff BBB, CNA stated she wore a gown and gloves and gathered Resident #6's bedding into a clear bag and took it to the laundry room and dropped it into a yellow barrel. 3. The MDS assessment dated [DATE] for Resident #83 identified a BIMS score of 02, which indicated severe cognitive impairment. The MDS documented the resident required substantial to maximal assistance with toileting hygiene and was always incontinent of bowel and bladder. The MDS listed diagnoses that included wound infection and pressure ulcer of the left hip, Stage 3 (full thickness tissue loss). The MDS recorded the presence of one unhealed, Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. The Care Plan dated 3/12/26 documented a focus area identifying the resident experienced mixed incontinence of bowel and bladder related to impaired mobility. The care plan interventions directed staff to check and change the resident before/after meals, with AM/HS (morning, bedtime), as needed, and to clean the peri-area with each incontinence episode. The interventions included staff should utilize a bolster to position between the legs to increase ease with cares due to forward flexion. Another focus area identified the resident had a pressure injury related to impaired mobility, dependent on wheelchair, dependent on staff for ADLs, incontinence, cognitive impairment, and impaired communication. The focus area identified 11/25/25 a Stage 3 pressure sore to the left hip. The care plan interventions directed staff to manage moisture by providing toileting at regular intervals, provide prompt incontinent care, and to utilize preventative skin care products. Observation on 05/13/2026 at 4:35 AM revealed upon entering the east end of 200 hall, a staff member exited room [ROOM NUMBER] and two large trash bags were placed on the floor just outside the door; one with trash and one with soiled linens. The staff member placed items in the bag, picked up both bags and walked down the hall. Observation on 05/13/2026 at 4:43 AM revealed the presence of strong ammonia / urine smell on hall 300 outside of room [ROOM NUMBER] where Resident #83 and Resident #12 resided. The odor continued down the hallway all the way to the end outside of room [ROOM NUMBER] where observation revealed an open trash bag with soiled briefs inside, open to air. Observation on 05/13/2026 at 4:46 AM revealed Staff A, CNA and Staff B, CNA, entered the room of Resident #83 without donning PPE. A sign on the outside of the door indicated Enhanced Barrier Precautions (EBP) in place. Staff B donned gloves then removed the gloves, went to place them in the oral pink container for toothbrushes in the bathroom, then stopped right before touching it and placed them in her uniform pocket. Staff B then washed hands after Staff A and donned new gloves. Resident #83 laid in bed with a thin floor mat in place and edge bolsters on the side of the bed. With gloved hands, Staff B removed the bolster from under the fitted sheet and rolled the bed pad in half beside the resident. Staff B then removed gloves, threw them away, then continued without washing hands to exit the room to obtain more wipes. Staff B returned and washed her hands. Resident #83's brief with the blue indicator line from front to back indicating a soiled brief. Staff A donned gloves and assisted to roll the resident to the right side. Staff B moved the brief in front and tucked between the legs. Staff A provided the wipes and Staff B wiped in small areas. Resident #83's legs were difficult to separate and staff failed to cleanse all areas. Staff B wiped and feces present. Staff B changed gloves and failed to wash hands. Staff B donned gloves and rolled the resident to the left side but not rolled enough to reach all areas. Staff B continued to wipe the same area repeatedly as feces remained present and her gloves visibly soiled with feces on all of the palm. Staff B changed gloves and continued without washing hands to wipe then Staff A instructed to pull the brief out. Staff B handled the brief heavily soiled with feces and continued to swipe the rectal area. Both gloves touched feces on wipes and then would touch the resident's right hip area to pull the brief out. Friction and shear heard audibly as Staff B pulled, pulled, pulled, and pulled using moderate force to remove the brief which made an 'eeking' sound with each pull related to the friction between the brief and the resident's skin. The brief soiled and Staff A failed to assist to pull resident over to provide access. Staff B again changed gloves and failed to wash or sanitize hands. Staff B tucked the soiled bed bad under the resident then placed a new brief. Then the resident rolled to the right and revealed an intact bandage labeled 5/12; the area of the pressure sore. Staff A removed the soiled bed pad and continued with the same pair of gloves. Staff rolled the resident back to get the brief to cover the resident. Staff failed to cleanse the full scrotal area, lower abdomen, either left or right hip, penis or foreskin area, or all areas of skin contaminated with urine or feces where the incontinent brief contacted skin. Both staff continued with the same pair of contaminated gloves, Staff A placed items in trash bags then changed gloves, without washing hands adjusted the bed controls. Staff B continued with the same pair of gloves, moved the glove box and wipes to the resident's bedside tray table, and then covered the resident and replaced the bolster. Items in room repositioned back how found, Staff B moved the trash can. Staff A left room with the soiled bags of trash and linens then placed trash in a bag on the floor in hall 300. Staff B then removed gloves and washed her hands. Staff A placed the soiled linen bag in the room at the end of the hallway, sanitized hands, and returned to the room to wash hands. Observation on 05/13/2026 at 5:20 AM revealed Staff B took a trash bag into an empty room [ROOM NUMBER] that was used to place garbage bags and soiled linen bags on the tiled floor. An observation on 5/13/26 at 6:59 AM Staff E, CNA and Staff DD, CNA, failing to perform hand hygiene, both CNAs donned gloves to prepare Resident #83 for transfer from bed and shower. Staff E, removed Resident #83's brief, noting bowel movement. Using gloved right hand pulls wipes from package, setting on bed by Resident #83's feet. Staff E, uses right hand, wiping to clean bowel movement, discards soiled wipe by setting it on open soiled brief, with same right hand touches package, removing another wipe, cleaning Resident #83's bottom, discarding used wipe on soiled brief and with right hand again touches package, removing another wipe, cleans BM and discards soiled wipe on brief. Staff E rolled and tucked soiled brief under Resident #83's bottom and hips, grabbing the package of wipes off the bed with dirty gloves and places the wipes on Resident #83's bedside table. After removing the dirty gloves, failing to perform hand hygiene, Staff E, dons new gloves and assists Staff DD roll Resident #83 side to side to remove the soiled brief and positioning him on a mechanical lift shower sling for transfer. Staff E and Staff DD transfer Resident #83 to the shower chair, covering him with shower blankets. Both CNAs then remove their gowns and gloves, Staff E pushes Resident #38 in the shower chair to shower room. Staff DD pushes the mechanical lift to the hall leaving it along the wall without cleaning the lift, both failing to perform hand hygiene after removing their gloves. During a treatment observation on 5/13/26 at 7:58 AM, Staff H, CNA rolls Resident #83 towards her, Staff J, LPN removes old dressing and packing, disposing of dressing and gloves in the trash can. Staff J, failing to perform hand hygiene, dons new gloves, washes Resident #83's wound site with soapy water and wash cloth, inserting and turning clockwise, rotating sides of wash cloth, cleaning clockwise. Staff J, removed her gloves, went to the bathroom and washed her hands. On 5/14/26 at 11:55 AM, Staff N, CNA is observed donning gown, gloves, and mask and enters Resident #83's room. At 12:10 PM Staff N, CNA exits Resident #83's room, gown removed, wearing gloves and mask, carrying soiled trash, enters the shower room to dispose soiled trash. Staff N, Returns to the hall still wearing the mask. Knocks and enters room [ROOM NUMBER] wearing the same mask. Observation on 05/13/2026 at 8:00 AM revealed Staff TT, CNA, donned a gown and gloves outside of room [ROOM NUMBER]. When asked how she knew whether the Enhanced Barrier Precautions (EBP) notice on wall outside of door indicated Resident #83 or Resident #12, Staff TT responded she was new to the facility, however, she had been told Resident #83 required EBP because he had a wound. Observation of incontinence care conducted earlier in the shift by Staff A CNA and Staff B CNA CNA, neither of which donned PPE during the care. 4. The MDS assessment dated [DATE] for Resident #52 identified a BIMS score of 09, which indicated moderate cognitive impairment. The MDS documented the resident totally dependent upon staff for toileting hygiene and always incontinent of bowel and bladder. The MDS documented diagnoses that included debility, chronic kidney disease, and overactive bladder. The Care Plan dated 3/12/26 documented a focus area identifying the resident as incontinent of bowel and bladder. The care plan interventions directed staff to check and change the resident before/after meals, with AM/HS (morning, bedtime), as needed, and to wash, rinse, dry peri-area as allowed or needed and clean peri-area with each incontinence episode. Observation on 05/13/2026 at 5:06 AM revealed staff entered Resident #52's room to provide personal care. A strong ammonia smell was observed throughout the room. Staff B, CNA, and Staff A, CNA, washed hands and donned gloves. Staff B uncovered the resident removing the blankets, then adjusted the bed and bed control fell to the floor. Staff B removed gloves and donned new gloves without washing hands. Staff A placed a new incontinence brief and bed pad on the bed with the box of gloves without a barrier. Staff B stood on the resident's left side, undid the brief and asked resident to assist to open her legs. Staff B wiped the abdominal fold under the pannus and barely down middle between the legs then stated okay, we are done. Staff B changed gloves but failed to wash or sanitize her hands. Staff assisted the resident to roll to the right side revealing a heavily soiled brief with feces present. Staff B continued with contaminated gloves to wipe the rectal area. At that time, the resident expressed she did not want the surveyor visualizing care and the surveyor stepped to the other side of the curtain. Staff failed to cleanse all areas on the front contaminated by the brief prior to the surveyor stepping out of view. The surveyor immediately heard gloves changed however observation had revealed no sanitizer present and the sink located in the bathroom. The staff continued care without ever washing or sanitizing hands. Staff A and B quickly came around the curtain to remove items and placed them in trash. Staff A stated they were going to change her gown. Both staff told the resident they were going to assist her to be pulled up in bed telling the resident this and asked about placing pillows. Staff failed to go to the bathroom to access hand sanitizer or wash hands and continued to handle trash bags and move items in the room. Staff B left the room with a trash bag then returned, then said needed one more bag. Staff B returned and washed her hands. Staff A remained on the other side of the curtain near the resident. At 5:18 AM Staff A went to the bathroom to wash hands while Staff B left the room with the soiled linen bag then returned to room and washed hands. The urine smell remained in the room after provision of incontinence care. 5. The MDS assessment dated [DATE] for Resident #85 identified a BIMS score of 04, which indicated severe cognitive impairment. The MDS documented the resident totally dependent upon staff for toileting hygiene, had an indwelling catheter, and always incontinent of bowel. The MDS listed diagnoses that included neurogenic bladder and stroke. The Care Plan dated 4/14/26 documented a focus area identifying the resident incontinent of bowel due to CVA (stroke) and weakness, pain, and impaired mobility. The care plan interventions directed staff to check and change before/after meals, with AM/HS (morning, bedtime), as needed, and to provide peri-area with each incontinence episode. Observation on 05/13/2026 at 9:36 AM revealed Staff H, CNA, and Staff TT, CNA, prepared to assist Resident #85 with personal care. Staff H and Staff TT donned gown and gloves prior to entering the room. Prior to entering the room, Staff H asked surveyor if she could tell her what all she needed to wear for PPE and for what activities required EBP; she commented she knew at least for the catheter care. Surveyor responded SSA (State Survey Agency) only there to observe and questioned Staff H on what training she received about EBP. Staff H answered she was a new CNA, this was her first job, worked for 2 months, she received training when in school from CNA program, but she had not received any training from the facility about EBP. Resident #85 laid in bed on his back with a catheter present. With gloved hands Staff H wiped on the left then right side of the groin and penis with a different wipe then wiped down the catheter tube 3 inches with a new wipe. Staff H rolled the resident to his right side and Staff TT wiped the rectal area front to back where feces was present. Staff H removed the soiled brief which contained feces and placed it directly on bed where the clean wipes sat. Staff H continued to wipe and then with the same contaminated gloves, Staff H grabbed a new clean brief, handed it to Staff TT who handed her the stack of feces wipes and brief which Staff H grabbed, then both continued to place a new brief without changing gloves. No wiping occurred of all the areas in contact with the soiled brief such as the right and left hips, or right and left buttocks. Both staff entered the bathroom and washed hands and donned new gloves. Staff TT went to empty the catheter bag and Staff H continued to assist the resident with changing his shirt . A nurse entered the room and Staff H reported the resident had a securement in place for the catheter but the resident reported pulling it off during the night. Both staff assisted to roll the resident back and forth to dress the resident. Placed the sling for the lift under the resident so they could assist the resident up when needed. Staff TT removed her gown and gloves, bagged the trash and soiled linens. Staff H removed her gown and gloves but failed to wash hands, then touched the resident's soda bottle, removed the cap, and provided the resident with a drink. Staff H positioned the bed down to transfer height and stated she would be back with a nurse to provide GT (gastronomy feeding tube) care. Leadership called Staff H over radio and stated she was needed right then in office. Staff H left the room without washing hands, to sign a form provided by leadership. On 6/3/26 at 11:29 AM an observation in Resident #85's room, the bedside table noted to be covered with multiple items, including an open unlabeled, undated irrigation kit with a bolus feeding syringe, sterile cap removed (indicating it had been used), and an unlabeled, undated, graduate with another bolus feeding syringe. 6. The MDS assessment dated [DATE] for Resident #73 identified a BIMS score of 08, which indicated moderate cognitive impairment. The MDS documented the resident did not refuse care. The Self Care Functional Abilities identified the resident required supervision or touching assistance for oral care, substantial to maximal assistance with upper/lower body dressing, and totally dependent upon staff for toileting and personal hygiene. The Mobility status identified the resident required substantial to maximal assistance in bed rolling left and right, sit to lying, and lying to sitting on side of bed, and totally dependent for sit to stand, chair-to-bed-to-chair, toilet and tub/shower transfers. The MDS documented the resident frequently incontinent of urine and always incontinent with bowels, which was a major change from the previous assessment. The MDS recorded the resident at risk of pressure ulcers/injuries with one unhealed Stage 1 pressure injury, one new unhealed Stage 4 pressure injury, and moisture associated skin damage (MASD). The Skin and Ulcer/Injury Treatments checked for a pressure reducing device for chair, pressure ulcer/injury care, and application of nonsurgical dressings and ointments/medications. The MDS recorded the resident received hospice care services. The care plan dated 4/13/26 that included the following focus areas and care plan interventions: Focus area revised 1/5/26 identified the resident had bladder and bowel incontinence related to impaired mobility and loss of peritoneal tone. The intervention created 4/5/23 instructed staff to clean the peri-area with each incontinence episode. The intervention created 9/2/25 instructed staff to encourage toileting and manage incontinence before/after meals, at AM (morning) and HS (bedtime), and as needed. Focus area revised 1/5/26 identified an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and impaired balance. The interventions revised 94/25 included: encourage the resident to be up in the wheelchair and in the dining room for meals; wheelchair for mobility; transfers with EZ (sit-to-stand) mechanical lift and assistance of 2 persons; and assist of 1 person for dressing, personal hygienic, and toilet use. Focus area revised 3/26/26 identified the resident had an actual skin impairment of a pressure ulcer to the back of her left thigh related to CHF (Congestive Heart Failure), morbid obesity and incontinence of bowel and bladder. The care plan documented on 3/11/26 a Stage 4 pressure sore present on the back of the left thigh. The interventions created 3/11/26 instructed: the use of a pressure reduction equipment and procedures as indicated for preventative measure equipment/procedure; turn and reposition; cushion to the wheelchair and specialty mattress on the bed; and encourage the resident to shift weight, if able, every 2 hours to assist with skin integrity and assist as needed. Focus area revised 3/30/26 identified a potential for pressure ulcer development related to incontinence and decrease in mobility with a note 3/10/26 Stage 4 pressure ulcer present on left rear thigh. Focus area revised 4/13/26 identified impaired cognitive function or impaired thought processes related to short term memory loss. The intervention created 4/3/25 instructed staff to cue, reorient and supervise as needed. The Progress Notes dated 3/24/26 at 5:04 PM documented a Health Status note that the resident was on an antibiotic for wound infection and supplement for wound healing. The Monthly Nursing Summary dated 5/6/26 documented the resident required: extensive 2 person physical assist for transfers and dressing; totally dependent upon 2 person physical assist for bed mobility and personal hygiene; and indicated toilet use activity did not occur. The summary recorded the resident always incontinent of bowel and bladder. The Weekly Wound assessment dated [DATE] recorded a wound summary. The summary documented a Stage 4 pressure sore to the left rear thigh measured 2.84 cm by 2.03 cm by 0.1 cm with 100% granulation, moderate amount of serosanguineous drainage with odor present. Noted interventions included pressure reduction mattress, Nutritional Supplements, but did not have wheelchair cushion, Specific Turning/Repositioning Program, Positioning Devices, or Heal Boots marked. The Progress Notes dated 5/8/26 at 1:08 PM documented the IDT team reviewed the resident's pressure ulcer to the posterior left thigh. The entry documented the Stage 4 wound treatment was effective and wound improved with no signs/symptoms of infection. The IDT updated the care plan and would continue to monitor. Observation on 05/13/2026 at 11:41 AM revealed a staff member entered the Resident #73's room and announced 'therapy'. The staff asked the resident if she wanted to get up for lunch and the resident responded yes. Staff H entered and said she would be back with the EZ stand. Staff TT informed and redirected Staff H that Resident #73 was on EBP (Enhanced Barrier Precautions, indicating the required use of gown and gloves with high contact cares) and Staff H and TT donned PPE (Personal Protective Equipment). Staff H acknowledged the last time care provided for Resident #73 was around 4:00 AM. Staff H commented unfortunately, once you get behind in the day there isn't much you can do, everything just gets pushed back further and further. Staff H verbalized they had just provided cares for Resident #86 and got her out of bed. Staff H stated Resident #73 was the last resident to get up for lunch. Staff H left the room to obtain more periwipes while Staff TT started with donning pants on the resident. Staff H returned and reported to Staff TT the nurse did Resident #73's wound care first thing in the morning. Resident #73's blanket pulled back to reveal the incontinence brief indicator with solid blue lines in front and a very strong ammonia smell in the room. Staff H used a remote to raise the bed and adjusted the gripper socks. Resident #73's left leg marked with black line to outline the area of cellulitis. Resident #73 cried out a bit when the gripper sock moved. Staff H lowered the bed to move the bed away from the wall then raised back up. Staff TT grabbed and opened a new brief and placed it on the foot of bed. Staff TT removed tabs of incontinence brief while having peri-wipes in hand, cleansed right the side abdominal fold then left side with a new wipe each time, then down the center. Staff H rolled the resident to the left side, Staff TT pulled the brief, rolled and brief heavily soiled with urine and feces. Staff TT wiped from front to back rectal area and part of the left buttock. Bandage on the back of lower left thigh just above the back of the knee, marked with dressing. Staff rolled back, failed to change soiled gloves or sanitize hands prior to placing a new brief and failed to cleanse all areas where the brief was in contact with skin. Staff H finished pulling out the soiled brief then the new brief placed with the same soiled, contaminated gloves. Both staff then removed gloves and gathered the trash. Staff H washed hands and Staff TT sanitized and donned new gloves. Staff TT returned to the bedside to pull up the pants to thigh level then assisted with 2 to rotate in the bed to the edge of the bed to connect the EZ stand lift into place. Without washing hands, the oxygen tubing was removed and Staff TT rolled up and placed in a bag on the oxygen concentrator. Assisted resident to doff hospital gown and don a shirt. EZ stand sling placed on top of fitted sheet in the same location where the heavily soiled brief laid, therefore the area contaminated. Both staff connected the sling loops, selecting both the 3rd green and 2nd black loops. Staff TT ran the controls and instructed the resident to stand nice and tall. Staff H unlocked while Staff TT and Staff H pulled up pants, moved to the wheelchair, and safety strap was around the resident. Staff H removed the sling, hung it over the machine, and both staff continued to touch items with contaminated gloved hands. Staff H put leg foot pedals on the wheelchair and stated the one pedal was broken so that was why they used the pillow to try to hold it in place. Staff H voiced not the best option, but they were working on ordering a new one. Staff F put a wedge type cushion in place under the resident's feet as feet approximately 6 inches from touching the pedals. Staff H stated the resident needed a new oxygen tank by the nurse. Staff TT combed the resident's hair. Staff H left the room with soiled trash and linens and said she would be back for the EZ stand. Staff H failed to wash her hands after removing her gloves or the EZ stand. Observation on 05/14/2026 at 7:34 AM revealed Staff VV, LPN and facility wound nurse, and the Nurse Practitioner (NP) stood outside of Resident #73's room with a treatment cart and prepared for wound care. The NP stated to Staff VV that the resident just finished antibiotics medication for cellulitis in the leg. They entered the room and Resident #73 laid in bed on her back. The NP removed the wound dressing to the lower left posterior thigh and measured 3.0 cm width and 2.5 cm length with 100% granulation tissue present with moderate serosanguinous drainage present after cleansing the wound. The NP and Staff VV commented the wound looked much better than before and the NP felt the cellulitis caused by the fungal infection from the knee but responded the antibiotic likely helped the pressure wound. Observation revealed the wheelchair seat without cushion and the NP indicated that normally the cushion was in the chair. The NP located the roho cushion on the floor between the bed and the bedside drawers/table. Observation on 05/14/2026 at 9:45 AM revealed Resident #73 sat in the recliner in a se[TRUNCATED]

Based on clinical record review, staff interview, and facility policy review, the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital, failed to obtain bed hold notifications, and failed to document disposition of resident belongings and discharge status, for 5 of 5 residents (Resident #1, #2, #7, #52, #93) reviewed for discharge processes. The facility reported a census of 81 residents. Findings include:1. Resident #1's Clinical Census printed 5/27/26 listed the following: 2/4/26: Hospital unpaid leave 2/16/26: Hospital unpaid leave The Notice of Transfer Form to Long Term Care Ombudsman dated February 2026 provided by the facility lacked documentation of Resident #1's hospitalizations. Resident #1's clinical record lacked documentation regarding a bed hold notification for the hospitalizations in February 2026. On 6/2/26 at 11:00 AM, Staff R, Regional Director of Admissions and Marketing, stated the previous social worker would've reported the discharge to the Ombudsman. She stated when she looked into it, the facility put the census information into the electronic health record (EHR) late, so when they pulled the report, they had the incorrect discharge date . She stated she'll be the one reporting now until the facility hires someone, and she'll recheck the list at the end of the month before sending it to the Ombudsman. An email on 5/27/26 at 2:59 PM from the Regional Director of Operations indicated the facility didn't have an Ombudsman policy. 2. Resident #2's MDS discharge return anticipated assessment dated [DATE] identified Resident #2 discharged [DATE] to a short-term general hospital. The Census tab of the EHR reflected Resident #2 transferred to the hospital on 4/19/26, 4/20/26, and 4/27/26. The Assessments tab of the EHR reflected only one transfer and discharge form recorded for 4/20/26. The clinical record lacked documentation of the required written orientation and transfer information completed and communicated on 4/19/26 and 4/27/26. The clinical record also lacked written bed hold notices for the transfers. The progress note dated 4/28/26 at 8:59 AM recorded a social service note. The entry recorded a follow-up done to sending Resident #2 to the hospital and noted Resident #2 stayed in the critical care unit. On 5/26/26 at 11:05 AM, Staff R, Social Service Designee, reported the bed hold notices that were being looked for regarding the residents triggered in the survey software for hospitalization weren't found and weren't done. This included Resident #1, Resident #2, Resident #7, Resident #52, and Resident #93. Staff R stated prior to her being designated, Staff NN stayed as the social service designee and she left around 4/24/26. Staff R said the copies of the written bed hold notices should be uploaded in the EHR under the documents tab. On 5/28/26 at 11:05 AM, the Director of Nursing (DON) responded she didn't know Resident #2's disposition or whether he passed away. The DON stated she hadn't looked at Resident #2's record recently and would need time to look it up. Review of the progress notes revealed they lacked any mention of Resident #2 passing away or the disposition of his belongings and medications. 3. The Census tab of the EHR reflected Resident #7 transferred to the hospital on 1/27/26, 2/23/26, and 3/16/26. Review of the clinical record for Resident #7 lacked documentation of a written bed hold notice or written orientation and transfer notification. 4. The Census tab of the EHR reflected Resident #52 transferred to the hospital on 2/15/26 and 2/19/26. Review of the clinical record for Resident #52 lacked documentation of any written bed hold notices. On 5/21/26 at 1:00 PM, Staff F, Minimum Data Set (MDS) Coordinator, reported Resident #52's son took Resident #52 out to the hospital in February 2026. Staff F recalled the son wanted to take her to the hospital and it wasn't uncommon for that to be the situation since he also took her to appointments. Staff F stated a transfer discharge note would be entered into the EHR. Staff F responded she didn't know what the staff were doing, but she'd send the Facesheet, transfer form, an order sheet, and call the hospital on why they sent Resident #52 to the emergency room. Staff F answered the process for a bed hold notice should've been to give it to the son when Resident #52 left for the hospital. The Director of Nursing (DON) responded she didn't know of any other documentation location other than the EHR under documents, progress notes, and user defined assessments where the bed hold notification would be found. The DON inquired if the facility was expected to notify the long-term care Ombudsman with transfers to the emergency room and received information that they were required to do so. An email confirmation from the Regional Director of Operations on 5/26/26 at 1:11 PM documented the facility couldn't locate any of the bed hold notices, which included Resident #1, Resident #2, Resident #7, Resident #52, and Resident #93. 5. The progress notes for Resident #93 dated 1/21/26 at 3:13 PM documented Resident #93 was transported to the hospital on 1/16/26 and returned to the facility on 1/19/26. Review of the clinical record for Resident #93 revealed it lacked documentation of a bed hold notice. The Bed Hold Notice Upon Transfer policy revised March 2025 instructed at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. The written information must specify the reserve bed payment policy in the state plan policy, if any, and the facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. The written notice must specify the conditions upon which the resident would return to the facility, including that the resident requires the services which the facility provides and is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan. The facility will provide the receiving provider contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, and all special instructions or precautions for ongoing care, as appropriate. The facility will provide the receiving provider comprehensive care plan goals and all other necessary information, including a copy of the resident's discharge summary, as applicable, and any other documentation to ensure a safe and effective transition of care. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file.

Based on clinical record review, staff interview, and facility policy review, the facility failed to revise care plans to accurately reflect resident needs in a timely manner for 3 of 3 residents triggered for care plan revisions (Resident #1, #86, #52). The facility reported a census of 81 residents. Findings include:1. The Notice of PASRR (Preadmission Screening and Resident Review) Level II outcome for Resident #1 dated 1/18/26 recorded a PASRR Determination for Resident #1 of Approved with Specialized Services. The census page of Resident #1's clinical record reflected the resident admitted on [DATE], transferred to the hospital on leave 2/4/26, readmitted on [DATE], transferred to the hospital on leave 2/16/26, and readmitted [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 recorded a most recent admission date of 2/10/26. Section A1500 section PASRR coded as 1 which indicated the resident did have conditions related to ID/DD (Intellectual Disability/Developmental Disability). Section A1510 checked all boxes yes for serious mental illness, Intellectual Disability, or Other related conditions. The care plan dated 3/12/26 documented a newly created entry initiated on 3/10/26 for the PASRR Specialized Services the resident needed to achieve optimal functioning and recovery. The care plan recorded an intervention created on 3/10/26 documented the provider who would provide ongoing psychiatric medication management by a psychiatrist starting 2/10/26, with referral to be made 3/10/26. No indication in the document as to why there would be a 2/10/26 start date prior to the 3/10/26 referral date. The care plan recorded an intervention initiated 3/10/26 to identify a provider for individual therapy to start on 3/12/26. The care plan recorded an intervention initiated 3/10/26 for social services to provide supportive counseling starting 2/10/26 as well as activities to be encouraged by nursing facility staff starting 2/10/26. The care plan recorded an intervention initiated 3/10/26 for the facility to obtain the resident's archived psychiatric/behavioral health treatment records to clarify history and make past records available to all medical and behavioral health service providers. The intervention documented this activity as an important component in the delivery of effective behavioral health and overall health care services and must be implemented in order to see that the resident's mental health treatment records were complete and comprehensive and that they follow the resident to various behavioral health primary providers. The care plan lacked timely revision to update it to include the PASRR Specialized Services the resident required upon initial admission date of 1/19/26. 2. The MDS assessment dated [DATE] for Resident #86 recorded an admit date of 10/1/25. The MDS coded the resident weight as 143 pounds with no weight loss or weight gain triggered. The MDS assessment dated [DATE] coded the resident weight as 169 pounds with a weight gain of 5% or more in the last month or gain of 10% or more in the last 6 months. The MDS assessment dated [DATE] coded the resident weight as 164 pounds with a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The weights vitals page of Resident #86's clinical record revealed the following weight values:10/1/25 at 5:08 PM 154.2 lbs. (pounds) by mechanical lift scale.This weight measurement struck out on 10/8/25 at 4:11 PM noting the strike out reason as technical error.10/1/25 at 8:46 PM 154.2 lbs. by wheelchair scale.10/3/25 at 10:52 AM 143.0 lbs. by mechanical lift scale.This weight measurement struck out on 12/17/25 at 8:47 PM noting the strike out reason as other. This entry was recorded by Staff G, Dietician. 10/4/25 at 8:21 AM 143.0 lbs. by mechanical lift scale.This weight measurement struck out on 12/17/25 at 8:47 PM noting the strike out reason as other. This entry was recorded by Staff G, Dietician. 10/9/25 at 2:20 PM 143.2 lbs. by sitting scale.This weight measurement struck out on 12/17/25 at 8:47 PM noting the strike out reason as other. This entry was recorded by Staff G, Dietician. 10/16/25 at 8:47 AM 145.0 lbs. by wheelchair scale.This weight measurement struck out on 12/17/25 at 8:47 PM noting the strike out reason as other. This entry was recorded by Staff G, Dietician. 11/1/25 at 11:44 AM 166.0 lbs. by wheelchair scale.12/1/25 at 1:39 PM 169.8 lbs. by wheelchair scale.1/21/26 at 4:17 PM 177.6 lbs. by wheelchair scale.1/21//26 at 7:18 PM 177.4 lbs. by wheelchair scale.2/1//26 at 8:58 PM 150.2 lbs. by wheelchair scale.This weight measurement struck out on 2/18/26 at 4:40 PM noting the strike out reason as re-weighed. This entry was recorded by Staff G, Dietician. 2/18/26 at 4:40 PM 182.0 lbs. by wheelchair scale.3/18/26 at 1:10 PM 164.4 lbs. by wheelchair scale.This weight measurement struck out on 5/7/26 at 2:20 PM noting the strike out reason as incorrect documentation. This entry was recorded by Staff G, Dietician. 5/7/26 at 2:20 PM 182.6 lbs. by wheelchair scale. On 10/1/25, the resident weighed 154.2 lbs. On 5/7/26, the resident weighed 182.6 lbs. which is a 18.42% Gain in 6 months. On 1/21/26, the resident weighed 177.6 lbs. On 5/7/26, the resident weighed 182.6 lbs. which is a 2.82% Gain in 3 months. The progress notes dated 12/17/25 at 8:48 PM documented a weight note for a weight gain with a current weight of 169.8 lbs. The entry recorded some questionable weights from the facility were discussed with the medical power of attorney and that the admit weight of 154.2 lbs. previously assumed to be in error was reinterred in the weight record. The entry noted the weight gain was an FYI (for your information). The progress notes dated 1/23/26 at 8:02 PM documented a weight note for weight gain with current weight 177.4 lbs. The entry recorded a 15.0% weight gain since admit and the Dietician provided education on excess calorie intakes. The progress notes dated 4/3/26 at 10:25 PM recorded a nutrition note. The entry documented the March '26 weight likely in question as no changes with food consumption that would result in weight loss and no change with diuretic medication (helps rid body of excess fluid). The entry noted the facility would continue to follow up after the April weight obtained. The progress notes dated 4/10/26 at 12:36 PM recorded a mini nutritional assessment. The entry documented a weight of 164.4 lbs. on 3/18/26 and in the last 3 months, there had been a weight loss greater than 6.6 lbs. The care plan dated 5/12/26 recorded a focus area initiated 10/8/25 by Staff G, Dietician, that the resident was at risk for altered nutrition/hydration status. The goal section for this focus area revised 5/12/26 documented the resident would maintain a present weight of 148 lbs. plus or minus 4% (142-155 lbs.) by 7/1/7/26. The care plan lacked any documentation pertaining to a weight loss or a weight gain and it failed to have a revision to reflect the resident's weight of 182.6 lbs. as of 5/7/26. In an interview on 5/21/26 at 12:50 PM, Staff F, MDS/Care Plan Coordinator responded that the MDS information of a weight loss was accurate at the time of the completion as the weights used to calculate the loss were not struck out at the time of doing the MDS assessment. Staff F denied being aware of the discrepancies in the weight values and voiced the Dietician was responsible for completing the nutrition section of the MDS and care plan. 3. The MDS assessment dated [DATE] for Resident #52 identified a readmission date of 2/24/26. The MDS coded under the High-Risk Drug Classes: Use and Indication the resident took anticoagulant medication in the 7 days or less since admission and an indication was noted. The Care Plan dated 3/12/26 documented a focus area revised 8/4/25 that identified the resident was on anticoagulant therapy related to a history of DVT (Deep Vein Thrombosis) and PE (Pulmonary Embolism). The care plan intervention dated 8/19/25 directed staff to administer anticoagulant medications as ordered by physician and to monitor for side effects and effectiveness every shift. The Progress Note dated 4/29/26 at 12:00 AM recorded a Date of Service visit completed by the Nurse Practitioner and signed 4/29/26 at 6:38 PM. The entry documented the resident's vaginal bleeding resolved after inpatient treatment and the anticoagulation discontinued from the last hospitalization but still active on the patient's MAR and the patient refusing. The Xarelto discontinued as recommended. The Order Recap Report run on 5/21/26 at 11:25 AM identified Xarelto tab 20 mg 1 tablet by mouth daily with supper started on 10/2/25 and ended on 4/29/26. The care plan lacked revision to reflect the resident's anticoagulant medication Xarelto discontinued on 4/29/26. On 5/21/26 at 1:00 PM, Staff F, MDS Coordinator, responded she was just getting the facility on a revised schedule to have the care plans done quarterly and revised with the MDS assessments. Staff F stated prior to revision, the facility was updating care plans only with the IDT (Interdisciplinary Team) with falls, wounds, and behaviors. Staff F stated she had been working long enough to get back on a schedule. When asked what was previously getting completed, Staff F responded the baseline care plans done on admission, along with comprehensive and significant change assessments and care plans. When asked if anyone else updates care plans, Staff F responded anyone on IDT could do it but going forward she would. Staff F responded she was not aware the anticoagulant medication for Resident #52 was discontinued and the care plan should have been revised when the medication was discontinued. The facility policy titled Care Plan Revisions Upon Status Change revised January 2026 included the following documentation: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures.

Based on grievance documents, clinical record review, resident interview, observation, and staff interview, the facility failed to provide timely and complete assistance to residents who needed help with toileting / incontinence care, grooming, oral care, and transferring for 6 residents reviewed for assistance with personal cares (Resident #81, #73, #83, #53, #85, #86) and 14 residents identified via grievance forms (Resident #81, #49, #43, #45, #78, #8, #83, #52, #22, #59, #25, #64, #66, formerly room [ROOM NUMBER]-B). The facility reported a census of 81 residents. Findings include: 1. The Grievance Form dated 1/15/26 signed by the Administrator recorded Resident #81 complained he wasn't getting checked and changed, providing assistance with incontinence care (care given for lack of bladder or bowel control), on the overnight shift. The Grievance Official Follow-Up section documented education went to staff on the 10:00 PM to 6:00 AM shift to ensure they checked and changed the residents every 2 hours. The form recorded no date of resolution but documented it would remain ongoing to check with Resident #81. The Grievance Form dated 1/16/26 signed by the Administrator recorded Resident #49 reported the aides weren't friendly, didn't get her ice water, didn't answer her call light, and she didn't receive her scheduled shower. The Grievance Official Follow-Up section documented education went to staff regarding resident dignity and all things that could hinder their dignity, reinforced it represented the resident's home, and spoke to staff specifically about Resident #49's shower schedule. The Grievance Form dated 1/29/26 signed by the Administrator as resolved on 1/30/26 recorded Resident #43 reported the overnight Certified Nurse Aides (CNA; staff members who provide basic care) didn't change her brief overnight, which resulted in a complete bed change. Resident #43 stated she already had skin issues and that two staff completed a check and change. The Grievance Form dated 1/30/26 signed by the Administrator as resolved on 1/31/26 recorded Resident #45 complained of sitting in his own bowel movement/feces for 14 hours and he didn't like it at the facility. The Grievance Official Follow-Up section documented the Administrator asked staff on that hall and they reported they changed Resident #45. The form documented an all-staff huddle conducted at 2:00 PM where staff talked about checking with residents to see if they needed assistance. The Grievance Form dated 2/1/26 signed by the Administrator as resolved on 2/1/26 recorded Resident #78 reported a concern with CNAs telling him they couldn't toilet him because they didn't have an EZ stand (sit-to-stand mechanical lift). The Grievance Official Follow-Up section documented the CNA reported that the EZ stand wasn't available, she helped Resident #78 use a urinal, and she eventually found an EZ stand to help him. The Grievance Form dated 2/4/26 signed by the Administrator as resolved on 2/4/26 recorded Resident #43 reported not getting checked and changed on the last 3 overnight shifts. The Grievance Official Follow-Up section documented the care need went onto the Treatment Administration Record (TAR; medication and treatment record), and staff would wake Resident #43 between 3:00 AM to 4:00 AM to check and change her. The Grievance Form dated 2/11/26 signed by the Administrator as resolved on 2/11/26 recorded Resident #8 reported a concern the staff didn't have incontinence briefs available for her on the overnight shift. The Grievance Official Follow-Up section documented the Administrator talked with Staff GG, Certified Medication Aide (CMA; staff member trained to give medications), who ordered supplies and reported they had large pull-ups but extra-large would go into central supply. The Grievance Form dated 2/12/26 signed by the Administrator as resolved on 2/18/26 recorded Resident #83's family member reported they wanted the staff to groom Resident #83 better and keep the room clean. The Grievance Official Follow-Up section documented the Administrator spoke with housekeeping to keep the room clean and with the CNAs to keep Resident #83 groomed. The Grievance Form dated 2/16/26 signed by the Administrator as resolved on 2/18/26 recorded Staff II, Licensed Practical Nurse (LPN; staff member who provides basic nursing care), reported a concern involving Resident #52. Staff II reported Resident #52 felt very upset upon return from the hospital around 12:00 PM because Staff JJ, CNA, didn't provide any care, no pericare (cleansing of perineal area after incontinence), and no assistance with any activities of daily living. The 2:00 PM to 10:00 PM shift called the nurse into Resident #52's room around 3:00 PM because Resident #52 needed help. Resident #52 reported to Staff II that she'd asked for help since returning from the hospital, and she still lay underneath all the hospital linens and draw sheet (transfer sheet) with a brief and all linen saturated with blood and urine from her mid-back to mid-thigh. The Grievance Official Follow-Up section documented the Director of Nursing (DON; staff member in charge of nursing) spoke with Staff JJ, who would begin retraining on 2/18/26, and the facility wanted Staff JJ to improve her care and undergo monitoring. The Grievance Form dated 2/19/26 signed by the Administrator as resolved on 2/19/26 recorded Resident #22 reported a concern that she didn't get a nightly snack at bedtime, didn't get a shower when she was supposed to, her bed wasn't being made, and the call light timing still took a while. The Grievance Official Follow-Up section documented only evening shift call lights, a snack went to the room, and she received a shower later that day. The Grievance Form dated 2/27/26 signed by the Administrator as resolved on 2/27/26 recorded Staff LL, Therapist (staff member who helps improve skills for daily living), reported a concern involving a resident who formerly resided in room [ROOM NUMBER]-B. Staff LL reported the resident put his call light on at 6:00 AM and called the front desk twice. A staff member by first name only took the call, but no one went to help the resident until 8:00 AM, and the resident almost missed breakfast. The resident reported the staff never cleaned up the room, never took laundry, and he waited 30 minutes to an hour for the call light answers. He noted staff left the call light on for an hour, and it recurringly happened for weeks on the 6:00 AM to 2:00 PM shift. The resident further reported being left on the toilet for up to one hour, no one emptied his urinal, staff came on the wrong shower days, and no one hung his clean laundry because staff threw it on a chair. The Grievance Form dated 2/28/26 signed by the Administrator as resolved on 3/2/26 recorded Resident #59 complained call lights took 1 hour to answer, he had a bowel movement in his brief and staff didn't change him in a timely manner, and he complained about his pain medications. The Grievance Form dated 3/11/26 signed by the Administrator as resolved on 3/12/26 recorded Resident #5's family member reported that using the bathroom took a very long time. The Grievance Official Follow-Up section documented staff needed to help Resident #5 in the bathroom and assist her with walking, and staff received education at a huddle at 2:00 PM on 3/12/26. A second white page cut off at the top of the form documented that staff told Resident #5, you can walk, that's why we leave you. The family member stated that while Resident #5 could walk, she couldn't clean herself after using the bathroom. The Grievance Form dated 4/13/26 signed by the Administrator as resolved on 4/13/26 recorded Resident #25 reported a concern he had to have a bowel movement at 6:30 AM, he put on his call light, and a girl walked in at 8:00 AM, shrugged her shoulders, and walked out. The Grievance Official Follow-Up section documented the Administrator spoke with Resident #25, who reported the CNA went into his room, turned off his light, and walked out. The Administrator let Resident #25 know they'd follow up on his complaint, and an investigation started. The form lacked any documentation of further follow-up or an interview with Resident #25, and it contained no information on whether the grievance was confirmed or not confirmed. The Grievance Form dated 4/14/26 signed by the Administrator as resolved on 4/15/26 recorded Staff Y, Occupational Therapist, reported Resident #64 grew agitated and yelled in the hallway when the therapist approached at 2:10 PM. Staff Y reported Resident #64 stated he had a wet brief at lunch, he told a CNA who told him they'd be right back, and Resident #64 felt upset because they never returned. Staff Y assisted Resident #64 with care. The Grievance Official Follow-Up section documented education at a huddle occurred on 4/15/26 at 2:00 PM and the Administrator would follow up. The Grievance Form dated 4/23/26 signed by the DON as resolved on 4/24/26 recorded Resident #66 reported being upset she wasn't getting up early on her Monday and Thursday shower days, and it happened again that morning. The Grievance Official Follow-Up section documented the Administrator educated staff at a huddle on 4/24/26. 2. Resident #81's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented no signs or symptoms of delirium (sudden severe confusion), verbal behaviors directed toward others occurred on 1 to 3 days of the 7-day look-back period, and Resident #81 didn't refuse care. The Care Plan dated 5/3/26 for Resident #81 documented a focus area for assistance needed for Activities of Daily Living (ADL; everyday self-care tasks) care related to weakness and decreased mobility. The care plan interventions directed staff to provide assistance with oral hygiene as needed, assistance of 1 person for bathing and dressing, check and change for toileting, and assistance of 2 persons and a Hoyer mechanical lift for transfers. Another focus area identified a history of urinary tract infections (UTI; infection in the urinary system) related to incontinence with poor hygiene. The care plan interventions directed staff to check at least every 2 to 3 hours for incontinence while awake and to wash, rinse, and dry soiled areas, and offer a urinal or bedpan if continent. On 5/11/26 at 3:00 PM Resident #81 stated the call lights take forever and the staff claim they're short-staffed. Resident #81 said when the staff do come in to help, they run in and right back out, which he believes happens due to how he voices his opinion. He stated he checked his phone and once waited up to 2 hours for help, and he frequently waits over a half-hour on all 3 shifts. Resident #81 commented he felt the 3rd shift was lazy and didn't give a damn. He reported he eats in his room because the staff leave him in his wheelchair for over an hour when they bring him back to his room. On 5/14/26 at 7:56 AM Resident #81 reported the staff hadn't yet assisted him with incontinence care because typically they didn't change him until around 11:00 AM. Resident #81 stated he knew it wasn't yet time to have staff assist him because it was breakfast time and they didn't have enough staff. Resident #81 reported he was currently wet with urine and had a bowel movement at the time of the interview, he hadn't undergone a change, and wouldn't until around 11:00 AM. Resident #81 voiced he felt okay with that because of the staffing concerns. 3. Resident #73's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 8, indicating moderately impaired cognition. The MDS documented Resident #73 didn't refuse care. The Self-Care Functional Abilities section identified Resident #73 required supervision or touching assistance for oral care, substantial to maximal assistance with upper and lower body dressing, and total dependency on staff for toileting and personal hygiene. The Mobility status section identified Resident #73 required substantial to maximal assistance in bed rolling left and right, moving from sitting to lying, and moving from lying to sitting on the side of the bed, and total dependency for sitting to standing, chair-to-bed-to-chair, toilet, and tub or shower transfers. The MDS documented Resident #73 experienced frequent urinary incontinence and constant bowel incontinence. The Care Plan dated 4/13/26 for Resident #73 included a focus area revised 1/5/26 that identified Resident #73 had bladder and bowel incontinence related to impaired mobility and loss of peritoneal tone (abdominal muscle tone). An intervention created 4/5/23 instructed staff to clean the perineal area with each incontinence episode, and an intervention created 9/2/25 instructed staff to encourage toileting and manage incontinence before and after meals, in the morning, at bedtime, and as needed. A focus area revised 1/5/26 identified an ADL self-care performance deficit related to fatigue and impaired balance. Interventions revised 9/4/25 instructed staff to encourage Resident #73 to sit in the wheelchair and go to the dining room for meals, utilize a wheelchair for mobility, complete transfers with an EZ stand mechanical lift and the assistance of 2 persons, and provide the assistance of 1 person for dressing, personal hygiene, and toilet use. A focus area revised 4/13/26 identified impaired cognitive function or impaired thought processes related to short-term memory loss, and an intervention created 4/3/25 instructed staff to cue, reorient, and supervise as needed. The Monthly Nursing Summary dated 5/6/26 documented Resident #73 required extensive 2-person physical assistance for transfers and dressing, total dependency on 2-person physical assistance for bed mobility and personal hygiene, and indicated toilet use didn't occur. The summary recorded Resident #73 constantly experienced bowel and bladder incontinence. On 5/13/26 from 4:15 AM to 11:41 AM staff failed to provide Resident #73 with any major position changes, incontinence care, grooming, or oral care during a continuous observation. At 11:41 AM staff finally assisted Resident #73 with morning care. The observation revealed the following: On 5/13/26 at 5:20 AM Staff B stated she last provided care for Resident #73 prior to 4:30 AM during the 4 o'clock rounds. Staff B stated Resident #73 only required the assistance of 1 person for incontinence care, so she performed the care herself. On 5/13/26 at 7:54 AM witnessed Resident #73 remained in bed lying on her back. On 5/13/26 at 9:10 AM saw Staff QQ, LPN, exited the room after sitting to watch Resident #73 eat breakfast while Resident #73 lay on her back in a semi-Fowler's position (head of bed raised 30 to 45 degrees) in bed. On 5/13/26 at 9:11 AM Staff H stated Resident #73 would get out of bed but staff took longer assisting others that morning. Staff H stated they normally had a float staff member between the 300 and 400 halls, but that day she had to wait for help from a second person. Staff H reported Resident #83 had to eat in his room that morning because she couldn't get him down to the dining room. She noted nurses had to remain available to supervise the dining area, so she couldn't take residents there after 7:30 AM. On 5/13/26 at 9:20 AM Resident #73 didn't know how to answer questions regarding her preference for eating in her room versus the dining room or whether she preferred to sit up in her wheelchair for breakfast. Resident #73 remained dressed in a hospital gown positioned in a semi-Fowler's position on her back, and an air mattress pump ran with a green light. On 5/13/26 at 10:28 AM observed staff provide care for other residents on the 300 hall while Resident #73 wasn't moved. Resident #73 rested with her eyes closed, remained clothed in a hospital gown, and stayed positioned in a semi-Fowler's position without any major position changes. On 5/13/26 at 11:02 AM witnessed Resident #73 remained lying in bed on her back while Staff H passed by with Resident #1. On 5/13/26 at 11:25 AM observed Resident #73 remained lying in bed in the same semi-Fowler's position on her back, but she'd slid down in the bed, and the room smelled strongly of urine and ammonia. Staff H and Staff TT entered Resident #86's room. On 5/13/26 at 11:29 AM watched Staff II entered Resident #73's room with medications. On 5/13/26 at 11:41 AM observed a therapy staff member entered the room and asked Resident #73 if she wanted to get up for lunch, and Resident #73 responded yes. Staff H acknowledged the last time she provided care for Resident #73 occurred around 4:00 AM, and she commented that once you get behind in the day, everything just gets pushed back further. Staff H stated Resident #73 represented the last resident to get up for lunch. Staff H and Staff TT proceeded to assist Resident #73 with incontinence care, dressing, and transferring, but skipped oral care. Resident #73's blanket pulled back and revealed the incontinence brief indicator with solid blue lines in front, and a very strong ammonia smell filled the room. Staff H and Staff TT failed to clean all skin areas that came in contact with the heavily soiled brief, which held urine and feces. Staff opened a new brief and placed it on the foot of the bed, used the EZ stand lift to transfer Resident #73, assisted her to doff her hospital gown, don a shirt, and Staff TT combed her hair. On 5/13/26 at 12:14 PM Staff H re-confirmed that she didn't provide any incontinence care for Resident #73 when she positioned the head of the bed up for breakfast, and no major position change occurred since the overnight shift completed it. 4. Resident #83's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 2, indicating severe cognitive impairment. The MDS documented Resident #83 required substantial to maximal assistance with toileting hygiene and constantly experienced bowel and bladder incontinence. The MDS listed diagnoses of a wound infection, a Stage 3 pressure ulcer (full thickness skin loss) of the left hip, and recorded the presence of one unhealed Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). The Care Plan dated 3/12/26 for Resident #83 documented a focus area for mixed bowel and bladder incontinence related to impaired mobility, and interventions directed staff to check and change the resident before and after meals, with morning and bedtime, as needed, and to clean the perineal area with each incontinence episode using a bolster between the legs. Another focus area identified a Stage 3 pressure sore to the left hip related to impaired mobility, wheelchair dependency, ADL dependency, incontinence, cognitive impairment, and impaired communication. Interventions directed staff to manage moisture by providing toileting at regular intervals, prompt incontinence care, and preventative skin care products. On 5/13/26 at 4:43 AM noted a strong ammonia and urine smell filled the 300 hall outside of room [ROOM NUMBER] where Resident #83 and Resident #12 resided. The odor continued down the hallway to the end outside of room [ROOM NUMBER] where an open trash bag held soiled briefs open to the air. On 5/13/26 at 4:46 AM observed Staff A and Staff B entered the room of Resident #83, whose brief showed a blue indicator line from front to back. Staff A donned gloves and helped roll the resident to the right side, while Staff B moved the brief in front and tucked it between his legs. Staff A provided the wipes and Staff B wiped in small areas, but Resident #83's legs proved difficult to separate and staff failed to cleanse all areas where feces remained present. Staff B changed gloves but failed to wash her hands, donned new gloves, and rolled the resident to the left side, but didn't roll him enough to reach all areas. Staff B continued to wipe the same area repeatedly as feces remained present and her gloves became visibly soiled with feces across the palm. Staff B changed gloves and continued without washing hands, and Staff A instructed her to pull the brief out. Staff B handled the brief heavily soiled with feces and continued to swipe the rectal area, and both of her gloves touched feces on the wipes and then touched the resident's right hip area to pull the brief out. Friction and shear could be heard audibly as Staff B pulled using moderate force to remove the brief, which made an 'eeking' sound with each pull against the skin. The brief was soiled and Staff A failed to help pull the resident over to provide access. Staff B again changed gloves and failed to wash or sanitize her hands, tucked the soiled bed pad under the resident, and placed a new brief. The resident then rolled to the right and revealed an intact bandage labeled 5/12 over the pressure sore area. Staff A removed the soiled bed pad and continued with the same pair of gloves while staff rolled the resident back. Staff failed to cleanse the full scrotal area, lower abdomen, either hip, the penis, the foreskin, or any areas of skin contaminated with urine or feces where the brief contacted the skin. 5. Resident #52's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 9, indicating moderate cognitive impairment. The MDS documented Resident #52 was totally dependent upon staff for toileting hygiene and constantly experienced bowel and bladder incontinence. The MDS documented diagnoses of debility (physical weakness), chronic kidney disease (gradual loss of kidney function), and an overactive bladder. The Care Plan dated 3/12/26 for Resident #52 documented a focus area for bowel and bladder incontinence, and interventions directed staff to check and change the resident before and after meals, with morning and bedtime, as needed, and to wash, rinse, and dry her perineal area with each incontinence episode. On 5/13/26 at 5:06 AM watched Staff B and Staff A washed their hands, donned gloves, and entered Resident #52's room where a strong ammonia smell filled the air. Staff B uncovered the resident, stood on her left side, undid the brief, and asked her to help open her legs. Staff B wiped the abdominal fold under the pannus (hanging flap of tissue) and barely down the middle between her legs, then stated, okay, we are done. Staff helped the resident roll to the right side, revealing a heavily soiled brief with feces present, and Staff B continued with contaminated gloves to wipe her rectal area. At that time, Resident #52 expressed she didn't want the care viewed, and the observation moved to the other side of the curtain. Staff failed to cleanse all areas on the front contaminated by the brief prior to the move out of view. Staff A and Staff B quickly came around the curtain to place items in the trash, and Staff A stated they were going to change her gown. Both staff told Resident #52 they'd help pull her up in bed and asked about placing pillows, but the urine smell remained in the room after the incontinence care. 6. Resident #85's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 4, indicating severe cognitive impairment. The MDS documented Resident #85 was totally dependent upon staff for toileting hygiene, utilized an indwelling catheter, and constantly experienced bowel incontinence. The MDS listed diagnoses of a neurogenic bladder (nerve-related bladder loss) and a stroke. The Care Plan dated 4/14/26 for Resident #85 documented a focus area for bowel incontinence due to a stroke, weakness, pain, and impaired mobility, and interventions directed staff to check and change him before and after meals, with morning and bedtime, as needed, and to provide care with each incontinence episode. On 5/13/26 at 9:36 AM witnessed Staff H and Staff TT prepare to help Resident #85 with personal care while he lay in bed on his back with a catheter present. With gloved hands, Staff H wiped the left then right side of his groin and penis with a different wipe, then wiped down the catheter tube 3 inches with a new wipe. Staff H rolled the resident to his right side and Staff TT wiped the rectal area front to back where feces lay present. Staff H removed the soiled brief containing feces and placed it directly on the bed where the clean wipes sat. Staff H continued to wipe and then, using the same contaminated gloves, grabbed a new clean brief and handed it to Staff TT, who handed her the stack of feces wipes and the soiled brief. Staff H grabbed the items, and both staff continued to place the new brief without changing their gloves. No wiping occurred across the areas in contact with the soiled brief, such as his hips or buttocks. Both staff then entered the bathroom, washed their hands, and donned new gloves; Staff TT emptied the catheter bag and Staff H helped the resident change his shirt. 7. Resident #86's Minimum Data Set (MDS) assessment dated [DATE] revealed diagnoses of a stroke, hemiplegia (paralysis on one side of the body), and heart failure. The MDS identified Resident #86 constantly experienced bowel and bladder incontinence, required maximal assistance to roll left to right, and stayed dependent for toileting hygiene, dressing, and electric wheelchair transfers. Her BIMS score was a score of 7, suggesting severe cognitive impairment, yet she usually understood others and had the ability to express her ideas or wants. The Care Plan Focus dated 10/14/25 indicated Resident #86 needed assistance with ADLS due to weakness and decreased mobility. The Interventions directed staff to provide incontinence care in the morning, at bedtime, check and change her before and after meals and as needed. On 5/14/26 at 9:00 AM saw staff provided breakfast to Resident #86 in her room while she lay in bed, and no activities of daily living care occurred. On 5/14/26 at 9:34 AM Resident #86 stated it'd been a good while since the staff checked and changed her, and she currently lay wet with urine. A document titled Point of Care (POC) History for Resident #86 revealed that on 5/14/26 her last toilet hygiene occurred at 12:49 AM, and the shower history between 5/18/26 and 5/27/26 revealed 9 days passed without a shower. On 5/14/26 at 9:54 AM Staff TT stated she checked Resident #86 when she brought breakfast in and planned to check with the shower aide to see if they were ready for Resident #86's shower; if not, she'd provide perineal care. On 5/14/26 at 10:00 AM Staff OO, CNA, stated she'd help the shower aide get Resident #86 immediately to the shower.

Based on observations, interviews and record review, the facility failed to provide a restorative program to residents with mobility concerns for 4 of 4 residents reviewed (Resident #3, #71, #83, #85). The facility reported a census of 81.Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS recorded active diagnoses that included heart failure, hypertension (high blood pressure), diabetes mellitus, anxiety, and depression. The MDS also documented that Resident #3 had an impairment on her lower extremity. Resident #3's Care Plan dated 5/3/26 lacked a restorative nursing program. On 5/12/26 at 12:41 PM Resident #3 stated that she didn't think a restorative program existed at the facility. Resident #3 stated that she didn't work with anyone, the facility only offered Tuesday group exercises, and she and her roommate planned to start doing exercises on television. Resident #3 noted that she broke her left leg back in September. At this time, Resident #3 self-propelled her wheelchair. On 5/14/26 at 2:02 PM Staff Y, Occupational Therapist (OT), stated that a restorative program didn't exist. Staff Y stated that therapy performs a recommendation and maintains a screening process. Staff Y noted that therapy executes a therapy-to-nursing Certified Nurse Aide (CNA) handoff maintenance plan for levels of function at discharge. Staff Y stated that the facility provides walk-to-dine programs, and if a resident has a contracture (permanent muscle tightening), therapy instructs CNAs how to apply the device. Staff Y stated that once they finish the form, they review it with nursing staff, obtain signatures, and return it to Staff O, Rehab (Rehabilitation) Director. Staff Y didn't know what Staff O did with the forms after that point. On 5/21/26 at 11:25 AM Staff O, Rehab Director, explained that staff utilized various methods to contact therapy. Staff O stated that the facility communicated care details to maintain strength and endurance through the care plan and the communication book at the nurse's station. Staff O stated that she participated in morning meetings to review progress notes, incidents, skin conditions, and falls. Staff O noted that the facility utilized staff huddles. Regarding Resident #3, Staff O didn't recall the last time therapy provided services to her. Staff O detailed that staff used a therapy-to-nursing CNA handoff maintenance plan, which involved both staff and residents if the resident understood the plan cognitively. Staff O stated that therapists held responsibility for training staff on these specific plans. Staff O noted that despite staff turnover, the communication book remained consistent and information stayed available on the Kardex (medical information system). Staff O stated that the facility offered Tuesday exercises through activities to encourage individual participation. On 5/27/26 at 11:31 AM Resident #3 stated she didn't remember if therapy discharged her on any individualized program. Resident #3 stated she wanted to get up and walk, and wanted to talk to therapy again about her walker. Resident #3 noted that she didn't see how staff managed to walk-to-dine her because they stayed so busy. Resident #3 stated that she felt left on her own to walk. Resident #3 noted that she could bear weight on her left leg and possessed the ability to walk to the bathroom or perform a pivot transfer to the toilet. On 6/3/26 at 1:44 PM Staff O stated she didn't think a policy existed. Staff O stated that the facility lacked a restorative program because therapy operated there all the time and maintained communication with the staff. Staff O stated that if residents had a hard time walking or experienced contractures, therapy picked them up right away. Staff O stated that the plans stayed individualized for the Home Exercise Program (HEP). Staff O noted that a therapist and the resident represented factors in making that decision. On 6/3/26 at 1:51 PM Staff O verified that no policy existed for therapy. 2. Resident #71's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS recorded active diagnoses that included a urinary tract infection (UTI), multiple fractures of right-side ribs, chronic obstructive pulmonary disease (COPD), cirrhosis of the liver, anxiety, and depression. The MDS documented no impairment to Resident #71's upper or lower extremities. The MDS recorded partial or moderate assistance to supervision or touching assistance for ambulation and mobility with the use of a wheelchair. The MDS documented that Resident #71 received restorative nursing programs on 0 of the past 7 days. Resident #71's Care Plan revealed a focus area for requiring assistance with Activities of Daily Living (ADLs) functions. An intervention initiated on 8/21/25 and resolved on 1/22/26 required mobility assistance of 1 person with a Front Wheeled [NAME] (FWW), and wheelchair use for mobility initiated on 1/22/26. Interventions initiated on 1/22/26 directed staff to encourage Resident #71 as much as possible and report any increased need for assistance, decline in mobility, falls, near falls, or increased fatigue and weakness to therapy. On 4/22/26, staff initiated an intervention for ambulation with the assistance of 1 person using an FWW and a wheelchair to follow. Resident #71's Therapy to Nursing CNA Handoff - Maintenance Plan dated 4/14/26 documented transfers as stand-pivot with standby assistance, the assistance of 1 person for ambulation with an FWW and a wheelchair to follow, and independence with wheelchair mobility. Further review of Resident #71's Care Plan showed it lacked a restorative nursing program. On 6/4/26 at 2:00 PM Staff J, CNA, stated that Resident #71 functioned independently in her room with her walker and used her wheelchair outside of her room. Staff J stated that Resident #71 required the assistance of 1 person and used a gait belt. Staff J stated that she never assisted Resident #71 while using her FWW and a wheelchair to follow. 3. Resident #83's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The MDS recorded active diagnoses that included Down Syndrome, aftercare following a hip joint replacement, a wound infection, adult failure to thrive, and pressure ulcers. The MDS documented substantial or maximal assistance to dependence for ambulation assistance. The MDS recorded a walker and a wheelchair as mobility devices utilized in the past 7 days. The MDS documented that Resident #83 received restorative nursing programs on 0 of the past 7 days. Resident #83's Care Plan documented that Resident #83 required staff assistance with ADL functions, with interventions to encourage Resident #83 to do as much as possible, use a wheelchair for mobility, and require a mechanical lift with the assistance of 2 persons for transfers. Resident #83's Therapy to Nursing CNA Handoff - Maintenance Plan dated 4/21/26 documented that Resident #83 required maximal assistance with the use of a mechanical lift and stayed dependent for assistance with mobility in his wheelchair. Further review of Resident #83's Care Plan showed it lacked a restorative nursing program. On 5/12/26 at 9:22 AM a confidential interview revealed that nurses and CNAs must respect Resident #83's wishes when he refuses care and cannot continue to push him. The interviewee stated that due to his cognitive status and Down Syndrome diagnosis, Resident #83 needed more encouragement, and without it, he might not have physically declined to his current status. The interviewee noted that Resident #83 entered the facility about a year ago after a hip fracture and hip replacement, walked at that time, and no longer possessed the ability to walk. The interviewee stated that Resident #83 stayed continent and could stand to use the bathroom on admission, but after his transfer to the 300 hall, this gradually stopped because he couldn't stand and became incontinent. 4. Resident #85's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS recorded active diagnoses that included a neurogenic bladder (lack of bladder control) with a catheter, aphasia (difficulty speaking), a stroke, hemiparesis (one-sided paralysis), dysphagia (difficulty swallowing), a pressure ulcer, and a right-hand contracture. The MDS documented that Resident #85 stayed dependent for ambulation with a wheelchair. The MDS documented that Resident #85 received restorative nursing programs on 0 of the past 7 days. Resident #85's Care Plan documented a focus area initiated 4/14/26 for hemiparesis related to a stroke, with interventions for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) to evaluate and treat as ordered. The Care Plan directed staff to provide range of motion (ROM), either active or passive, with morning and evening care daily, and to reposition or ambulate Resident #85 as tolerated at least every 2 hours. Further review of Resident #85's Care Plan showed it lacked a restorative nursing program. On 5/19/26 at 2:05 PM Staff H, CNA, stated that staffing improved that day, with 14 residents on the 300 hall. Staff H noted that 5 residents required an assistance of 2 persons, which created difficulty when only one CNA held an assignment to the hall. Staff H stated that the CNA from the 400 and 500 hall helped if a float did not exist, but more residents entered that hall through admissions, which hindered their ability to assist. Staff H expressed uncertainty if the increased staffing on the 300 hall represented an actual change or resulted from state surveyors being present. Staff H stated that the facility lacked a restorative program, and if physical therapy had time, they showed CNAs the ROM and recommended exercises for individual residents, but she lacked certainty on how all CNAs became aware of those details. Staff H stated that she never received training on recommended restorative therapies from the facility, only the basic ROM taught in CNA school. Staff H noted that residents on the 300 hall with ROM included Resident #83 and Resident #85, and she tried to complete the exercises when they lay down after breakfast or lunch but often failed due to a lack of help. On 5/19/26 at 2:05 PM Staff CC, CNA, stated that she also never received training on each resident's restorative therapies or exercises from the facility, only what she learned in CNA school. When asked how she knew which resident required ROM exercises completed, Staff CC responded that if staff had to sign off on it in the resident's record, then they supposed they should do it. On 5/27/26 at 3:57 PM the Director of Nursing (DON) stated in a brief and dismissive tone that CNAs received education from therapy upon hire during their initial onboarding regarding what ROM and exercise activities applied to the individual resident. The DON stated that residents who required ROM or adaptive equipment stayed noted on their Kardex. The DON noted that all CNAs had been shown where to access the Kardex.

Based on observations, record review, staff interviews, and facility policy review, the facility failed to ensure nursing staff demonstrated the competencies and skills necessary to provide nursing services that met residents' needs. This was evidenced by Certified Nursing Assistants (CNAs) failing to perform proper hand hygiene, provide appropriate incontinence care, and demonstrate knowledge and implementation of Enhanced Barrier Precautions (EBP) and other infection prevention and control practices for 4 residents whose care was observed (Resident #83, #85, #52, #73).The facility also failed to ensure licensed nursing staff possessed the knowledge and competencies necessary to assess, monitor, and provide individualized, person-centered care based on residents' clinical conditions. This was evidenced by a nurse's inability to accurately identify and communicate Resident #83's and Resident #85's baseline status, current condition, changes in condition, and coordination of care with healthcare providers. The facility reported a census of 81 Residents. Findings include: 1. Resident #83's Minimum Data Set (MDS) assessment dated [DATE] documented a score of 2, indicating severe cognitive impairment. The MDS recorded active diagnoses of Down syndrome (a genetic disorder causing developmental delays), a hip replacement, a wound infection, adult failure to thrive (unexplained physical decline), and pressure ulcers. The MDS also documented that Resident #83 required substantial to maximal assistance to total dependence for walking. Review of Resident #83's Care Plan documented a focus area initiated 10/31/25 for a communication deficit as evidenced by difficulty understanding others or difficulty being understood. Resident #83 required full staff assistance with dressing and incontinence care, and the assistance of two staff members with the use of a mechanical lift for transfers. Another focus area identified Resident #83's potential for impaired skin integrity related to incontinence, a cognitive communication deficit, and wheelchair dependence. Interventions directed staff to monitor and document the location, size, and treatment of skin injuries, report abnormalities or a failure to heal, and monitor for signs and symptoms of infection. Staff were also directed to utilize enhanced barrier precautions (EBP) related to pressure ulcers on both hips and buttocks. Review of Resident #83's Electronic Health Record (EHR) revealed documentation of erythema (superficial skin redness) to the left hip and thigh on 4/30/26. The record showed a provider evaluation and orders for an antihistamine to treat a rash for three days, along with instructions for continued monitoring and to report to the provider if no improvement occurred. On 5/1/26 Resident #83's EHR documented a provider encounter that noted a rash to the left lower extremity with no significant improvement. The area remained red, blotchy, and showed increased warmth. The provider diagnosed left leg cellulitis (a bacterial skin infection), ordered staff to stop the antihistamine, and directed them to start antibiotics twice daily for 10 days. A nursing progress note dated 5/2/26 at 10:18 AM documented Resident #83 had a temperature of 99.2 degrees Fahrenheit. Staff administered Tylenol with effectiveness and gave the antibiotic for the rash, noting the redness lessened since the prior day. On 5/2/26 at 8:14 PM a nursing progress note stated that after further assessment of Resident #83 and a discussion with Resident #83's Power of Attorney (POA), staff determined Resident #83 needed a transfer to the emergency room (ER) for further evaluation. The note recorded that Resident #83's left lower extremity rash didn't appear to improve and spread to the right lower extremity. Resident #83's vital signs showed a temperature of 99.2 degrees Fahrenheit, a blood pressure of 89/43, a heart rate of 101, and an oxygen level of 93% on room air. Resident #83 didn't eat supper but drank a full glass of chocolate milk. Review of ER notes dated 5/2/26 documented Resident #83 arrived via ambulance for a rash. Facility staff reported to emergency medical services (EMS) staff that the patient developed a rash and became hypotensive (having low blood pressure) a few days ago. Resident #83 presented with a right lower and left lower extremity rash that went up and down his legs, and his left calf appeared redder and more swollen. The facility reported his systolic blood pressure (top number of blood pressure) hadn't risen above 80 for the past two days, with no fevers or chills. The history obtained from the facility nursing staff indicated that two days ago Resident #83 developed a rash on the left side of his body, received a prescription for an antihistamine, and yesterday received a prescription for antibiotics. That morning the rash spread, his temperature reached 99 degrees Fahrenheit, his systolic blood pressure stayed in the 80s, and staff noticed increased lethargy and a lack of eating. Further review of Resident #83's ER documentation on 5/2/26 at 9:23 PM stated that Resident #83's sister called requesting an update. A registered nurse (RN) relayed that Resident #83 would undergo admission to the hospital for intravenous (IV) antibiotics. Resident #83's sister reported that she visited the facility yesterday and strongly encouraged that the patient goes to the hospital. The sister reported the facility told her they would start antibiotics and re-evaluate. Review of the hospital Discharge summary dated [DATE] stated Resident #83 underwent admission from his facility on 5/2/26 for sepsis (a life-threatening systemic response to infection) related to left lower extremity cellulitis. Resident #83 presented with a rash, swelling, and hypotension. Review of Resident #83's vital signs revealed the following documentation: 4/30/26 at 2:36 AM: temperature 98.4, blood pressure 117/60, pulse 81, oxygen 95% on room air; 5/1/26 at 3:16 AM: temperature 98.8, blood pressure 124/68, pulse 78, oxygen 94% on room air; 5/1/26 at 4:28 PM: temperature 101.3; 5/1/26 at 6:27 PM: temperature 98.8; 5/2/26 at 1:38 AM: temperature 98.4; 5/2/26 at 10:19 AM: temperature 99.2; 5/2/26 at 7:50 PM: temperature 99.2, blood pressure 89/43, pulse 101, oxygen 93% on room air. On 5/12/26 at 9:22 AM during a confidential interview, an interviewee stated that in regard to Resident #83's rash, hospital admission, cellulitis, and sepsis, the Director of Nursing (DON) stated, well, I probably would have recognized it if I had seen it. On 6/3/26 at 11:10 AM during an interview, an EMS provider stated that on 5/2/26 she helped transport Resident #83 from the facility to the ER for an evaluation of what staff called in as a rash. Once at the facility, the EMS provider saw that Resident #83's rash covered both legs all the way up to his waist. A facility nurse told the EMS provider that the rash developed over two days. The EMS provider noted that the nursing staff should've known medical interventions were required before they called for a transport, and she stated that staff had no idea what Resident #83's baseline function was. On 6/3/26 at 12:45 PM during an interview, a hospital Social Worker reported that when Resident #83 was seen in the ER and underwent admission to the hospital, the facility nurse reported Resident #83 developed a rash and became hypotensive a few days ago. The hospital Social Worker stated a facility nurse told her, I don't know much about this Resident. When the hospital Social Worker asked to speak with another staff member who knew Resident #83, the facility nurse informed her no one else worked who could give an update because it was the weekend. The hospital Social Worker stated Resident #83's sister requested that the facility send Resident #83 to the ER on [DATE], but the facility declined and stated they wanted to try antibiotics first. On arrival at the ER, EMS staff informed the hospital Social Worker and ER nurses that Resident #83's antibiotics were discontinued and the facility wasn't administering them. The transport staff also reported that no staff on duty at the facility could answer questions about Resident #83's baseline, current concerns, or the reason for the transfer. The hospital Social Worker also noted that Resident #83's incontinence brief was dry on arrival, but the transfer linens underneath him were saturated with urine, indicating the facility staff quickly changed Resident #83's brief before transport but didn't change the linens. 2. Resident #85's Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 4, indicating severe cognitive impairment. The MDS recorded active diagnoses of a stroke, aphasia (a language disorder affecting speech and comprehension), hemiplegia (one-sided paralysis), dysphagia (difficulty swallowing), and a neurogenic bladder (a nerve-related loss of bladder control) requiring a catheter. The MDS documented a physical impairment to one side of the upper extremities and an impairment to both sides of the lower extremities. The MDS recorded Resident #85 as dependent on the assistance of two staff members with the use of a mechanical lift and a wheelchair for mobility. The MDS failed to document Resident #85's gastrostomy feeding tube (G-tube) for feeding and nutrition. Review of Resident #85's Care Plan documented a focus area initiated 9/4/25 that identified Resident #85 ran a risk for altered nutrition and hydration status related to cognitive status, a post-stroke condition, a feeding tube, a foley catheter, and being bed or chair bound. Interventions included monitoring for signs and symptoms of intolerance with G-tube feedings. A focus area initiated 7/29/25 noted Resident #85 required tube feeding related to dysphagia secondary to a stroke. Interventions specified that Resident #85 stayed dependent on tube feeding and water flushes, and directed staff to see physician orders for current feeding orders. Further review of the care plan documented a need for enhanced barrier precautions (EBP; clinical infection control practices) because Resident #85 utilized a G-tube and a foley catheter, and had a pressure ulcer. Review of Resident #85's EHR revealed that on 5/6/26 a Dietitian recommended that staff hold G-tube feedings for six nights. The Dietitian recorded that she would plan to re-assess in one week, and asked if the provider agreed to hold the feeding for six nights and complete weekly weights for four weeks, noting a copy went to the physician for review. Review of Resident #85's Nursing Progress Note dated 5/12/26 at 4:16 PM documented that a weight note came back signed by an Advanced Registered Nurse Practitioner (ARNP) with an order that stated it was okay to follow the recommendations. Review of Resident #85's May 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed an order to connect the feeding tube from 9:00 PM to 3:00 AM for Osmolite 1.2 at 96 mL/hr. The order carried a start date of 4/25/25, a hold date starting 5/12/26, and a discontinued date of 5/15/26. The documentation indicated that nursing staff held the G-tube feeding as ordered on 5/12/26, 5/13/26, and 5/14/26. On 5/15/26 at 3:17 PM the Dietitian documented that Resident #85 stated he did well with the feeding holds. The note recorded that his Osmolite 1.2 at 95 mL/hr., which started at 9:00 PM and ended at 3:00 AM, stayed on hold. The note featured a message asking to extend the hold for the feedings through 5/21/26, and the Dietitian provided the note for advisement. On 5/15/26 at 4:49 PM an MDS Coordinator documented a new order to continue the hold for the G-tube feedings until 5/21/26 for Resident #85. The note recorded that Resident #85 stayed on a regular diet and ate three meals per day and snacks. Review of Resident #85's EHR revealed an order entered by the MDS coordinator on 5/15/26 at 3:46 PM. The order instructed staff to connect the feeding tube from 9:00 PM to 3:00 AM for Osmolite 1.2 at 95 mL/hr. The scheduling details specified that the order applied every day at bedtime, carried a start date of 5/15/26, and carried an end date of 5/21/26 at 11:59 PM. The May 2026 MAR/TAR indicated an order with a start date of 5/15/26 to connect the feeding tube from 9:00 PM to 3:00 AM for Osmolite 1.2 at 95 mL/hr. at bedtime until 5/21/26. The documentation indicated that staff administered feeding via the G-tube on 5/15/26 and 5/16/26, held it on 5/17/26, 5/18/26, and 5/19/26, and administered it on 5/20/26 and 5/21/26. An order for a 60 mL water flush every hour via the G-tube from 9:00 PM to 3:00 AM carried a start date of 4/25/26, and the documentation indicated that staff completed the water flushes as ordered for 30 or 31 days. On 5/22/26 at 10:52 AM the Dietitian documented recommendations to discontinue the G-tube feedings and the hourly water flushes during feeding. The note asked if the provider agreed to discontinue the feedings and flushes, and the Dietitian noted a copy went to the physician for advisement. On 5/19/26 at 4:42 PM during an interview, Staff U, LPN, confirmed he worked overnight shifts on 5/15/26 and 5/16/26. Staff U stated he connected and administered Resident #85's feeding on Friday 5/15/26 as the MAR indicated. On Saturday 5/16/26 Staff U stated he didn't administer the feeding as indicated on the MAR. He noted that during the shift change report, he learned that Resident #85's feeding required a hold, but he couldn't find an order in the Electronic Health Record stating that the feeding stayed on hold or discontinued. On 5/21/26 at 11:17 AM witnessed a bottle of Osmolite with 400 mL remaining and a feeding bag with 500 mL of water hung on a pole with tubing inserted through the feeding pump. Both the bottle of feeding and the bag of water lacked a date of use. A feeding syringe and a graduate sat on the bedside table labeled 5/20 PM. On 5/27/26 at 3:57 PM during an interview with the DON, the MDS Coordinator, the Facility Administrator, a Rehab Director, Staff O, Rehab, and a Regional Director of Operations, the recommendations made by Staff G, Dietitian, for Resident #85 underwent a review that highlighted concerns related to communication with the provider, the timing of communication, and the nursing process for completing orders. Staff answered several questions regarding the expectations for nursing communications with the physician, the procedure for processing orders, and nursing documentation to obtain clarification. The DON provided brief responses in a dismissive tone, stating that the Dietitian makes recommendations and puts them in the provider's box for review, and once the provider reviews them, the nurse processes any changes. After questioning about the timeframe for reviewing these recommendations, the DON stated that the provider came onsite every Thursday and reviewed them at that time. The DON didn't feel that the timeframe from when staff made recommendations to when the provider reviewed them and just processed the order represented a concern. During the interview, a lack of response from the Facility Administrator and the DON's tone and manner of communication suggested irritation, which affected the flow and depth of the interview. On 6/1/26 at 2:49 PM the feeding pump was no longer seen in Resident #58's room. On 6/3/26 at 11:30 AM further review of Resident #85's EHR failed to indicate that the Dietitian's recommendations on 5/22/26 to discontinue the G-tube feedings and water flushes had been communicated to, reviewed by, or approved or declined by the physician. In a communication received via email on 6/9/26 at 11:50 AM the facility's Regional Director of Operations stated that after reviewing Resident #85's record and the sequence of events, management agreed that the concern centered on the communication, transcription, and follow-up process related to the dietitian's recommendations and the G-tube feeding order. She noted that the provider reviewed Staff G's recommendation to hold the G-tube feeding on 5/12/26. The subsequent recommendation on 5/15/26 to extend the hold through 5/21/26 underwent review and received approval from the provider the same day. The hold was accurately reflected in the progress note; however, when staff entered the order onto the MAR, the wording didn't clearly reflect that the feeding had to remain on hold through 5/21/26. This created the potential for inconsistent interpretation by nursing staff. The facility recognized that after the hold period ended on 5/21/26, staff should've obtained clarification timely regarding whether the feeding had to resume, remain on hold, or be discontinued. The Dietitian re-evaluated the resident on 5/22/26 and recommended the discontinuation of the feedings and flushes. The provider has since reviewed the resident, including seeing the resident last week, and the facility has ensured that the current order status has been clarified and accurately reflected. She added that regarding the order review process, transcribed and processed orders are reviewed by the nurse entering the order, and then another licensed nurse on the following shift reviews it as part of the facility's order verification process. A third level of review occurs through clinical oversight by a designee during a clinical review, a record review, or a morning clinical meeting to ensure that orders, progress notes, and provider recommendations stay consistent. The facility's expectation is that staff communicate provider recommendations related to nutrition, enteral feedings (tube feedings), or other resident-specific interventions to the provider timely and follow up on them until the provider gives direction. If an unclear order, discrepancy, or change in a stop date occurs, nursing staff are expected to contact the provider for clarification before continuing or discontinuing the intervention. The facility provided Care and Treatment of Feeding Tubes Policy dated March 2019 directed that feeding tubes will be utilized according to physician orders, which typically include the kind of feeding and its caloric value, volume, and duration. The policy instructed that the facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs. The policy stated that the facility will notify and involve the physician or designated practitioner of any complications, and in evaluating and managing care to address the complication and risk factors. 3. On 5/13/26 at 4:46 AM watched Staff A, CNA, and Staff B, CNA, enter the room of Resident #83 without donning personal protective equipment (PPE). A sign on the outside of the door indicated EBP in place. Staff B donned gloves, removed them, went to place them in an oral container in the bathroom, stopped right before touching it, and placed them in her uniform pocket. Staff B then washed her hands after Staff A and donned new gloves. Resident #83 lay in bed with a thin floor mat in place and edge bolsters on the side of the bed. With gloved hands, Staff B removed the bolster from under the sheet and rolled the bed pad in half beside Resident #83. Staff B then removed her gloves, threw them away, and continued without washing hands to exit the room to get more wipes. Staff B returned and washed her hands. Resident #83's brief showed a blue indicator line from front to back, indicating a soiled brief. Staff A donned gloves and helped roll Resident #83 to his right side. Staff B moved the brief in front and tucked it between his legs. Staff A provided wipes and Staff B wiped in small areas, but Resident #83's legs were difficult to separate and staff failed to cleanse all areas where feces lay present. Staff B changed gloves but failed to wash her hands, donned new gloves, and rolled Resident #83 to his left side, though she didn't roll him enough to reach all areas. Staff B continued to wipe the same area repeatedly as feces remained present and her gloves became visibly soiled across the entire palm. Staff B changed gloves and continued without washing hands, and Staff A instructed her to pull the brief out. Staff B handled the brief heavily soiled with feces and continued to swipe the rectal area. Both of her gloves touched feces on the wipes and then touched Resident #83's right hip area to pull the brief out. Friction and shear could be heard audibly as Staff B pulled four times using moderate force to remove the brief, which made an 'eeking' sound against Resident #83's skin. The brief was soiled and Staff A failed to help pull Resident #83 over to provide access. Staff B again changed gloves and failed to wash or sanitize her hands, tucked a soiled bed pad under Resident #83, and placed a new brief. Resident #83 then rolled to the right, revealing an intact bandage labeled 5/12 over a pressure sore area. Staff A removed the soiled bed pad and continued with the same pair of gloves while staff rolled Resident #83 back. Staff failed to cleanse his scrotal area, lower abdomen, hips, penis, foreskin, or any areas contaminated with urine or feces where the brief contacted his skin. Both staff continued with the same pair of contaminated gloves, and Staff A placed items in trash bags, changed gloves without washing her hands, and adjusted the bed controls. Staff B moved a glove box and wipes to the bedside tray table, covered Resident #83, and replaced the bolster. After items in the room were repositioned back to how they were found, Staff B moved a trash can. Staff A left the room with soiled bags of trash and linens and placed the trash in a bag on the floor in the hallway. Staff B then removed her gloves and washed her hands. Staff A placed the soiled linen bag in a room at the end of the hallway, sanitized her hands, and returned to the room to wash her hands. On 5/13/26 at 8:00 AM saw Staff TT, CNA, don a gown and gloves outside of room [ROOM NUMBER]. When asked how she knew whether the Enhanced Barrier Precautions notice on the wall indicated Resident #83 or Resident #12, Staff TT responded she was new to the facility but was told Resident #83 required precautions because he had a wound. Staff noted that during the incontinence care conducted earlier by Staff A and Staff B, neither aide donned personal protective equipment. On 5/13/26 at 9:33 AM Staff H asked if it could be clarified which care activities required gown protection. Staff H was questioned on what training she received about EBP and she responded that she hadn't received any specific training from the facility since her hire. Staff H commented she received training in a school program and was a brand-new aide who had worked at the facility for two months. 4. On 5/13/26 at 5:06 AM witnessed staff enter Resident #52's room to provide personal care while a strong ammonia smell filled the room. Staff B and Staff A washed their hands and donned gloves. Staff B uncovered Resident #52, adjusted the bed, and the bed control fell to the floor. Staff B removed her gloves and donned new gloves without washing her hands. Staff A placed a new brief and bed pad on the bed with a box of gloves without a barrier. Staff B stood on Resident #52's left side, undid her brief, and asked her to help open her legs. Staff B wiped her abdominal fold under the pannus (hanging flap of tissue) and barely down the middle between her legs, then stated, okay, we are done. Staff B changed her gloves but failed to wash or sanitize her hands. Staff helped roll Resident #52 to her right side, revealing a heavily soiled brief with feces present. Staff B continued with contaminated gloves to wipe her rectal area. At that time, Resident #52 expressed she didn't want the care viewed, and staff stepped to the other side of the curtain. Staff failed to cleanse all areas on the front contaminated by the brief prior to the move out of view. Staff changed gloves, though no sanitizer lay present and the sink stood located in the bathroom. Staff continued care without washing or auditing their hands. Staff A and Staff B came around the curtain to place items in the trash, and Staff A stated they were going to change her gown. Both staff told Resident #52 they would help pull her up in bed and asked about placing pillows. Staff failed to go to the bathroom to access hand sanitizer or wash their hands and continued to handle trash bags and move items. Staff B left with a trash bag, returned, and stated she needed one more bag. Staff B returned and washed her hands, while Staff A remained on the other side of the curtain near Resident #52. At 5:18 AM Staff A went to the bathroom to wash her hands, while Staff B left the room with a soiled linen bag, returned, and washed her hands. 5. On 5/13/26 at 9:36 AM watched Staff H and Staff TT prepare to help Resident #85 with personal care after donning gowns and gloves. Prior to entering, Staff H asked what she needed to wear for personal protective equipment and what activities required precautions, commenting she knew at least for catheter care. Staff H was questioned on what training she received about EBP, and she answered she was a new aide whose first job lasted two months and she received training in school but hadn't received any training from the facility. Resident #85 lay in bed on his back with a catheter present. Staff H wiped the left then right side of his groin and penis with a different wipe, then wiped down the catheter tube three inches with a new wipe. Staff H rolled Resident #85 to his right side and Staff TT wiped the rectal area front to back where feces lay present. Staff H removed the soiled brief containing feces and placed it directly on the bed where clean wipes sat. Staff H continued to wipe and then, using the same contaminated gloves, grabbed a new clean brief and handed it to Staff TT, who handed her a stack of feces wipes and a brief. Staff H grabbed the items, and both staff continued to place a new brief without changing their gloves. No wiping occurred across his hips or buttocks in contact with the soiled brief. Both staff then entered the bathroom, washed their hands, and donned new gloves; Staff TT emptied the catheter bag and Staff H helped Resident #85 change his shirt. A nurse entered the room and Staff H reported Resident #85 had a securement in place for the catheter but pulled it off during the night. Both staff helped roll Resident #85 back and forth to dress him and placed a transfer lift sling under him. Staff TT removed her gown and gloves, and bagged the trash and soiled linens. Staff H removed her gown and gloves but failed to wash her hands. Staff H then touched Resident #85's soda bottle, removed the cap, and provided him with a drink. Staff H positioned the bed down to transfer height and stated she would return with a nurse to provide gastrostomy feeding tube care. Leadership called Staff H over the radio and stated she was needed right then in the office, and Staff H left the room without washing her hands to sign a form. 6. On 5/13/26 at 11:41 AM witnessed a therapy staff member enter Resident #73's room and ask if she wanted to get up for lunch, and Resident #73 responded yes. Staff H entered and stated she would return with an EZ stand lift. Staff TT informed and redirected Staff H that Resident #73 lay on precautions, and Staff H and Staff TT donned personal protective equipment. Staff H acknowledged she last provided care for Resident #73 around 4:00 AM, and she commented that once you get behind in the day, everything just gets pushed back further. Staff H verbalized they just provided care for Resident #86 and got her out of bed, and she stated Resident #73 represented the last resident to get up for lunch. Staff H left the room to get more wipes, while Staff TT started donning pants on Resident #73. Staff H returned and reported to Staff TT that the juices did Resident #73's wound care first thing in the morning. Resident #73's blanket pulled back to reveal the brief indicator with solid blue lines in front, and a very strong ammonia smell filled the room. Staff H used a remote to raise the bed and adjusted her gripper socks. Resident #73's left leg lay marked with a black line to outline an area of cellulitis, and she cried out a bit when the sock moved. Staff H lowered the bed to move it away from the wall, then raised it back up. Staff TT grabbed and opened a new brief and placed it on the foot of the bed. Staff TT removed the tabs of the brief while holding wipes, cleansed the right-side abdominal fold, then the left side with a new wipe, and then down the center. Staff H rolled Resident #73 to her left side, and Staff TT pulled the brief, which lay heavily soiled with urine and feces. Staff TT wiped from front to back across the rectal area and part of the left buttock. Staff saw a bandage marked with a dressing on the back of her lower left thigh just above the knee. Staff rolled her back and failed to change soiled gloves or sanitize their hands prior to placing a new brief, and failed to cleanse all areas where the brief contacted her skin. Staff H finished pulling out the soiled brief, and the new brief lay placed with the same soiled, contaminated gloves. Both staff then removed their gloves and gathered the trash. Staff H washed her hands and Staff TT sanitized her hands and donned new gloves. Staff TT returned to the bedside to pull up her pants to thigh level, then helped rotate her to the edge of the bed to connect the lift. Without washing hands, staff removed the oxygen tubing, and Staff TT rolled it up and placed it in a bag on the oxygen concentrator. Staff helped Resident #73 doff her hospital gown and don a shirt. The lift sling lay placed on top of the fitted sheet in the same location where the heavily soiled brief had been, which contaminated the area. Both staff connected the sling loops, selecting the third green and second black loops. Staff TT ran the controls and instructed the resident to stand up tall. Staff H unlocked the lift while Staff TT and Staff H pulled up her pants, moved her to the wheelchair, and placed a safety strap around her. Staff H removed the sling, hung it over the machine, and both staff continued to touch items with contaminated gloves. Staff H put leg foot pedals on the wheelchair and stated one pedal lay broken, which was why they used a pillow to hold it in place. Staff H voiced it wasn't the best option but they were working on ordering a new one. Staff F put a wedge cushion in place under the resident's feet because her feet sat approximately six inches from touching the pedals. Staff H stated Resident #73 needed a new oxygen tank set up by the nurse. Staff TT combed the resident's hair. Staff H left the room with soiled trash and linens and stated she would return for the lift. Staff H failed to wash her hands after removing her gloves or the lift machine.

Based on observations, staff interviews and policy review, the facility failed to label and date open food items in the refrigerator, and freezer. During the initial observation of the kitchen numerous food items were not stored in a safe manner that would prevent foodborne illness to the residents and several food cooking surfaces were in need of cleaning. The facility reported a census of 81 residents. Findings include:During the initial kitchen observation on 5/11/26 at 1:51 PM the walk through with the Dietary Director revealed the following: Dry Storage: An open, unlabeled, and undated bag of cheerios not taped shut.Cortonia noodles not labeled or dated.Cortonia Bowtie noodles not labeled or dated.Brown sugar container not labeled or dated. An open and uncovered butter container sitting on the counter with the butter knife sitting in it. Cooler: An open, unlabeled, and undated large bag of mozzarella cheese. The steam table had old food particles on it and had not been cleaned or sanitized after lunch. The top of the stove had not been cleaned and had food particles on it. On 5/11/26 at 2:30 PM the Dietary Director advised all food items should be labeled and dated if not in their original container. The items observed all should have been marked. Typically, on Mondays she checked all food items to ensure they are labeled and dated and she had not had a chance to do so that day. The Dietary Director advised she is short of staff but would get things cleaned as soon as possible. On 5/13/26 at 10:31 AM when queried, the head cook advised all open food items should be labeled and dated. The Sanitation Inspection policy dated March 2026 directed all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. The department shall establish a sanitation program for food services based on applicable state and federal requirements. The sanitation program will provide for inspections to be conducted of the food service areas.

Based on observation and staff interviews, the facility failed to maintain essential equipment to ensure safe operating condition. On inspection, 2 out of 2 commercial dryer lint filters were completely filled with lint that decreased airflow. The facility reported a census of 81 residents. Findings include:During an observation on 5/13/26 at 3:35 pm, the facility laundry room contained 2 washers, actively washing loads and 2 dryers, one actively drying a blanket. Upon inspection of the dryer that was off, when opened, the dryer lint filter was completely filled and a moderate amount of lint was present on the bottom of the compartment. Upon inspection of the second dryer, the filter and compartment contained a larger amount of lint. During an interview on 5/13/26 at 3:35 pm, when inquired how often the dryer filters are cleaned, Staff CCC, Laundry aide stated she did not clean them as maintenance cleans them in the morning. During an interview on 5/13/2026 at 3:38 pm, Staff Q, Maintenance Director stated the lint filters were cleaned one time a day by the maintenance staff. When inquired to see his daily cleaning log, Staff Q stated he did not have a log form for the cleaning of the lint filers but will have one made immediately. Staff Q stated he will clean both dryer filters before further use. Manufacture instructions of the commercial dryer was not available.

Based on clinical record review, hospital record review, facility policy review, family and staff interviews, the facility failed to provide timely assessment and intervention for 2 of 3 (Resident #1 and Resident #8) residents in the sample. The facility failed to respond to reports of a change in condition for Resident #1, which resulted in a hospitalization for sepsis; and failed to notify the provider of the need to evaluate and review a 30-day order for psychotropic medications for a new admission (Resident #8) prior to their expiration. The facility reported a census of 85 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #1 dated 9/18/25 identified a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS coded that the resident needed setup or clean-up assistance to eat. The MDS documented diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), heart failure, and diabetes.The Care Plan of Resident #1 identified a Focus Area of Needing Assistance with Activities of Daily Living (ADL). It documented Resident #1 as being independent with eating after staff set up. The Care Plan identified a Focus Area of Altered Cardiovascular Status. It directed staff to monitor/document and report as needed for any symptoms which included fatigue. The Care Plan identified a Focus Area of Risk of Increase in communication problems. It directed staff to allow adequate time to respond and request clarification from the resident to ensure understanding. It additionally directed staff to monitor/document for any physical/non verbal indicators of discomfort or distress and follow-up as needed and to monitor/document/report as needed any changes in ability to communicate. The Progress Note dated 10/26/25 at 4:47 pm documented Resident #1 was sent to the hospital due to altered Mental Status. The hospital records revealed an arrival time to the Emergency Department as 10/26/25 at 5:28 pm, being admitted to the Intensive Care Unit on 10/27/25 at 2:33 pm. The hospital records documented in the emergency room, the resident was hemodynamically stable (meaning her blood pressure, heart rate and circulation were steady and adequate) but she was not responding verbally. Per the note, she did follow simple instructions and the provider ordered a CT (computed tomography) scan (an imaging test to detect for injuries, internal bleeding, etc) which was unremarkable, with lab results indicating an underlying infection.Several hours later, a hospitalist physician documented that the resident had became increasingly hypoxic (not enough oxygen reaching the body's tissues or organs) and required up to 6 liters of oxygen. During the first day of hospitalization, the resident was given diagnoses which included Sepsis (a life-threatening condition that happens when a person's immune system response overreacts to an infection, which can damage body tissues and organs) with acute renal (kidney) failure; acute hypoxic respiratory failure (a life-threatening condition where the body's lungs fail to adequately provide oxygen to the bloodstream, leading to low oxygen levels) and acute metabolic encephalopathy (a rapid decline in brain function caused by a disturbance in the body's metabolism). She had not been released from the hospital at the time of the survey. On 10/30/25 at 12:28 pm, Staff A, Certified Medication Aide (CMA) stated that on Sunday, 10/26/25 she had last given Res #1 medication in the late afternoon. She stated she told the nurse at that time the resident was kind of staring off into space and not talking much. She was able to take her medication but appeared to have a hard time swallowing. She stated the resident normally could talk, although she was very soft spoken. On 10/30/25, Staff B, Certified Nurse Aide (CNA) stated that when she started her shift at 6:00 am on 10/26/25, she realized right away that Res #1 was not feeling well. She stated she went to the resident's room to get her up for breakfast, and Res #1 did not respond verbally and her breathing didn't seem normal. She stated she reported this to Staff C, Licensed Practical Nurse (LPN). She added that Staff C told her this had started on the prior day, 10/25/25. She said Staff C instructed her to get Res #1 up for breakfast so staff proceeded to get her up and took her to breakfast in the dining room. She described that Res #1 ate very little, and was having difficulty remaining sitting upright, as she was leaning forward in her wheelchair so she and another staff member put her back in bed. She stated they did not attempt to get the resident up for lunch. She was dressed and incontinence cares and positioning were provided throughout the rest of the shift. She stated they also pushed extra fluids as she was not eating and turned her more frequently than normal, approximately every hour. She stated she last saw her around 1:30 pm, and prior to that day, she had not worked with Res #1 for a few days. On 10/30/25 at 2:25 pm, the Advanced Registered Nurse Practitioner (ARNP) for the facility stated she had been told the resident had been sent out to the facility over the weekend due to stroke-like symptoms. She stated she was only aware of the facility calling the on call service on Sunday afternoon, October 26th, and otherwise no other calls had been recorded. She provided, via email, documentation from the on call provider who took the weekend call. The triage note from the on call provider dated 10/26/25 documented the resident's nurse reported that upon starting her shift at 2:00 pm, she checked the resident's oxygen levels and noted the resident was a little bit warm and exhibited altered mental status, described as a little bit off from her baseline. The note further documented the nurse consulted with the Certified Nurse Aides (CNA), who reported the resident had been exhibiting these symptoms for approximately one day. The nurse attempted to arouse the resident but noted she did not respond well and appeared lethargic. The nurse additionally observed a little bit of left-sided facial drooping. Vital signs were recorded as a blood pressure of 97/71 (this is lower than considered normal range but consistent with the resident's baseline) and temperature of 99 degrees Fahrenheit. The note further detailed that the resident's son wished for the resident to be sent out for evaluation to the hospital and therefore the resident was being sent via emergency services to the emergency room for evaluation.Staff C, LPN stated she worked from the day shift for eight hours on Saturday, 10/25/25 and Sunday 10/26/25 with Res #1. On 10/26/25, she stayed for an additional eight hours, but moved to a different area of the facility for the second shift. She stated she did not recall anything out of the ordinary with Res #1 on Saturday. She said on Sunday morning, the CNA did come to her and report the resident to be lethargic (a state of decreased mental alertness). She stated in response to this, she assessed her vital signs and blood sugars, which had been elevated. She added that at the 2:00 pm shift exchange, she reported to the oncoming nurse to keep an eye on the resident, and that nurse (a staffing agency nurse rather than a facility employee) later became concerned about the resident and asked for assistance. She stated that Res #1 was often sleepy and she did not consider lethargy to be anything new. Review of Progress Notes failed to reveal any documentation of change of status for Res #1. On 10/26/25, two documentations of blood sugar being checked by Staff C were revealed, both timed as 12:43 pm, with no vital signs being documented by Staff C except her oxygen saturation at 8:10 am. On 11/3/25 at 11:38 am, Staff D, CNA stated she cared for Res #1 on Saturday, 10/25/25 for both the morning and afternoon/evening shifts, from 6:00 am until 10:00 pm. She recalled that she gave Res #1 a shower on Saturday morning and Res #1 was not feeling well. She did not want to go to the dining room and requested a meal tray in her room for both breakfast and lunch. She stated she reported this on Saturday morning to Staff C, LPN.On 11/3/25 at 2:40 pm, in a second interview, Staff D, CNA stated she knew the way Res #1 was acting was not normal for her. She stated she needed to feed the resident that day (the resident normally feeds herself) but she mostly took fluids for both breakfast and lunch. She stated she recalled reporting this to both Staff C, LPN as well as a second nurse, Staff E, Registered Nurse (RN), in the evening. She stated Staff E did go and assess the resident that evening after she had told him Res #1 reported she felt like she was having a hard time breathing. Staff E, RN was unable to be reached for an interview and did not respond to messages. On 11/4/25 at 10:46 am Staff F, RN stated she arrived at the facility for a 2:00 pm to 10:00 pm shift on 10/26/25. Staff F works for a staffing agency and is not employed by the facility. She stated she had probably last seen Resident #1 approximately two weeks earlier. She stated during shift exchange report, Staff C, LPN told her that Res #1 had been experiencing a general decline over the last two days and had been having high blood sugars which had been monitored and were slowly dropping. She stated upon her initial assessment, she noticed a mental status decline from the last time she had worked with the resident. She described when she took the resident's hand to check her blood sugar, her hand felt hot to the touch. She tried to talk to her but the resident was minimally responsive to her. She said the resident's eyes were open but she was staring off in a daze. She stated she knew she didn't look right, so she checked her blood sugar level and her vital signs at that time. She returned later in the shift for a second assessment and spoke to the CNAs on duty who reported this was not the normal presentation of the resident. She stated one of the CNAs (she could not recall the name of the CNA) told her she had reported concerns about the resident several times to the nurses but felt nothing was being done. She said the CNA also told her the resident had gotten worse since the last time she reported it. Staff F stated at that time, she went to another hall of the facility to locate another nurse to come assist her. She located Staff G, RN. She said Staff G immediately stated the resident needed to be sent to the hospital. She then notified the resident family and the on call provider and the resident was sent to the hospital. On 11/4/25 at 11:13 am, Staff G, RN stated Staff F came to her and requested assistance with Res #1. She stated when she arrived to Resident #1's room, she noted the resident had a slight left sided facial droop and was not talking right. She stated the resident is typically quiet but was markedly different from her usual baseline during her assessment. She stated she recommended the resident be sent to the hospital. She assisted Staff F in making phone calls and preparing paperwork to be transported to the Emergency Room. On 11/4/25 at 12:17 pm, during a second interview with Staff A, CMA she stated on 10/26/25, Resident #1 to an extent was off. She stated Resident #1 was always tired but she had concerns and reported it to Staff C, LPN. She recalled Staff C had told her that Res #1 had just recently had a vaccine and that was likely why she was not feeling well. She stated at the beginning of her shift, Res #1 was still talking but as the day went on, she was not speaking at all. She stated she reported this to both Staff C and Staff F. She recalled that Staff C told her she had checked the resident's vital signs and blood sugars and they were fine. The vaccination portion of the resident's Electronic Health Record (EHR) was reviewed. Documentation revealed no vaccine had been administered to Resident #1 since January of 2025. The Medication Administration Record (MAR) for October of 2025 was reviewed. This revealed Res #1 was scheduled to receive an RSV vaccine on 10/25/25, but it was not documented as having been received. The facility policy titled Notification of Changes, revision date of 03/2025, documented the following as its policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.The policy documented under Circumstances Requiring Notification to includePoint 2: Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status which may include life threatening conditions or clinical complications.2. The MDS of Resident #8 dated 9/16/25 identified the presence of short and long-term memory impairment. The MDS documented diagnoses which included anxiety disorder and bipolar disorder. The MDS documented the resident received antipsychotic, antianxiety and antidepressant medications during the look-back assessment period. The Care Plan of Resident #8 identified a Focus Area of risk of complications related to the use of psychotropic drugs. The Care Plan directed staff to monitor for the continued need of medication as related to behavior and mood and to monitor for side effects and to consult the physician and/or pharmacist as needed. On 11/3/25 at 10:34 am, a family member of Res #8 stated she had several concerns about the care her family member received in the facility. She clarified her biggest concern was that sometime between June of 2025 when he was admitted to the facility, and August of 2025 when she accompanied him to a psychiatric medical appointment, he had completely stopped taking his psychotropic medications. She stated they had just been cut off cold turkey. She expressed that prior to admission to the facility he took depakote (an anticonvulsants or antiepileptic drug. It is often used as a mood stabilizer in patients with bipolar disorder such as Res #8), seroquel (an antipsychotic medication) and trazodone (an antidepressant medication, often given at night to promote sleep). She stated she was not notified of these medications being stopped. She stated when she found out he was no longer on the medications and brought concerns forward to the facility, they were restarted. The hospital paperwork of Res #8 revealed he was admitted to inpatient behavioral health on 4/17/25 due to bipolar disorder and being found outdoors outside of his home disrobed. Listed diagnoses included bipolar disorder, restlessness and agitation and insomnia. The paperwork indicated a discharge date of 6/3/25 from the hospital to the facility. His discharge instructions included the medications of trazodone, 50 mg at bedtime for 30 days, quetiapine (seroquel), 200 mg and bedtime for 30 days and divalproex (depakote), 2000 mg at bedtime for 30 days. Upon admission to the facility, Staff H, LPN entered the orders as written into Res #8's electronic health record. On 11/3/25 at 3:45 pm, Staff H, LPN stated whenever the facility receives a new admission, the medical provider reviews the medication list. She believed the review would include a stop date for the medication if one was provided. She stated normally, seeing psychotropic medications stopped abruptly would be a concern, but stated they always follow physician orders. On 11/3/25 at 4:00 pm, a representative from the facility's contracted pharmacy confirmed the original orders they received for Res #8 on 6/2/25 was for 200 mg of seroquel for 30 days. He stated the order was then restarted on 8/18/25. He stated the portion of the pharmacy he works in was simply to supply the medications and the medication reviews and recommendations were completed by a consulting pharmacist. He stated he would put in a request for that person to contact the State Surveyor.The Progress Note dated 7/9/25, authored by the ARNP, noted the resident was still taking depakote, seroquel, and trazodone. The Medication Administration Report for July of 2025 revealed the resident had last taken the depakote on 7/2/25, the seroquel on 7/3/25 and the trazodone on 7/3/25. All three medications were stopped without tapering (a decrease in dosing). The Progress Note dated 8/15/25 documented the resident attended outpatient therapy at the community hospital and returned to the facility, documenting he had a psychiatric appointment scheduled for 8/18/25. The Progress Note dated 8/17/25 documented the resident reported to his family he was not sleeping well at night. The note documented a family member stated the resident had previously been on depakote, trazodone and risperidone (a different antipsychotic medication). Staff E, RN authored this note, which also included he had reviewed the prior hospital records and it was unclear why the resident was no longer on the medications. The Progress Note dated 8/18/25, authored by Staff I, RN (former staff member, was the Director of Nursing [DON] at the time of the note) documented Res #8 had orders in place at admission to take Trazodone, Seroquel, and Depakote for 30 days and the medications ended on 7/4/25. The note further documented the resident would be attending a psychiatric appointment that day at the community hospital. The August 2025 MAR of Resident #8 revealed new orders for Trazodone, Depakote, and Seroquel were all started between 8/18/25 and 8/20/25. On 11/3/25 at 2:22 pm, Staff I, RN, former DON, stated she had been speaking to Res #8's family about his psychiatric meds in August of 2025. She stated at times, the hospitals will make an autostop date of 30 days on psychotropic medications due to Centers for Medicaid and Medicare Services (CMS) regulations regarding psychiatric diagnoses. She stated that was likely what happened with Res #8 on admission. She stated the resident's family member had came to her and asked her to look at the resident's medications. She said it was then they realized the discharging hospital had placed the orders for only 30 days. His family member stated the community hospital had always managed Res #8's psychotropic medications and requested he get an appointment there to get them restarted. She added the facility did request a pharmacy review as well and the Medical Director for the facility did wish for the community hospital to continue to handle the psychotropic medications for Res #8. She added that if she had been the admitting nurse who entered the orders into the EHR, she would have questioned the 30 day stop. On 11/4/25 at 10:00 am, the ARNP stated that to her memory, the facility had never notified her of Resident #8's orders having a stop date for 30 days upon admission. She stated she would never recommend hard stopping psychotropic medications without first tapering the doses down. She recalled a family member speaking to her recently, prior to the resident's death, about how upset she was about the medications having been stopped the way they were. The ARNP stated she had no idea how it happened. She described that for all new admissions, she is provided with a list of medications the resident is on but she was unable to state if stop dates were included on these lists. She also added she had written an order for Res #8 to receive services from the consulting behavioral health services who see residents in the facility. She clarified they also may not have been aware of the 30 day stop date of the medications. On 11/4/25 at 10:57 am, a second representative from the consulting pharmacy stated she had paperwork documenting the pharmacy had questioned the 30 day stop date and she would forward those documents. An email was received from the second pharmacy representative on 11/4/25 at 11:08 am. She included two documents on separate dates showing the pharmacy did bring up the 30 day stop date to the facility. She stated one of the documents was signed and acknowledged by the medical provider but did not address the 30 day stop date.The admission Medication Review for Resident #8, dated 6/3/25 included under the section of incomplete or vague directions needing clarification: Please clarify if orders sent for 30 day supply should be continued. This document was signed at the bottom by the ARNP and dated 6/5/25 with no clarification included as per the request. The Medication Regimen Review for the facility, dated 6/1/25 - 6/18/25, included, for Res #8, under Findings/Recommendation: Please follow-up with the prescriber to clarify the 30 day stop dates on Res #8's psychotropic meds. Each of them appear to be maintenance meds that would likely be necessary to continue ongoing. On 11/4/25 at 2:11 pm, the Regional Director of Operations stated if a resident has a decline of condition, her expectation is for the medical provider to be notified. She additionally stated if the pharmacy makes a medication recommendation, her expectation is for those recommendations to be followed up on.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure Resident#32 received diabetic shoes as ordered by the physician on 7/10/24 to maintain good foot health and to prevent complications for a resident with a known history of bilateral foot diabetic ulcers. The failure continued throughout July and an encounter note on 7/26/24 recorded the resident required diabetic shoes due to a history of type 2 diabetes mellitus with foot ulcer and neuropathy (nerve damage). the facility failed to follow up with a shoe vendor to ensure the shoes ordered. On 8/26/24 the resident expressed a desire for the diabetic shoes and on 8/30/24, the facility identified the resident had developed a foot ulcer. The survey team found concerns with 1 of 1 residents reviewed with a history of diabetic wounds(Resident #32). The facility reported a census of 61 residents. The IJ was determined on 12/16/24 at 3:00 PM. The IJ began on 7/26/24. The IJ immediacy was removed on 12/18/24 at 11:55 AM. The facility staff removed the Immediate Jeopardy on 12/19/24 through the following actions: The DON and designee(s) conducted a full-house audit on diabetic residents to determine at-risk diabetics and ensure proper preventative foot care. An audit was conducted to ensure all treatments, supplies, and equipment were readily available for order by the physician and were being followed to ensure residents received the proper preventative foot care. DON or designee(s) reviewed the medical records of diabetic residents to ensure that weekly skin assessments were completed and treatment recommendations/orders were in place. The DON or designee conducted a care plan audit to ensure that treatment recommendations/orders were included in the care plan and that they were being followed All facility policies and procedures related to podiatry services, skin integrity foot care, and physician orders reviewed and revised as needed. Education provided to regional Clinical Manager at Curana to ensure that all practitioners that come to Pine Acres will be collaborating with the IDT team to ensure referrals are made timely and appropriately An audit of orders, interventions, and devices regarding foot care and foot services was conducted by the Nursing Supervisor(s) to ensure proper use. The DON/Corporate Nurse/Consultant educated all licensed nurses on facility policies and procedures related to diabetes, foot care, and appropriate wound treatment measures. This included ensuring residents had necessary support surfaces and pressure-relieving devices and that staff followed the manufacturer's recommended use. The DON/Corporate Nurse/Consultant educated all licensed nurses on appropriate documentation, which included transcription and entering treatment orders on the physician's order sheet in the EHR and the resident's TAR. DON/Corporate Nurse/Consultant educated all nurse aides on preventative diabetic foot care. DON/Corporate Nurse/Consultant conducted daily treatment record and nursing documentation audits to ensure accurate and complete documentation of diabetic foot care and preventative measures. For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen by the DON and Corporate Nurse DON/Corporate Nurse/Consultant Monitoring will continue to monitor/audit the following: o Observation of treatments for diabetic foot care prevention and orders o Weekly physician orders o Weekly diabetic skin treatment orders related to diabetics. o Treatment recommendations and orders are being added and processed into the EHR and TAR A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 8/11/24, listed diagnoses for Resident #32 which included diabetes, muscle weakness, and repeated falls. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 5/24/23, stated the resident was at risk for diabetic ulcers of the left and right feet and would have no complications related to the ulcer through the review date. The entries directed staff as follows; - ensure the application of appropriate protective devices to the affected areas. -inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. -monitor, document, and report as needed signs and symptoms of infection to any open areas to include; redness, pain, heat swelling or pus formation A 7/10/24 shoe vendor Diabetic Footwear Prescription Form listed the diagnoses of polyneuropathy (a disease that affected multiple nerves throughout the body, causing weakness, numbness, and pain) and a history of callus (a thickened area of skin that formed on the body as a result of repeated friction, pressure, or irritation) and listed the covered procedures as depth shoes and diabetic inserts. The top of the form stated the prescription must be accompanied by a signed statement of certifying physician. A 7/26/24 00:00 provider Encounter Note stated the resident had a history of Type 2 diabetes with foot ulcers and required diabetic shoes. Encounter Note dated 8/16/24 00:00 listed medication Sulfamethoxazole/Trimethoprim (antibiotic) DS (double strength) take twice daily for ten days, indicated use: left foot and heel infection. An 8/21/24 00:00 provider Encounter Note stated the resident requested diabetic shoes and (facility staff) placed the order. An 8/30/24 4:27 PM Nursing Note stated the resident had a wound to his left heel which measured 5 inches x 3 inches across the entire heel. The facility obtained a treatment order and an order for boots, including no shoe to left foot until healed. The facility lacked further documentation regarding the provision of the resident's diabetic shoes. The facility lacked documentation of communication or follow-up with the shoe vendor between 7/10/24 and 8/30/24 when the resident developed the heel wound. A 9/3/24 provider Encounter Note stated the resident had wounds to his left foot and the resident was not aware of how he sustained the wounds. A diabetic shoe order was completed on 7/26/24 and staff waited to hear back from the shoe vendor regarding the shoes. A 9/11/24 Skin/Wound note stated the wounds deteriorated and the resident had an order for an antibiotic, labs, and an x-ray. A 9/17/24 provider Encounter Note stated the left heel was not improving. The resident would likely need debridement(a procedure which involved removing dead or infected tissue from a wound). A 9/25/24 Nursing Note stated the resident underwent debridement. A 10/1/24 provider Encounter Note stated the resident's heel was not improving. A 10/7/24 Order Note stated facility staff informed the shoe vendor his diabetic shoe order was on hold due to his foot ulcer. The facility documentation lacked action of the facility to reach out, and follow up with getting the resident diabetic shoes, to help protect the residents other foot. A 10/14/24 Nursing Note stated the resident's wound would not heal. 10/15/24 Nursing Notes stated the resident's heel had redness around the wound with an odor. The notes documented a new treatment order and the resident received an order for vascular testing(a test to determine blood flow). A 10/24/24 Nursing Note stated the facility received a call from the foot clinic and the resident's wound worsened. The clinic wished to send the resident to a surgeon for evaluation. A 10/25/24 Nursing Note stated the resident admitted to the hospital. A hospital Progress Note, dated 10/31/24, stated the resident had an X-ray of the left foot on 10/24/24 which showed acute osteomyelitis(inflammation of the bone) and a wound culture which showed pseudomonas(a bacteria). The resident underwent a left foot amputation on 10/26/24. An 11/2/24 Nursing Note stated the resident had an above the ankle amputation on 10/31/24. An 11/13/24 provider Encounter Note stated the resident had a left foot amputation on 10/26/24 and a left below the knee amputation on 10/31/24. The facility policy Wound Treatment Management, revised 11/2024, stated in order to promote wound healing the facility would provide evidence-based treatments in accordance with current standards of practice and physician orders. On 12/2/24 at 11:59 a.m., Resident #32 stated he had to have his leg amputated and he was upset about it. He stated he did not know how this happened. On 12/5/24 at 8:37 a.m., via phone Staff G shoe vendor Office Manager stated they requested additional paperwork from the facility in order to carry out the shoe order but they did not receive it. She stated she called the facility and informed them of this but they continued to send the same paperwork. On 12/5/24 at 8:55 a.m., via phone, Staff F Medical Doctor(MD) stated he could not say for certain if the shoes would have prevented the resident's ulcers but stated the shoes would help reduce ulcers. He stated if there was an order for diabetic shoes, he would want this carried out as soon as possible. He stated the facility would follow-up with the paperwork to make sure they obtained them. On 12/5/24 at 9:58 a.m., the Director of Nursing(DON) stated if they faxed an order for shoes, they would follow up within 24-48 hours and absolutely would follow up within 2 weeks. She stated staff should keep checking on this until it was resolved. On 12/5/24 at 2:59 p.m., the Administrator stated she had no additional documentation related to communication between the facility and the shoe vendor.

Based on observation, record review, family and staff interviews, hospital notes, Emergency Medical Service (EMS) report and policy review, the facility failed to ensure residents were adequately supervised for 1 of 3 resident's reviewed for elopement (Resident #1). The facility staff failed to know Resident #1 left the facility unattended, was severely cognitively impaired and wore a wander guard bracelet to alert staff if attempting to leave the facility. Resident #1 was last seen by staff on 10/21/24 at approximately 1:45 PM. The resident ambulated approximately 0.2 miles from the facility and suffered a fall. The EMS was called and they alerted the facility on 10/21/24 at approximately 2:15 PM that the resident had fallen and would be transported to the Emergency Department (ED) for evaluation. The facility failed to provide adequate supervision to prevent 1 of 4 residents, who the facility identified as being at risk for elopement, from exiting the facility unsupervised. The State Agency informed the facility on 10/28/24 at 5:30 PM of the Immediate Jeopardy (IJ) that began as of 10/21/24. The facility staff removed the IJ on 10/29/24 through the following actions: a. Residents at risk for elopement were re-evaluated using Point Click Care (PCC) (facility's electronic health care system) elopement risk assessment tool, care plans were updated, and wander guards were checked for appropriate functioning. b. All doors were immediately checked for proper functioning, and no concerns were identified. A call was placed to make an appointment to have doors and alarms inspected. This was completed on 10/23/24, with no active issues regarding door functioning and alarm systems. c. Immediate education with all staff provided on the elopement and wander guard policy and will continue to educate until all staff have been thoroughly informed and trained. d. The Minimum Data Set (MDS) coordinator reviewed section E of the MDS and associated Care Area Assessments (CAA). Care plans were reviewed and updated to reflect the audit findings. Concerns were not identified. e. The Director of Nursing (DON) or designee will audit all new admissions for elopement risk and ensure interventions are in place. f. On 10/24/24, the Interdisciplinary Team (IDT) reviewed the most recent fall risk assessments for all resident identified as potentially at risk for falls. Residents determined to be at risk have completed care plan updates, and the interventions currently in place are appropriate. g. The IDT ensured that all residents identified as at risk for falls had safety measures and resident-specific interventions added to their care plans. h. The IDT ensured that the safety measures and resident-specific interventions added to the care plans were also reflected on the Kardex so the Certified Nurses Assistants (CNAs) had access to this information. i. The DON and designee(s) instructed the CNA's to review the updated Kardex before their next shift. The scope lowered from a J to an G at the time of the survey after ensuring the facility implemented education and made appropriate changes to their process and procedures. The facility identified a census of 68 residents. Findings include: The Admission MDS assessment dated [DATE] revealed Resident #1 admitted to the facility on [DATE] and had diagnoses of Alzheimer's disease, dementia, seizure disorder, a hip fracture, malnutrition, depression, osteoporosis, tachycardia, history of falling, and dizziness. The MDS recorded the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 indicating severe cognitive impairment. The resident had wandering behavior that occurred daily. The MDS indicated the resident used a walker and had independence for toileting, dressing, bed mobility and transfers. The MDS documented the resident had a life expectancy of 6 months or less and was receiving hospice care. It further documented the resident had a wander/elopement alarm used daily. The Care Plan initiated on 11/11/22 revealed the resident had a self-care deficit in activities of daily living (ADL's) related weakness and decreased mobility secondary to diagnoses of convulsions, Alzheimer's disease and osteoporosis. The resident transferred and ambulated independently using a four-wheeled walker. The Care Plan revealed the resident was receiving hospice services, took medication for depression and a seizure disorder, and an opioid medication as needed for pain management related to hospice care and the resident had a risk for falls. The Care Plan further documented a Focus Area for resident being at risk for elopement. Interventions for staff included: wander guard to left ankle and check for proper function every shift, encourage participation in activity program, signage outside the resident's room so resident can locate correct room and consider any pattern of exit seeking need or behavior to alter resident schedule, treatment, medications or environment to manage behavior and ensure safety. An Admission assessment dated [DATE] completed by Staff A, Licensed Practical Nurse (LPN), revealed Resident #1 admitted from the hospital. Resident alert and oriented to person, place and time and not deemed an elopement risk at that time. An Elopement Risk Assessment completed on 1/28/24 by Staff B, LPN, revealed Resident #1 had a score of 13 indicating resident was at risk for elopement. A wander guard bracelet was applied at that time. The Clinical Physician Orders documented an order dated 1/28/24 for a wander guard safety device. Please verify that device is in place and working. Replace if non-functioning. A Quarterly/Comprehensive Assessment was completed on 8/24/24 and the Elopement Risk Assessment revealed a score of 19 indicating the resident to be at risk for elopement. Progress Notes dated 1/1/24 through 10/21/24 indicated the following related to exit seeking and elopement: a. 1/8/24 at 1:54 PM - Social Services made resident and family aware of room move to be completed. Stated no concerns. b. 1/11/24 at 2:16 PM - Social Services noted resident was moved to new room, and reoriented to room. c. 1/12/24 at 7:31 PM - Nursing noted resident was transitioning to new room without difficulty. Up an about per norm today. No other concerns. d. 1/14/24 at 6:04 PM - Nursing noted resident presenting with increased confusion this shift. Continues to go to 300 hall to look for his room. When he finds his items are no longer there he walks around the halls looking for his new room. Redirected resident to room [ROOM NUMBER] times prior to evening meal. Resident is very pleasant and always grateful to be brought back home. e. 1/28/24 at 7:00 PM - Nursing noted Resident #1 observed walking towards front exit door to look out window and within seconds the front door alarm sounded. Staff B, LPN responded to alarm immediately. Resident seen walking out the door and down the front walkway. Resident then turned to the right following sidewalk. Staff B followed behind resident calling his name. Resident heard his name and turned around. Asked resident what he was doing out here? Resident replied my house is just up this street. pointing to the sidewalk. Attempted to re-orient resident that he has lived at the facility since he became ill and it was pretty chilly to be walking around outside. Resident agreed it is chilly. and was agreeable that he did live at the community and we could go back. Resident was escorted back to his room. Given comfort meds for restlessness. Reassessed for elopement risk with a score of 13 and at risk for elopement. A wander guard applied at this time. Hospice, Power of Attorney (POA), and Administration notified of attempted elopement and addition of wander guard. Primary Care Provider (PCP) on-call notified and order obtained. f. 1/29/24 at 4:04 AM - Nursing noted resident up asking to go home. Resident stated his house was just right across the street. Resident redirected back to his room. g. 1/29/24 at 6:14 AM - Nursing noted alarm sounding in activity dining room, resident noted by maintenance man to fall as he walked out the door. Resident fell on to left buttocks. Light blue discoloration noted to left side. Resident stated he had some pain in left buttocks. No skin issues noted. Resident then said, the pain is gone now. Maintenance man stated resident did not hit his head. Hospice and doctor notified. Regional Nurse on-call notified. h. 1/29/24 at 6:39 AM - Nursing noted the Power of Attorney (POA) was notified of fall. i. 1/29/24 at 4:00 PM - Nursing noted the resident attempting to go out front door. Staff with resident. Resident insisted on going outside. Three staff members walked with resident. Resident insisted on walking around the building looking for his house. Resident assisted into maintenance door of building. j. 1/29/24 at 4:18 PM - Nursing noted a call was placed to hospice and family by social services to see if family would come visit or hospice would send someone to see resident. Music therapist from hospice with the resident at this time. k. 1/30/24 at 10:51 AM - Social Services noted the resident has had some increased confusion and wandering last few days. Hospice volunteer was in house to help with resident getting more acclimated to his room. l. 1/30/24 at 2:12 PM - Nursing noted no wandering or exit seeking behaviors this shift. Urinalysis (UA) sent to lab, awaiting results. No behaviors noted. m. 1/30/24 at 8:24 PM - Nursing noted resident remains on 15 minute checks, no wandering noted. Resident has been staying in room. n. 2/1/24 at 1:59 PM - Nursing noted no exit seeking behaviors. o. 2/1/24 at 8:17 PM - Activities noted resident has had no exit seeking behaviors today. He has been to meals in dining room and ambulates around inside of facility. Denies having any lower abdominal discomfort or dysuria. No abnormal urine odors reported. Continues on fall follow up. Denies acute pain. p. 2/2/24 at 3:00 AM - Nursing noted resident currently resting quietly in bed. Resident has not been up and down the hall this shift or exit seeking. Resident has not exited the facility in the past 3 days and therefore, the 15 minute checks is suspended at this time. Call light within reach. q. 3/1/24 at 9:30 AM - Nursing noted the maintenance manager came to nurse and informed that resident followed him outside when maintenance manager was going to his work shed. Maintenance manager noticed resident coming through the facility door and assisted resident in turning around and brought resident back inside. DON, Administrator, Advanced Registered Nurse Practitioner (ARNP), POA and also hospice notified. r. 3/4/24 at 8:20 AM - The Interdisciplinary team (IDT) met to discuss resident exiting with maintenance person. Redirected easily at this time. No injuries noted. No changes noted to cognition, function or behavior. Immediate intervention was to call hospice and provide distraction. Encourage to participate in activities in community and request increase visit from hospice music therapist. s. 4/5/24 at 10:09 AM - The IDT met to discuss resident's exit seeking behaviors. Resident's room is down the hall away from the exit door. Resident is ambulatory and independent with his walker. Resident is very restless, anxious. Resident likes to ambulate. Resident is on hospice services. Registered Nurse (RN) will notify hospice of resident's behaviors and have them come assess resident. Resident continues to wear his wander guard. Staff will continue to monitor. Will follow up next week to discuss resident. Resident likes to watch the birds t. 4/16/24 at 3:26 PM - Nursing noted resident has been observed wandering and attempting to go outside, resident easily re-directed and now resting in room. u. 6/5/24 3:45 PM - Nursing noted resident exit seeking. Resident redirected. Hospice and POA notified. v. 6/17/24 at 3:11 PM - Nursing noted resident went out the side door of the facility. Staff acknowledged resident was outside. Staff assisted resident back inside the building. Staff offered to take resident for a walk, resident declined. Resident offered coffee. Resident went to the dining room for coffee. w. 7/18/24 at 9:49 AM - Nursing noted resident has been exit seeking this morning. Staff have redirected resident with coffee. Resident in the dining room drinking coffee and people watching. x. 7/18/24 at 1:07 PM - Nursing noted resident has been exit seeking most of the shift. Staff are re-directing resident, offering coffee, offered to sit and talk with resident. Hospice and POA notified. y. 7/19/24 at 10:52 AM - Nursing noted resident's POA, hospice, and case manager notified of resident's exit seeking. z. 7/20/24 at 1 :45 PM - Nursing noted resident continues to be exit seeking, resident re-directed. aa. 7/21/24 at 11:45 AM - Nursing noted resident continues to be exit seeking this shift, resident not easily re-directed. bb. 7/21/24 at 5:50 PM - Nursing noted resident has not been exit seeking on this shift. Continue to monitor. Wander guard noted to be in place and functioning properly. cc. 7/22/24 at 1:39 PM - Nursing noted no exit seeking reported this shift. Hospice nurse here today and took resident outside. Resident has not voiced desire to leave facility. dd. 7/22/24 at 9:33 PM - Nursing noted resident has had no exit seeking behavior this shift. ee. 8/3/24 at 10:46 AM - Nursing noted resident has been exit seeking most of the shift, resident not easily redirected. Call placed to family to come and sit with resident ff. 8/6/24 at 1:00 PM - Nursing noted resident has been exit seeking throughout the building. Resident is easily redirected with a cup of coffee, a snack, or 1:1. Hospice updated. gg. 8/8/24 at 4:15 PM - Nursing noted resident continues to be exit seeking, resident not easily redirected. Family has been notified and came in to visit. hh. 8/21/24 at 12:54 PM - Nursing noted no exit seeking behaviors thus far into shift. Resident remains hospice level of care, no acute changes or concerns. All medications and treatments administered per orders. Will continue to monitor ii. 8/30/24 at 10:55 AM - Nursing noted they talked with hospice about resident being very addiment about leaving. Hospice directed to give PRN (as needed) lorazepam and morphine. Also called POA to see if family could come visit. Will call back in an hour. jj. 10/21/24 at 6:00 PM - Nursing noted per hospice phone call to the facility resident has a C1 and C2 fracture. He has a C-collar on. Unsure at this time regarding discharge plan. Resident will see neurosurgeon. kk. 10/21/24 at 8:16 PM - IDT met to discuss resident exiting the facility, at this time root cause analysis reveals resident exited immediately following a hospice visit. New intervention, care conference scheduled with family and hospice to ensure visitors check out with facility staff prior to leaving so the facility can provide diversional activities. Resident remains in the hospital at this time will monitor for changes and update the plan of care as indicated. ll. 10/21/24 at 10:36 PM - Nursing noted EMS came to facility. Asked if resident lived here. EMS reported resident was found outside and had fallen. 911 called by a neighbor. EMS came to the facility for a face sheet and medication list. They are taking him to the hospital. The Treatment Administration Record (TAR) dated 10/1/24 through 10/31/24 revealed orders for the following: a. To monitor for refusal of care, withdrawn, or social isolation. Note that specific behaviors for individual resident will be documented in resident's progress note when behavior is identified. Complete every shift for behavior. Observations select N if monitored and no behaviors were observed. Select Y if monitored and behaviors were observed. Select chart code Behavior observation and document behaviors in progress note. Started 10/6/23. b. Resident has wander guard safety device. Please verify that device is in place and working. Replace if non-functioning every shift related to Alzheimer's disease, + working and - not working. Started 1/28/24. Documentation indicated it was checked and functioning on day shift on 10/21/24. An EMS report created at 1:55 PM on 10/21/24 revealed the ambulance was dispatched to a private residence for a fall. Upon arrival at 2:02 PM, the patient was found in a right lateral recumbent position. Bystanders on scene stated that their neighbor had seen an elderly man lying on the ground outside of their home via the ring doorbell. The neighbors who owned the property where the patient was located, called the bystanders to check on the patient. Patient stated that he was currently a resident at a nearby facility. Patient stated he was bored and wanted to take a walk. Patient ended up walking approximately 2 blocks away from the facility prior to the fall. Patient denied loss of consciousness from the fall. Patient originally stated he was on a blood thinner. Patient stated he was having pain in his neck from the fall. Patient denied pain anywhere else in his body. EMS staff were able to obtain further information on the patient from the nearby facility. Per the EMS staff the facility staff reported the patient was on hospice care and was currently a resident of the facility. Staff stated they had no idea the patient had left the facility. Medication and medical history list were provided by staff. Medication list revealed patient was not currently taking a blood thinner. Upon assessment, patient was alert and oriented to baseline. Patient has a history of Alzheimer's and was able to answer the majority of questions but still had baseline confusion. Patient's airway was patent, breathing was non-labored. Skin was pink, warm and dry. Patient's pupils were equal and reactive. Upon physical assessment, patient neck was palpated which revealed pain and tenderness. Patient rated his pain 9/10 in his neck. Patient was also noted to have a minor abrasion to the top of his head. Patient was placed in a c-collar. Patient was placed on a scoop stretcher and lifted to the cot. Patient was removed from scoop stretcher and placed in a supine position. Patient was administered 4 mg of Zofran prior to Fentanyl administration due to spinal immobilization, patient having a history of Zofran use and concern for vomiting. Due to patient's pain, patient was administered 40 mcg of Fentanyl. Patient appeared much more comfortable after administration and patient positioning. Patient was noted to close his eyes during transport. Patient arrived at the ED at 2:36 PM and placed in a room and was sheet lifted to hospital bed while c-spine was held mid-line. Patient was left with his belongings. ED report dated 10/21/24 at 2:43 PM revealed resident was brought to the ED via ambulance and admitted to the hospital on 10/23/24 at 3:10 PM with report of unwitnessed fall. Resident is under hospice care at a nursing home and was found 2 blocks away. Complains of head and neck pain. Denied loss of consciousness. History of Alzheimer's. Diagnoses included closed displaced fracture of first cervical vertebra, closed odontoid fracture (fracture of C2 vertebrae) and abrasion on scalp without infection. Of note, according to family, the resident had been recommended to be an elopement risk from the facility, and had an ankle bracelet that was supposed to notify staff if he attempted to exit the building. It appears facility staff were unaware that the resident had exited the building until after he had sustained his injury. Neurosurgery management recommendation for the cervical spine fractures will be immobilization in a cervical collar. Family made aware of the significantly elevated risk of aspiration given acute cervical spine fractures and necessity for cervical spine immobilization. An Elopement Risk Assessment was completed on 10/21/24 after his most recent elopement with a score of 20 putting the resident at risk for elopement related to resident being mobile with a walker, verbalization of desire or plan to leave the facility unsupervised, Alzheimer's disease, being cognitively impaired and being on 2 or more medications including psychoactive's. Per the Incident Report dated 10/21/22 at 10:28 PM competed by the DON, at approximately 2:14 PM EMS came to the facility asking if Resident #1 resided here, once confirmed EMS requested a face sheet and medication list. Information given to EMS. EMS reported to DON that the resident was found approximately 0.2 miles away on the same road as the facility. EMS reported resident fell and a neighbor called 911. They were taking the resident to ED. Immediate action taken: Elopement policy and procedure education provided to the staff and an investigation was initiated. Resident taken to the hospital. Notes included: a. On 10/21/24 at approximately at 6:00 PM the hospital called to report injury noted post evaluation included C1 and C2 Fractures. Family declined surgery. Administrator aware. b. An IDT reviewed of the investigation completed on 10/22/24 determined that the root cause was that resident can be regimented. He travels from his room to the dining room and for coffee. If these areas are occupied this may have thrown his pattern off. Resident was last seen at 1:45 PM by housekeeping. He walked by while they were cleaning his room. When there is a deviation from his schedule it may increase confusion. New intervention is to provide diversional 1 on 1 activities when resident's visitors leave and when there is deviation from his schedule such as room cleaning. The Facility's Investigation File revealed the following information: Per the DON at approximately 2:15 PM on 10/21/24, EMS arrived at the facility asking if Resident #1 resided at the facility. Once the RN confirmed that the resident did reside at the facility, she provided EMS a face sheet and current medication list. EMS reported to the DON that the resident was found approximately 0.2 miles on the same road as the facility, in a residential area. One of the homeowners contacted EMS to report that this resident had fallen, and EMS was taking the resident to the ED for evaluation. Resident was able to ambulate independently throughout the facility with a four-wheeled walker. Resident had a visitor from hospice prior to lunch which could have potentially altered his daily routine. After lunch, the resident was returning to his room, which was being cleaned at approximately 1:45 PM, which prompted the resident to not go directly into his room as per his normal routine. Per the Facility Investigation File permanent measures to prevent recurrence included the following: a. 1:1 was placed immediately on the front door until confirmation of proper functioning was obtained by maintenance and all active wander guards were tested to ensure alarm function. All doors were immediately checked for proper functioning and no concerns were identified. A call was placed to make an appointment to have doors and alarms inspected. This was completed on 10/23/24, with no active issues regarding door functioning and alarm systems. b. All residents that were at risk for elopement were re-evaluated utilizing the elopement risk assessment tool in PCC, care plans updated, and wander guards checked for appropriate functioning. c. Immediate education with all staff provided on the elopement and wander guard policy and will continue to educate, until all staff have been educated. d. MDS coordinator reviewed section E of the MDS and associated CAA, care plans were reviewed and updated to reflect the audit findings. Concerns were not identified. e. The DON or designee will audit all new admissions for elopement risk and ensure interventions are in place. f. All new hires will receive education on elopement, wandering and resident safety from the social services designee. g. All exit doors will be checked daily for 30 days to ensure proper use and function. h. A Quality Assurance Performance Improvement (QAPI) plan was implemented, and all findings will be discussed in the monthly meeting. i. Main entrance was moved to the 1499 door, and a receptionist was placed in front of that door, and the old entrance door is no longer in use as a main entrance door and is locked per fire safety regulations. Visitors are encouraged to use the new entrance to ensure resident safety and monitoring. The Facility Investigation File revealed the following written statements: a. A written statement dated 10/21/24 by Staff C, Certified Nursing Assistant (CNA), stated they were on the 100 hall all day. Staff C did not see any residents leave or hear any alarms going off. b. A written statement dated 10/21/24 by Staff D, Director of Recreation, stated at about 11:00 AM Resident #1 was sitting in the main dining room. Staff D asked the resident if he would like to have a bag of popcorn and he replied yes. Staff D then gave the resident a bag. c. A written statement dated 10/21/24 by Staff E, Cook, stated they left at 1:55 PM and at that time Staff E, did not see any residents walking around outside when they were leaving. d. A written statement dated 10/21/24 by staff F, Housekeeping Aide, stated they were cleaning resident #1's room at 1:45 PM and Resident #1 was walking around. e. A written statement dated 10/21/24 by Staff D, stated Resident #1's wander guard was checked in the afternoon. tested monitor and it was working properly on the resident's right ankle. Staff D, further stated Resident #4's wander guard was checked and was on the resident's right wrist and was working properly. f. A written statement dated 10/21/24 by Staff G, Dietary Aide, stated they saw Resident #1 at lunch time around 12:30 PM g. A written statement dated 10/21/24 by Staff H, Food Service Supervisor, stated they saw Resident #1 about 12:30 PM at lunch. Resident #1 was sitting at the table eating lunch talking to a hospice lady. h. A written statement not dated by Staff I, CNA stated they were working on hall 2 and never heard the alarm go off or saw Resident #1 leave the building. Staff I saw the resident at lunch and walking the hall around 12:15 PM. Resident #1 was wearing dark pants, a long sleeve shirt and shoes. i. A written statement dated 10/23/24 by the Provisional Administrator stated she had reached out to Hospice to get notes in regards to a scheduled visit for Resident #1 on the day of 10/21/24. At the time she was awaiting statements from any visitors from hospice. J. A written statement not dated by Staff J, RN, stated they were at the nurse's station for end of shift charting. At approximately 2:20 PM a woman dressed in a uniform came into the facility. Staff J stood up from the desk to address her. She asked if she could see Resident #1. Staff J asked if they could ask who they were? She stated they had just found Resident #1 up the street. Staff J immediately walked her to the DON's office and explained the situation. Staff J stated they did not see Resident #1, they were on hall 1. The facility provided audits on door alarms that were being completed weekly on the following dates: 8/30/24, 9/6/24, 9/13/24, 9/20/24, 9/27/24, 10/4/24, 10/11/24, and 10/18/24. The exits audited included: For Fountain West: TV lounge, side conference room, patio room, hall 2, hall 3, hall 4, therapy entrance, main kitchen, main entrance and center courtyard. For Heritage Court: north courtyard, south courtyard, front entrance, north exit and south exit. All audits indicated alarms were functional with no problems noted. An Elopement Drill Documentation Form stating Elopement drills are to be conducted at least twice a year and across all shifts, was completed on 10/22/24 for the day and evening shift with 43 staff signing they participated in the drill. Another Elopement drill was completed on 10/29/24 in the 300 hall with 22 staff signing they were involved in the drill. They were educated on the different types of alarms used in the facility at that time as well. In an interview on 10/23/24 at 10:05 AM, a staff person with an outside vendor there to check the doors for safety stated they were asked to come to the facility to check on the alarmed door going from the main entrance into the long-term care (LTC) area and also the alarmed south door off the nurse's station to ensure they were functioning properly. The south door is an exterior door and the other is an interior door to enter into the LTC area. They stated the doors were functional and working correctly. The alarms were functional on both the interior and exterior door. In an interview on 10/24/24 at 10:18 AM, a family member of Resident #1 stated the resident wore a wander guard bracelet all the time but they were unsure if it was functional at the time of the elopement. They reported they were not sure the facility even knew the resident was missing as the facility was not the ones who found the resident. The resident was found about 2 blocks away, at 1200 15th street. They stated that a homeowner in the community was not at home but happened to see the resident fall or on the ground on his Ring camera. He called a neighbor and asked if they would go check to see what was going on. That is when the neighbor found the resident and called the EMS. They reported the resident suffered a fracture of the C1 and C2 vertebrae. They reported that EMS had said they tried to call the facility but no one answered the phone. They reported the resident was [AGE] years old and was in hospice prior to this incident. They do not plan any type of surgical intervention for the resident due to resident being too frail. The resident will be in comfort care and hospice again once leaving the hospital. They reported the hospital will be keeping the resident for further observation prior to discharge as he is having increased difficulty swallowing and the hospital physician wants to monitor that for a bit. The resident is currently in a neck brace and they prefer he wear it but since he is comfort care, he can wear it as he tolerates. They stated the resident has removed it for the time being as he found it uncomfortable. The hospital has the resident's pain well controlled with the medications they are using. They reported there is currently not a discharge date planned but they know they will need to place the resident somewhere. They stated they are fearful to return the resident to this facility as they have allowed him out 3 or 4 times in the past but found him in the parking lot the other times. This time the resident actually got out and went up the very large hill and two blocks down the street using his walker and no one even noticed him missing it sounds like. They stated they haven't heard anything more from this facility since the initial call stating the resident had eloped, fell and was taken to the hospital. In a phone interview on 10/28/24 at 9:53 AM, Staff K, Supervisor with hospice reported that per their records, Resident #1 was seen on 10/21/24 by Staff L, CNA with hospice from 8:01 AM to 9:07 AM for a routine visit. Staff M, Licensed Massage Therapist (LMT) with hospice was in house to see him from 1:55 PM to 2:10 PM. Staff M's notes indicated the resident was not in the room and Staff M notified the staff. No other facility visits were noted on that day. They do have documentation that they were notified at 2:27 PM by the facility DON of the resident's elopement and that he was found 2 blocks away in a residential area and EMS was called by a homeowner. Hospice spoke with the POA who was in the ED with the resident at 3:14 PM related to the need to suspend hospice services at that time. In an interview on 10/28/24 at 11:45 AM, the Provisional Administrator stated at the time of the elopement there were 2 main entrances. One was the South entrance by the nurse's station and the other was the main entrance that was open and to the right was assisted living and the left was the nursing area. The main entrance that was monitored every 1/2 hour until midnight on 10/21/24 was the South entrance by the nurse's station. That door was locked from the [TRUNCATED]

Based on observations, clinical record review, hospital documentation, staff interviews and facility policy review the facility failed to ensure 1 of 3 residents reviewed (Resident #2) was free from accidents. Resident #2 experienced a fall on 6/26/24 and staff were to ensure he had gripper socks on per his care plan. On 6/27/24 Resident #2 experienced another fall and was found to have regular socks on, not gripper socks. Resident #2 complained of right hip pain and the nurse noted the resident's right foot to be rotated externally. The resident was sent to the hospital for evaluation and found to have a right hip fracture. The facility reported a census of 68 residents. Findings include: According to Resident #2's Admission Minimum Data Set (MDS) assessment tool with a reference date of 6/14/24 documented he had a Brief Interview of Mental Status score (BIMS) of 4. A BIMS score of 4 suggested severe cognitive impairment. Resident #2 exhibited wandering behavior daily. The MDS documented Resident #2 was independent for indoor mobility and required supervision or touching assistance for lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, walk 10 feet, walk 50 feet with two turns. Resident #2 utilized a wheelchair and had no impairments to his upper and lower extremities. The MDS documented the following diagnoses for Resident #2: end stage renal disease, atrial fibrillation, benign prostatic hyperplasia, obstructive uropathy, UTI) last 30 days), thyroid disease, malnutrition, cognitive communication deficit. The Care Plan focus area with an initiated date of 6/24/24 documented Resident #2 was at high risk for falls due to weakness, end stage renal disease and poor safety awareness. The following interventions were put in place: staff were instructed to anticipate and meet his needs (initiated 6/24/24), be sure his call light is within reach (initiated 6/25/24), encourage him to use the call light for assistance, ensure he is wearing appropriate footwear, shoes or gripper socks when ambulating or mobilizing in his wheelchair (initiated 6/26/24) and his wheelchair foot pedals are to be removed unless he is being assisted in his wheelchair (initiated 6/26/24). On 10/10/24 at 8:50 AM Resident #2 sat in his wheelchair with yellow gripper socks on. The Progress Notes documented the following: a) On 6/26/24 at 9:28 AM Certified Nursing Assistants (CNA) called this nurse to the dining room due to Resident #2 falling. Staff in the dining room reported resident was standing up from his wheelchair to ambulate and fell . When the resident was asked what happened, he stated he tripped over the wheelchair peddles. Resident #2 had regular socks on and no shoes on. b) On 6/26/24 at 2:25 PM the interdisciplinary team (IDT) discussed resident and 2 falls in less than 24 hours. Resident did not have shoes on but had socks on. Intervention: no foot pedals on his wheelchair unless resident is being pushed. Staff will continue to monitor the resident. c) On 6/27/24 at 5:10 PM the Registered Nurse (RN) was called to the resident's room by the CNA. Resident #2 was in the supine position when the nurse arrived. He complained of pain to his right hip that worsened with leg movement. His right foot rotated externally, pain with palpation but denied hitting his head. The nurse noted no other visible injuries and was able to move his upper extremities, with normal left leg movement. Order received to send to the emergency room (ER) and left the facility at 6:00 PM. d) On 6/27/24 at 11:58 PM Resident #2 has a right hip fracture per his wife. e) On 6/28/24 at 8:15 AM the IDT reviewed resident's fall. Resident continues to self-transfer himself has had 3 falls in 3 days. Resident does not use his call light to call for assistance. With this fall he was wearing regular socks and when he got up to transfer himself from the bed to the chair he slipped and fell . Resident is currently in the hospital, already in therapy. f) On 7/3/24 at 10:17 PM resident readmitted from the hospital at approximately 7:00 PM. Resident had a fracture on his right acetabular (socket of the ball and socket hip joint). The facility provided the following document titled Witnessed Fall: a) Dated 6/26/24 at 8:50 AM CNAs called this nurse to the dining room due to Resident #2 falling. Staff in the dining room reported resident was standing up from his wheelchair to ambulate and fell . Resident reported he tripped over his wheelchair peddles. Resident #2 had regular socks on and no shoes. Resident as oriented to person and the form had a check mark next to socks in the predisposing environmental factors. In the predisposing physiological factors section there were check marks next to confused and impaired mobility. A check mark was next to ambulating without assistance in the predisposing situation factors section. The facility provided the following documents titled Un-witnessed Fall: a) Dated 6/25/24 at 3:00 PM staff noted resident kneeling on the floor next to the bed. Resident stated he was attempting to self-transfer to bed and the bed pushed to the side. No injuries noted. b) Dated 6/27/24 at 5:42 PM Resident #2 was in the supine position when the nurse arrived. Noted pain to right hip what worsened with leg movement. Resident #2 denied hitting his head. Resident's call light was on his bed and he stated he slipped getting up to sit on the chair. In the predisposing environmental factors section there was a check mark next to socks. Gripper socks and shoes were not checked. In the predisposing physiological factors section there was a check mark next to impaired memory. There were no predisposing situation factors checked. In the other information section staff documented resident self-transferred himself. He is an assistance of 1 staff with a front wheeled walker. Resident is non-compliant with this and self-transfers often. This is the resident's third fall in three days. Clinical record review revealed a Trauma Admission History and Physical (H&P) with a performed or dictated date of 6/28/24 at 12:39 AM. The H&P documented it was reported that Resident #2 has had a few falls at the facility and now has right hip pain. He was evaluated in the Emergency Department and was found to have a right acetabulum fracture. A CT scan of his abdomen and pelvis showed comminuted fracture of the right acetabulum. Orthopedics recommended non-surgical management. On 10/10/24 at 1:25 PM the Director of Nursing (DON) stated when Resident #2 first came to the facility he was there for rehab and was doing really well. He has had a few falls because he self-transfers a lot and they have tried all kinds of things to help prevent them. The day they sent him to the emergency room , she was in the vicinity so she assessed him. She was pretty sure his hip was broken because his foot was externally rotated. He told her he was getting up because he wanted to leave. When asked what interventions were in place at that time she stated the changed his push call light to a pad one, then wrapped it in bright tape to encourage him to use it. They made sure his bed was in the lowest position, fall mat on the floor, made sure his bed was against the wall. After he fell on [DATE] they noted he had regular socks on so they added that he needed to have gripper socks on. He would just get up on his own and fall; he just could not bare his weight. The DON stated he most likely should have had his gripper socks on while in bed given his 3 falls in 3 days and him self-transferring. On 10/10/24 at 2:03 PM the Administrator stated after Resident #2's fall on 6/26/24 they added grippy socks to his care plan, signs in his room to use his call light and bright tape on the call light. For the 6/27/24 fall the Administrator indicated the note stated socks when she was informed he was not wearing gripper socks before that fall. She was informed the unwitnessed fall document had checked socks with gripper socks being an option, she acknowledged she saw that. She was also informed the IDT note documented he wore regular socks when he got up to transfer himself from the bed to the chair, he slipped and fell . She acknowledged that's what the note read. When asked since Resident #2 had had 3 falls in 3 days, with reports of self-transferring without using a call light, should his gripper socks been worn on 6/27/24, she stated if it was an intervention that was put in place, they should have been on. The facility provided a document titled Fall Prevention Program with a revised/reviewed date of 7/2023 indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to thoroughly investigate a major injury (Resident #1) and separate an alleged abuser from the victim (Resident #11), for 2 of 5 residents reviewed. On 09/10/2023, Staff N, Certified Nurses Aide (CNA) was reported as being rough with Resident #11 during repositioning by jerking and pulling on Resident #11's neck and then Staff N continued to work the rest of the shift on 09/10/2023 and also the entire shift on 09/11/2023, caring for Resident #11 and other vulnerable residents. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. On 8/19/23 at approximated 6:00 a.m., Staff A, Certified Nursing Assistant (CNA) assisted Resident #1 to transfer. During transfer the resident became anxious, was waiving her arms, Staff A heard a loud sound and lowered the resident to the floor. Resident #1 sustained a right arm fracture and required hospitalization and surgery. The facility investigation failed to identify that Staff A, CNA had failed to use a gait belt during the transfer. The facility reported a census of 73 residents. The facility was notified of the Immediate Jeopardy (IJ) on October 23, 2023 at 3:40 p.m. The IJ was removed on October 25, 2023. The Facility Staff removed the Immediate Jeopardy through the following education: Compliance with Reporting Allegations of Abuse/Neglect/Exploitation: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations. *Compliance Guidelines: The facility will develop and operational policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is written its control to prevent occurrences. 1. Screening 2. Training 3. Prevention 4. Identification 5. Alleged violation 6. Investigation 7. Protection 8. Reporting/Response The scope and severity was lowered from an J to and G at the time of the survey after ensuring the plan of correction was put in place and implemented. Finding include: 1. The Significant Change in Status Minimum Data Set (MDS) for Resident #11, with an assessment reference dated 9/25/2023, documented diagnoses including Cancer, Osteoporosis, Malnutrition, Depression, Anxiety, Bipolar Disorder, and restlessness and agitation. The MDS revealed the resident with short and long term memory problems, severely impaired for decision making abilities, verbal and other behavioral symptoms directed towards others, does not resist cares, and required total assist of two staff for all aspects of daily living. The MDS revealed no functional limitations in range of motion to upper or lower extremities and the wheelchair as primary mode of transportation. The Care Plan with a initiated date of 11/10/2021 revealed resident has self care deficit as evidenced by requiring assistance with activity of daily living (ADL's), impaired balance during transitions requiring assistance and/or walking, incontinence Dx: intellectual disability, abnormal posture, muscle weakness, bipolar, history of cancer, glaucoma, rheumatic valve disease. Interventions include: *TOILETING: 1 Assist. Provide peri-care with every incontinent episode and PRN *TRANSFER: 2 people assist. with mechanical hoyer lift *Use full body slings for hoyer transfer. *EATING: Assist x 1- Dependent on staff *Ask yes/no questions as indicated in order to determine needs. An Incident Summary Report Dated 9/11/2023, at 5:20 p.m. documented as follows; with an incident occurred dated 9/10/2023 at 8:00 a.m., report that this writer received a statement from Staff J, Assistant Director of Nursing (ADON) at approximately 2:45 p.m., in regards to an allegation of abuse made by employee Staff M, CNA, against employee Staff N, CNA. The employee indicated she was in the dining room at breakfast and saw Resident #11 slumped over the side of her chair with her face resting on the arm rest and her arm hanging over the left side of her chair. Staff reported that she attempted to reposition and indicated she did not know this resident as the employee was new to the community. Employee waited for Staff N to come and assist her. Staff M, indicated that when Staff N, came to assist the resident that Staff N jerked patients head and the resident's top half moved to the right in the chair. The resident is extremely contracture and had jerky movements. Resident can be difficult to reposition due to her rigidity. The Progress Notes dated 9/11/2023 at 3:58 p.m., documented as follows; Incident Note, Late Entry: Staff M reported that on 9/10/2023, while in dining room waiting on a room tray noted that Resident #11 was leaned over in her wheelchair with her head resting on the arm rest. Staff M attempted to reposition her and asked Staff N, to assist. Staff M, stated that Staff N, put her hand on Resident #11 top of head. Then jerked on Resident #11 neck when trying to reposition her. Staff M could not say for sure that this action was done with the intent of Harming the resident. She was unable to give further details but felt as though it was rougher then was intended/needed. This nurse reviewed skin around head/forehead, no redness, bruises or abrasions were noted to the head. Resident did not appear to be in pain at this time. Resident is primarily non-verbal. She will at times look towards a voice or person. She was resting in recliner per her norm at this time. Resident has very poor truck control and is regularly in a contracted position. She prefers to lean or lay on her right side. She will at times kick her legs out or wiggle herself but does not do this with purpose. On 10/10/2023 at 10:12 a.m., Staff M, CNA confirmed and verified that the facility was aware of the allegation of abuse on 9/10/2023 right after breakfast. On 10/11/2023 at 11:00 a.m., Staff L, Licensed Practical Nurse (LPN) confirmed and verified that Staff M, CNA, reported the allegation of abuse to the facility nurses on 09/10/2023, sometime after the breakfast meal. Interview on 10/11/2023 at 2:30 p.m., Staff N, CNA, confirmed and verified that they continued to work their entire shift on 9/10/2023 and also their entire shift on 9/11/2023 with all the residents in the facility. Interview on 10/17/2023 at 9:22 a.m., the facility Administrator confirmed and verified that Staff N, CNA, continued to work their entire shift on 9/10/2023 and 9/11/2023 and that the facility failed to separate the alleged abuser from the victim. The Employee Timecard Report with a period dated 09/10/2023 to 09/23/2023, revealed Staff N, CNA, punched in on: *9/10/2023 at 5:51 a.m., and punched out at 2:07 p.m. *9/11/2023 at 5:52 a.m., and punched out at 2:05 p.m. The Abuse, Neglect and Exploitation policy with a date of 07/2023, stated that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriations of residents property. *Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiate. 1. The Licensed Nurse will: *Respond to the needs of the resident and protect him/her from further incident/ *Remove the accuse employee from resident care areas. *Notify the Director of Nursing or designee *Notify the Administrator or designee *Notify the attending physician, residents family/legal representative *Document actions taken in the medical record *Complete an incident report is indicated 35438 2. The Quarterly MDS assessment with a reference date of 6/28/23 for Resident #1 documented a score of 10 of 15 on Brief Interview for Mental Status (BIMS) test which indicated moderate cognitive impairment. The resident had diagnoses that included dementia, osteoporosis, muscle weakness, and anxiety and required extensive assistance of one staff for bed mobility, transfer, ambulation, dressing, toilet use, and personal hygiene. The resident had no falls since reentry. A Nursing Care Plan dated as initiated on 8/1/22 identified a focus area: Activities of Daily Living (ADL) self-care deficit, with a goal of maintaining current level of function, and directed the following interventions: Transfers and ambulates with the assistance of 1 staff member and four wheeled walker (FWW), and one person assist for toileting. The Care Plan further identified resident has had falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment and/or the use of medications that may increase fall risk, with a goal that resident will have no serious injury from falls, and directed the following interventions: Ensure resident is wearing proper footwear, follow all facility protocol related to falls which included: report, investigate, and immediate intervention and long-term interventions. A Fall Risk assessment dated [DATE] documented a score of 18 which indicated a high risk of falls. Observation on 10/18/23 at 2:15 p.m. Resident #1 was observed to transfer. Resident appeared anxious, and was noted to shakily and unpredictably move her arms, and yell out in a high-pitched tone. A Progress Note written by Staff C, Registered Nurse (RN) at 6:29 a.m. 8/19/23 documented that Staff C was alerted by the CNA that the resident had been lowered to the floor on 8/19/23 at 6:03 a.m. in the resident's restroom. Staff C assessed and suspected a right shoulder injury. The resident was placed in a wheelchair and a call to the on-call was placed to obtain permission to send to the local hospital. On 10/16/23 at 4:05 p.m., Staff C, RN recalled he had been called to Resident #1's room by Staff A, CNA who had reported the resident was on the floor. Staff C reported that he responded immediately and found the resident on the floor near the toilet in her room. Confirmed Staff A had been the only staff person in the room at the time of the fall, and had reported the resident had lost balance during the transfer, was flailing around, and hurt the arm while being lowered to the ground. Staff C stated that he had documented in a progress note but thought someone else had filled out the incident report. Staff C confirmed that an incident report or risk assessment should be filled out with all falls. During an interview on 10/16/23 at 2:52 p.m., Staff D, Licensed Practical Nurse (LPN) confirmed that she had responded to the room to assess Resident #1 who was on the floor and yelling in pain. Staff D recalled that the resident had complained of right arm pain. Staff D reported that after an assessment was completed staff assisted the resident from the floor with a gait belt. Staff D stated that she would expect staff to use a gait belt for all staff assisted transfers. Staff D responded that Staff A had reported trying to get resident over to the toilet, the resident was flailing around and she lowered her to the floor. Staff D responded she had not filled out an incident report, that would have been the responsibility of Staff C, RN. Staff D reported that she had assumed that he had filled out the incident report due to the fact that there was a fall, and the process would be to do a fall-risk management assessment to fully investigate the circumstances of the fall. In an interview on 10/16/23 at 2:59 p.m., Staff A, CNA recalled on 8/18/23, at approximately 6:00 a.m. she had gone in to provide care to Resident#1. The Resident requested to use the bathroom, so she assisted the resident to walk to the bathroom with her walker. Once in the bathroom, the resident started to turn, and Staff A reported to assist with removal of the residents clothing. Staff A reported the resident became hysterical without warning and started flailing her arms. Staff A reported she had heard a sound like clothes ripping, and noticed the resident's arm was limp and lowered the resident to the floor. Staff A denied that she had seen resident strike arm on anything. Staff A responded that she had not used a gait belt to ambulate and transfer the resident. Staff A, clarified that she had not anticipated that she would need a gait belt, no gait belt was available in the room and she was not wearing one. Staff A stated she knew that she should have used a gait belt, but would have had to go get one and didn't. Further interview on 10/17/23 at 5:18, Staff A clarified that she had eased the resident to the floor by grasping the waist of the resident's pants. Staff A denied that she had grasped the resident by the arm at any time. In an interview on 10/16/23 at 2:45 p.m. the Administrator stated that she had referred the investigation to the previous DON. The Administrator reported she would have expected that a Interdisciplinary report and investigation would have been completed, however she was unable to provide it. The Administrator stated that she wasn't as involved at the time as she reported now being. In an interview on 10/16/23 at 6:15 p.m. the previous DON confirmed she had completed the investigation but could not recall the specifics. The previous DON stated there should have been a risk assessment completed. In an interview on 10/17/23 at 5:00 p.m. the Administrator and Interim Director of Nursing (IDON) stated that they had questioned how Staff A had transferred the resident and had received a text message that she had transferred by grasping at the waist of the resident. The IDON had questioned the previous DON if a gait belt had been used, but the DON had resigned without answering her question. An Investigation Self-Report Amendment submitted to the Department by the facility included the following; Resident#1 had a fall with injury on 8/19/23. The resident was in the restroom and staff were assisting to the resident to the bathroom. The resident grabbed the grab bar for assistance. Staff A, CNA while assisting heard a pop in the resident's right arm. Staff A lowered the resident to the floor and notified the nurse. Resident#1 assessed and sent to the local emergency room (ER) for evaluation. Resident#1 sustained a fracture of the right humerus. The Resident was admitted to hospital and surgery was performed. A Hospital Operative Report dated 8/21/23 documented a preoperative diagnosis of closed right displaced, comminuted (broken in numerous pieces) humerus (upper arm bone) fracture. History documented resident sustained a fall resulting in the injury. Decision was made to operatively repair the fracture. Review of a facility policy titled, Use of Gait Belt, dated 4/2/22 directed to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. The policy included the following guidelines: Responsibility of each employee to ensure they have a gait belt available for use at all times when at work. Failure to use gait belt properly may result in termination. Review of a facility policy dated as reviewed on 7/2023 included: Investigation of alleged abuse, neglect, and exploitation. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and the cause. Providing complete and thorough documentation of the investigation.

Based on clinical record review, hospital records, resident, staff and advanced registered nurse practicitioner interview along with the facility protocol/policy, at the time of the investigation, the facility failed to provide ongoing assessment and intervention for a resident who demonstrated an unstageable wound to the right lateral plantar foot that was covered with eschar. The facility was not able to provide any wound documentation, and failed to follow through with wound clinic referral for which resulted in the resident being admitted to the hospital with septic shock (blood poisoning, for which can lead to organ failure, and death) related to osteomyelitis (infection in the bone for which travels in the bloodstream) and gangrene (tissues death) to the residents right foot for which resulted in the resident having a guillotine (emergency surgical amputation to prevent the spread of infection) amputation (removal of the limb) on 9/12/23 and a below the knee amputation on 9/20/23 for 1 of 6 residents reviewed. (Resident #12). This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility identified a census of 73 residents. The facility was notified of the Immediate Jeopardy (IJ) on October 17, 2023 at 5:16 p.m. The IJ was removed on October 19, 2023. The Facility Staff removed the Immediate Jeopardy through the following actions: 1. To accurately asses each residents skin status 2. On 10/6/2023 skin evaluation orders were updated and the process for skin assessment was updated to be completed in the Assessment tab in PCC. 3. On 10/6/2023 skin evaluation orders were updated and the process for skin assessment was updated to be completed in the Assessment tab of PCC with a stand-alone assessment to be completed every 7 days by a licensed nurse. 4. On 10/3/2023 and ongoing all licensed and Certified staff have been educated on wound care, Skin assessment, Timely intervention, Wound intervention, prevention, and healing. Verification of an understanding of this material was done through a Nurse and/or Nurse aide Competency Test. 5. A complete house sweep was conducted to identify any new areas of concern, following the audit systems results, on 10/17/2023. 6. Director of Nursing (DON) or designee will monitor documentation of treatments (5) Resident records per week for (1) month then (10) records every (1) month for (2) months. Discrepancies will be promptly reported to the Administrator and Nurse Consultant for immediate corrective action. 7. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. The scope and severity was lowered from an IJ to and G at the time of the survey after ensuring the plan of correction was put in place and implemented. Findings include: 1. A Quarterly Minimum Data Set (MDS) assessment form dated 7/30/2023, documented Resident #12 had diagnosis that included orthostatic hypotension, renal insufficiency, renal failure, diabetes mellitus, need for assistance with personal care, varicose veins of bilateral lower extremities with pain and abnormalities of gait and mobility . The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15, for which indicated intact cognition and had the ability to make needs known, needing limited assistance of two (2) staff members with bed mobility, extensive assistance of (2) for transfers, dressing, toilet use and bathing. The assessment also documented the resident with being at risk for developing pressure ulcers/injuries with no use of pressure reducing device for bed, chair and no turning/repositioning program. A Care Plan with a initiated date of 7/31/2023 and revision date of 8/03/2023, documented the resident had a Stage 5 pressure ulcer on resident right foot related to immobility. Interventions include the following: *Administer treatments as ordered and monitor for effectiveness. *Educate the resident/family/caregivers as to causes of skin break down, including: transfer/positioning requirements, importance of taking care during ambulating/mobility/, good nutrition and frequent repositioning. *Follow facility policies/protocols for the prevention/treatment of skin breakdown. *heel protectors on at all times, float heels while in bed, monitor and report if area deteriorates. *Inform the resident/family/caregivers of any new area of skin breakdown. *Weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate. The Progress Notes dated 7/31/2023 at 11:10 a.m., documented communication - with Physician Situation: Noted to have a 1.0 cm x 0.5 cm x 0.2 cm open area to foot. Area appears to be pressure related at this time. Area had small amount of drainage. No odor. Resident reports pain when pressure is applied. The Progress Notes dated 7/31/2023 at 8:04 p.m., documented Text: new orders: heel protection treatment and protection all times. An Occupational Therapy Evaluation an Plan of Treatment dated 8/01/2023-8/11/2023, documented patient training initiated with positioning in wheelchair as patient displays skin breakdown on ball of right foot and awaiting appointment with wound doctor outside of the facility. The Progress Notes dated 8/03/2023 at 8:28 a.m., documented, Order Note: New order obtained at this time to discontinue current treatment for heel. Start Cleanse with wound cleanser of choice, apply betadine moistened gauze, cover with abdominal pad and wrap with gauze, change daily and PRN (as needed). Refer to wound clinic. Prevalon boot at all times as tolerated. Will set up appointment for wound clinic. The Care Plan lacked documentation of the Prevalon boot at all times as tolerated order dated 8/3/23 at 8:28 a.m. from the Progress Note. The Progress Notes dated 8/04/2023 at 4:39 p.m., documented, Skin/Wound Text: Wound area to right foot ( heel). Additional amino acid supplement to promote wound healing. A Weekly Pressure Wound Assessment tool dated 8/10/2023 at 2:37 p.m., documented acquired pressure area to right foot as healed. The Progress Notes dated 8/10/2023 at 5:56 p.m., documented, Order Note: Encounter note received from ARNP (Advanced Registered Nurse Practitioner) with new orders to discontinue wound treatment to heel. Continue heel protection and notify office if redness, bogginess or open wound recurs. A Weekly Skin Review Form dated 8/13/2023 at 3:39 p.m., documented resident presents with dry skin to the lower shins. Charting reflects resident frequently refuse preventive treatments. Post-podiatry visit resident has areas of concern noted to her right foot. Areas included: *right lower leg (front) dry patch measuring 6 centimeters (cm) by 2 cm with scabs throughout. *right toe(s), 3rd toe nail was trimmed by podiatry, nail was cut short and open area formed. Scant blood drainage noted on sock. Band-Aid removed. Wound cleaned and new Band-Aid applied. 1 cm by 1 cm open spot at the first knuckle of the same toe. No drainage or sign/symptoms of infection noted. *right toe(s), right 4th and 5th metatarsal-contains a callous that has been shaved leaving a open spot in the interior measuring 6 millimeters by 5 millimeters with a 3 millimeter depth. Skin is hard and dry around the edges with a soft dark red interior wound bed. No signs/symptoms of infection at this time. The Progress Notes dated 8/13/2023 at 4:19 p.m.,documented, Note Text: Skin assessment completed on right foot this afternoon after concerned noted post podiatry visit. -3rd toe nail was trimmed by podiatry nail was cut short and open area formed. 4 mm x 1 mm. Scant blood drainage noted on sock. Band-Aid removed. Wound cleaned and new Band-Aid applied. 1x1 mm open spot at the first knuckle of the same toe. No drainage or s/s of infection noted. -Right 4th and 5th Metatarsal area contains a callous that has been shaved leaving a open spot in the interior measuring 6 mm x 5 mm with a 3 mm depth. Skin is hard and dry around the edges with a soft dark red interior wound bed. No signs/symptoms of infection at this time. The Progress Notes dated 8/14/2023 at 9:00 a.m., documented, Nursing Note Text: Fax received to apply triple antibiotic ointment to open areas and cover with non-adherent dressing once daily. Monitor for improvement and report if not improving or patient has signs/symptoms of infection. A Metro Geriatric Service Encounter note dated 8/28/2023 at 2:42 p.m., revealed resident chief complaint-right foot wound. *This patient is seen for routine encounter. *Right lower extremity wound. Unable to be seen by wound nurse practitioner due to hemodialysis schedule. Right lateral plantar foot with eschar. Unstageable pressure wound. Will discontinue triple antibiotic ointment and start betadine and refer to wound clinic. *Orders and Requisitions: *Refer to wound clinic *Please use Prevalon boots as ordered. *Plan Notes: *Continue current level of care. *Dressing changes as above. *Refer to wound clinic. The Progress Notes dated 9/01/2023 at 12:36 p.m. documented, Health Status, Note Text: Call placed to Wound Clinic to follow up on information that was sent for referral. Appointment scheduled at this time for Friday at 7:30 a.m Awaiting call back from transport to set up transportation. The Progress Notes dated 9/12/23 at 6:15 a.m., documented Health Status Note Text: During 5:00 a.m., medication pass resident was not responding to nurse, resident would open her eyes then shut them, when checking mental status she would state her name but didn't know place month or year. Resident was twitching and jerking. Blood pressure attempted to get via manual cuff. Resident unable to swallow sips of water to take medication. Call placed to receive orders to send to emergency room . Call placed to family, left message on cell phone of resident being transferred to emergency room . The Progress Notes dated 9/12/2023 at 11:02 p.m., documented, Note Text: Call placed to Hospital to check in on resident admitted to Critical Care Unit (CCU) Admitting Diagnosis: Sepsis The Pre-Arrival Summary dated 9/12/2023 at 7:14 a.m., documented, patient was brought into the emergency department due to confusion and twitching this morning at 5:00 a.m. The emergency room notes dated 9/12/2023 at 7:15 a.m., documented, this patient present with weakness and lethargy. The onset was just prior to arrival. The character of symptoms is generalized. Patient was ok last night when went to bed at 11:00 p.m., but when they woke her up at 5:00 a.m., patient was less alert and twitching per facility On emergency medical service arrival patient was more alert and oriented but had borderline low blood pressure. Patient appears fatigued on arrival but arousable to voice and denies any complaints. Chronic right foot ulceration. skin appears to be warm, dry with large necrotic ulceration to right foot with surrounding erythema and warmth. Antibiotic ordered due to suspected right foot as source of sepsis. Diagnosis=septic shock, soft tissue infection of right foot. Condition=critical The Hospital Progress notes dated 9/12/2023 at 11:19 a.m., documented, [AGE] year-old female with a history of end stage renal disease, chronic hypotension who presents with septic shock suspected secondary to soft tissue infection on the right foot. Will obtain MRI of the right lower extremity to rule out osteomyelitis. Reviewing with the patient, a large colonic chronic foot wound measuring 4 cm by 4 cm appearing somewhat deep. Patient with large 4 cm by 4 cm necrotic wound on the distal lateral plantar aspect of the right foot. The Pharmacy Antibiotic Kinetic Consult dated 9/12/2023 at 1:36 p.m., documented patient brought into the emergency department due to confusion and twitching this morning at 5:00 a.m. Blood pressure that time was noted to be 70/59. Patient has large colonic chronic foot wound measuring 4 cm by 4 cm appearing somewhat deep. Facility nurse reports they have been dealing with this foot wound for the last 3 to 4 weeks, and have had wound care consulted, with regular wound care occurring. The Vascular Consult dated 9/12/2023 at 6:09 p.m., documented, patient with bilateral Charcot foot deformity, chronic right foot wound. *Right foot x-ray, numerous gas bubbles overlying the distal fifth metatarsal and abnormal appearance of the distal fifth metatarsal suspicious for osteomyelitis *Sepsis Today's Plan= consulted with podiatry for poor prognosis of right lower extremity limb salvage, discussed at length risks and benefits of proceeding with guillotine amputation versus keeping the patient comfortable, patient agreed to proceed with amputation this evening. will perform right above ankle guillotine amputation. The Podiatrist Surgery Progress Note dated 9/12/2023 at 6:21 p.m., documented, resident with plantar left forefoot ulcer, necrotic right forefoot ulcer/cellulite/developing abscess with probable osteomyelitis, poor prognosis for right lower extremity limb salvage, will consult vascular surgery. The Vascular Amputation Operative Note dated 9/12/2023 at 9:21 p.m., documented, preoperative diagnosis= septic right deep space diabetic foot infection, with hypotension. Procedure= Guillotine right foot amputation. Podiatry had evaluated the patients septic right diabetic foot, and deemed it unsalvageable. The patient was evaluated, and noted to have deep space tenderness, and foul gangrenous tissue in the lateral foot. The right foot is chronically inverted, due to Charcot diabetic foot. The History and Physical Consultation dated 9/13/2023 at 2:48 p.m., documented on arrival to the emergency department on 9/12/2023, patient reports that she got confused. Reviewing with the patient she has a large right colonic chronic foot wound measuring 4 cm by 4 cm appearing somewhat deep. Patient was evaluated at the bedside. Right foot x-ray personally reviewed and was significant for gas bubbles overlying the distal fifth metatarsal and abnormal appearance of the distal fifth metatarsal suspect osteomyelitis. Guillotine amputation of right lower extremity covered in surgical bandages with swelling and erythema appreciated proximal to bandaging. The Vascular Operative Notes dated 9/20/2023 at 2:40 p.m., documented pre-operative diagnosis= sepsis/right foot osteomyelitis/status post urgent right ankle guillotine amputation. Procedure=right below knee amputation The History and Physical Consultation report dated 9/21/2023 at 9:41 p.m., documented patient presented to the emergency department on 9/12/2023 in the early morning by the emergency medical service as an emergent transfer from a local nursing home. Reportedly she was confused and has a chronic foot wound measuring 4 cm by 4 cm for the last 3-4 weeks, her normal self yesterday, however at about 5:00 a.m., this morning she was no longer objectively alert and oriented to person, place and time which is her baseline. Patient was lethargic, arounsable but only alert to persons, place, or time or situation. She was found to be in septic shock and transferred to the Intensive Care Unit for pressor support. Septic Shock was secondary to osteomyelitis of her right foot and positive culture for proteus (acquired infection), vascular was consulted and status/post guillotine amputation on 09/12/2023 and later status/post below knee amputation on 9/20/2023. Assessment/Plan *Acute Right foot osteomyelitis secondary to right foot gangrene. *Chronic Diabetic right foot wound with bilateral Charcot foot deformity status/post below knee amputation *9/12/2023, right foot x-ray, numerous gas bubbles overlying the distal fifth metatarsal, abnormal appearance of the distal fifth metatarsal suspect osteomyelitis. *9/15/2023, pathology= right foot, above ankle amputation, ulcer with gangrenous necrosis and acute osteomyelitis, margins grossly viable. The Hospital Progress notes dated 10/10/2023 at 3:42 p.m., documented the hospital course, patient initially presented to the emergency department from local nursing home on 9/12/2023, due to weakness/lethargy, right foot wound and hypotension. Patient was found to be in septic shock with right foot osteomyelitis. Patient was admitted to Intensive Care Unit for pressor support and was started on broad spectrum antibiotics. Vascular surgery was consulted and patient underwent right ankle amputation on 9/12/2023 and then on returned to the operating room on 9/20/2023 for right below the knee amputation. Pathology showed nonviable subcutaneous tissue involving stump, focal calcifications tibia arteries, and excision margin with grossly viable tissues. Interview on 10/9/23 at 3:30 p.m., Resident #12, confirmed and verified that the hospital did an emergency guillotine amputation on 9/12/2023 and a below the knee amputation on 9/202023 and that they were not aware of the area on their right foot was necrotic and had gangrene. Resident #12, felt that if the facility would of done the twice weekly bathing and did weekly skin assessment as required the amputation could of been prevented. Interview on 10/16/23 at 4:45 p.m., Staff I, LPN (licensed practical nurse)(mds coordinator), confirmed and verified that the clinical record lacked documentation of the weekly skin sheets being completed on Resident #12 after 8/13/2023. Staff I also confirmed and verified that the expectation of the nursing staff are to do weekly skin assessments and complete baths as scheduled two times per week. Interview on 10/16/2023 at 5:00 p.m., the facility administrator, confirmed and verified that the clinical record lacked documentation of Resident #12 skin sheets being completed weekly after 8/13/2023, and it is the expectation of the nursing staff to do them weekly and the facility will take responsibility to make sure the resident receives the cares that they deserve. Interview on 10/17/23 at 3:10 p.m., Staff J, LPN, confirmed and verified that Resident #12 clinical record lacked any documentation of weekly skin sheets being completed after 8/13/2023 and that it is expected that nursing staff complete the skin sheets weekly. Interview on 10/18/23 at 9:45 a.m., the facility Advanced Registered Nurse Practitioner (ARNP) was aware of the necrotic area on Resident #12's right lateral plantar foot with eschar from a visit on 8/28/2023 and explained that an order was given to have the resident seen at the wound clinic and if the facility would of informed the ARNP that Resident #12 was not seen at the wound clinic an order to send Resident #12 to the emergency room would of been given due to the area being necrotic and would of expected the facility to notify and inform of any changes. Completing an Accurate Assessment Regarding Pressure Injuries, Facility Policy and Practice with no date, revealed that the assessment must accurately assess the residents status and to assure that each resident receives an accurate assessment reflective of the residents status at the time of the assessment by staff that are qualified to assess relevant care areas and knowledge about the resident status, needs, strengths, and areas of decline. Why Its Done- to accurately assess each residents skin status. First things First-Read the instructions in the RAI manual How You Do It- 1. Following the instructions in the RAI manual (utilization guidelines), complete the MDS section M and Care Area Assessment using: a. Staff member interviews (if appropriate) b. Observations/wound assessments c. Medical Record review Complete the Electronic Medication Administration Record (EMAR), skin assessment in EMAR Go to assessments, open up weekly skin review. Complete for date scheduled. If new area, measure and document in assessment. If new areas identified, open risk management. Notify Medical Doctor and Power of Attorney Obtain treatment order Document in progress notes Notify wound nurse

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure two (2) of five (5) residents actively reviewed (#1 & #4), received adequate supervision to protect against hazards in the environment. Review revealed Resident #1 required assistance of one staff with a gait belt for transfer. On 8/19/23 at approximated 6:00 a.m., Staff A, Certified Nursing Assistant (CNA) assisted Resident #1 to transfer without a gait belt. During transfer the resident became anxious, was waiving her arms, Staff A heard a loud sound and lowered the resident to the floor. Resident #1 sustained a right arm fracture and required hospitalization and surgery. Additionally, the facility failed to provide 1:1 supervision as assigned for Resident #4 identified with agitation, aggression, exit seeking and trespassing behaviors. On 9/27/23 Staff B, CNA left Resident #4 unsupervised to go on break. Resident #4 exited the building without authorization. The facility reported a census of 73 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 6/28/23 for Resident #1 documented a score of 10 of 15 on Brief Interview for Mental Status (BIMS) test which indicated moderate cognitive impairment. The resident had diagnoses that included dementia, osteoporosis, muscle weakness, and anxiety and required extensive assistance of one staff for bed mobility, transfer, ambulation, dressing, toilet use, and personal hygiene. The resident had no falls since reentry. A Nursing Care Plan dated as initiated on 8/1/22 identified a focus area: ADL (Activities of Daily Living) self-care deficit, with a goal of maintaining current level of function, and directed the following interventions: Transfers and ambulates with the assistance of 1 staff member and FWW (four wheeled walker), and one person assist for toileting. The care plan further identified resident has had falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment and/or the use of medications that may increase fall risk, with a goal that resident will have no serious injury from falls, and directed the following interventions: Ensure resident is wearing proper footwear, follow all facility protocol related to falls which included: report, investigate, and immediate intervention and long-term interventions. A Fall Risk assessment dated [DATE] documented a score of 18 which indicated a high risk of falls. Observation on 10/18/23 at 2:15 p.m. Resident #1 was observed to transfer. Resident appeared anxious, and was noted to shakily and unpredictably mover her arms, and yell out in a high-pitched tone. A Progress Note dated at written by Staff C, Registered Nurse (RN) at 6:29 a.m. 8/19/23 documented that Staff C was alerted by the CNA that the resident had been lowered to the floor on 8/19/23 at 6:03 a.m. in the resident's restroom. Staff C assessed and suspected a right shoulder injury for the resident. The resident was placed in a wheelchair and a call to the on-call was placed to obtain permission to send to the local hospital. In an interview on 10/16/23 at 4:05 p.m., Staff C, RN recalled he had been called to Resident #1's room by Staff A, CNA who had alerted resident was on the floor. Staff C stated responded immediately and found resident on the floor near the toilet in her room. Confirmed Staff A had been the only staff person in the room at the time of the fall, and had reported resident had lost balance during transfer, was flailing around, and hurt the arm while being lowered to the ground. In an interview on 10/16/23 at 2:52 p.m., Staff D, Licensed Practical Nurse (LPN) confirmed that she had responded to the room to assess Resident #1 who was on the floor and yelling in pain. Staff D, recalled that the resident had complained of right arm pain. Staff D stated after the assessment the staff had assisted the resident from the floor with a gait belt. Staff D stated that she would expect staff to use a gait belt for all staff assisted transfers. Staff D stated that Staff A had reported trying to get the resident over to the toilet and, the resident was flailing around and Staff A, CNA lowered the resident to the floor. In an interview on 10/16/23 at 2:59 p.m., Staff A, CNA recalled on 8/18/23, at approximately 6:00 a.m. she had gone in to provide care to Resident#1. The resident requested to use the bathroom, so Staff A assisted the resident to walk to the bathroom with her walker. Once in the bathroom, Staff A started to turn and assist the resident with her clothing. Staff A reported the resident became hysterical without warning and started flailing her arms. Staff A reported she had heard a sound like clothes ripping, and noticed the resident's arm was limp and lowered resident to the floor. Staff A denied that she had seen resident strike arm on anything. Staff A responded that she had not used a gait belt to ambulate and transfer resident. Staff A clarified that she had not anticipated that she would need a gait belt, no gait belt was available in the room and she was not wearing one. Staff A stated she knew that she should have used a gait belt, but would have had to go get one and didn't. Further interview on 10/17/23 at 5:18, Staff A clarified that she had eased to the floor by grasping the waist of the resident's pants. Staff A denied that she had grasped the resident by the arm at any time. In an interview on 10/17/23 at 5:00 p.m. the Administrator and Interim Director of Nursing (IDON) stated that they had questioned how Staff A had transferred the resident and had received a text message that she had transferred by grasping at the resident at the waist. The IDON had questioned the previous DON if a gait belt had been used, but the previous DON had resigned without answering her question. An investigation self-report amendment submitted to the Department by the facility included the following; Resident had a fall with injury on 8/19/23. The resident was in the restroom and staff were assisting the resident to the bathroom. The resident grabbed the grab bar for assistance. Staff member assisting heard a pop in the resident's right arm. Staff member lowered resident to the floor and notified the nurse. Resident assessed and sent to the local emergency room (ER) for evaluation. Resident reported to have a fracture of the right humerus. Resident admitted to hospital and surgery performed. A Hospital Operative Report dated 8/21/23 documented a preoperative diagnosis of closed right displaced, comminuted (broken in numerous pieces) humerus (upper arm bone) fracture. History documented resident sustained a fall resulting in the injury. Decision was made to operatively repair the fracture. Review of a facility policy titled, Use of Gait Belt, dated 4/2/22 directed to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. The policy included the following guidelines: Responsibility of each employee to ensure they have a gait belt available for use at all times when at work. Failure to use gait belt properly may result in termination. 2. The Quarterly MDS assessment with a reference date of 9/3/23 for Resident #4 documented a score of 9 of 15 on Brief Interview for Mental Status (BIMS) test which indicated moderate cognitive impairment. The resident had diagnoses that included a stroke, anxiety, dementia and independent bed mobility, transfer, ambulation, dressing, toilet use, and personal hygiene. The MDS documented that verbal behavioral symptoms directed towards others and wandering occurred 1-3 days. A Nursing Care Plan dated as initiated on 2/20/23 identified a focus area as follows; Resident has episodes of behaviors as evidenced by being combative, negative verbalizations, refusal of medications/cares. The Care Plan included the following directives: Administer medications as ordered, 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. Minimize the potential for the resident's disruptive behaviors by offering tasks which divert attention. Observe for early warning signs of oncoming behaviors. Call by name. Remove from unwanted stimuli. Utilize the language line for communication. The Nursing Care Plan further identified a focus area: Resident an elopement risk/wanderer related to history of attempts to leave facility unattended, impaired safety awareness dated as initiated on 4/18/23, with a goal that resident will not leave the facility unattended and included the following directives: 8/7/23 Resident attempted to leave the facility: monitor hours of sleep, stop sign place on skilled door to remind, continue wander guard in place and redirect as appropriate. 9/23/25 Resident attempted to leave facility, due to extreme behaviors sent to hospital for evaluation 9/25/23 Resident attempted to leave the facility, 1:1, wander guard in place Disguise exits: cover door knobs, handles and tape floor Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book Identify pattern of wandering, and intervene as appropriate Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Wander alert device, verify device is working every night and replace if it is not functioning appropriately. When resident wants to go outside assist the resident to exit. If the resident refuses to re-enter the facility call family to assist per request. An Interdisciplinary Team Progress Note dated 9/26/23 at 9:57 a.m. documented that alarms triggered staff to the activity room door where resident was noted to be outside. Resident discharging home on Friday with daughter. Immediate interventions: 1 on 1, wander guard in place, continue with medication management. A Nursing Progress note dated 9/28/23 at 2:53 a.m., Staff E, Licensed Practical Nurse (LPN) documented on 9/27/23 at 9:50 p.m. she was at the nurse's desk when the door alarm goes off. Alarm board alerted the door at the bottom of the 200 hall was sounding. Staff E ran to the door and exited and found resident in the parking lot sitting in wheelchair self-propelling to the bottom of the hill, another staff person also responded. Approached resident who was waving fists, and throwing rocks. Police were summoned for assistance, resident was returned inside facility buildings. Assisted to his room and given snacks and fluids. One on one assigned to resident for the night shift with new staff member. One on one supervision will continue through the shift. In an interview on 10/11/23 at 4:20 p.m., Staff F, LPN stated on 9/27/23 on the evening shift Staff B, CNA had been assigned to provided 1 on 1 supervision for Resident #4 due to behaviors and elopement risk. Staff F stated that he had observed Staff B on a hand-held electronic device during the shift so he reminded Staff B that she was supposed to be watching the resident. The nurse stated that he felt Staff B was not being attentive to the resident so he helped out by redirecting and anticipating the resident's needs. Staff F stated when he left work at approximately 9:45 p.m. Staff B was sitting at the front desk with the resident and he had assured that staff knew that he was leaving. Staff F, LPN responded that a one on one for a resident with dementia and behaviors is required to have all their attention focused on the resident so you can quickly identify changes in behavior and intervene. Staff F reported that he would not leave a one on one resident unattended unless he had been assured that someone else was assigned the responsibility and able to provide 1 on 1 supervision. In an interview on 10/16/23 at 12:42 p.m., Staff E LPN stated that she worked the night shift starting 9/27/23, when she arrived at work she passed Staff F, who was leaving work. Staff E reported that she was aware that a 1 on 1 had been initiated for the resident based on his behaviors and that the resident had gotten outside, with supervision previously. Staff E recalled when she arrived Staff B CNA was at the front desk, and was assigned the 1 on 1, however Resident #4 was not in sight. Staff E questioned Staff B who was with the resident and Staff B shrugged her shoulders and stated that she needed a break, Staff B then denied that she had assured responsibility for 1 on 1 had been assigned to another staff person to take break. At that same time the 200 hall exit alarm sounded and Staff E responded. Staff Ee exited the facility and noted that the resident was outside but with two oncoming staff. Staff E confirmed staff stayed with the resident until the resident returned inside the facility and 1 on 1 supervision reinstated. Staff E, LPN stated she would expect a staff person assigned to 1 on 1 supervision to be with that resident at all times, to anticipate needs, redirect, diffuse behaviors, and keep safe. Staff E responded that she would never expect staff to leave resident unattended and the staff person assigned to the 1 on 1 would be responsible to ask for help, have someone else assigned to resident before leaving their responsibility as the 1 on 1 staff member. In an interview on 10/12/23 at 12:30 p.m. Staff B, CNA confirmed that she had been assigned the 1 on 1 supervision for Resident #4. Staff B responded that she understood her responsibility was to be with the resident at all times, and stated that she should not have left the resident to go into the breakroom unless a peer had assumed responsibility for Resident #4. Staff B further responded under no circumstances would you leave a resident who required 1 on 1 supervision unattended. An Interdisciplinary Team Note dated 9/28/23 at 9:51 a.m., initiated by the DON documented that a complete skin assessment of the resident was completed with no skin issues. Continue 1 on 1, wander guard in place. Review of an Employee Disciplinary Form dated 9/27/23 documented that Staff B, CNA was issued a suspension for an occurrence that was described as: Staff B was assigned to resident #4 as a 1 to 1 for resident that eloped on 9/27/23. Review of a facility Staff In-Service Training attendance sign in sheet dated 9/27/23 documented staff were educated that for a 1 to 1, keep resident in eyesight at all times. Observation on 10/11/23 at 3:00 p.m. the 200-door exit was alarmed but not a wander guard exit. Observation revealed an interior exit door, a foyer and an exterior alarmed exit. Beyond the exterior door there is a cemented area that leads to the front parking lot. The DON provided a screenshot from her cell phone that was sent to staff on 9/25/23 at 11:00 p.m. that directed Resident #4 required 1 to 1 supervision. The facility was unable to provide a facility policy that addressed the responsibility of a 1 to 1 situation.

Based on observation, clinical record review, policy review, staff interview, and resident interview, the facility failed to provide an environment free from physical abuse for 7 residents who reported staff were rough with them during cares (Residents #7, #10, #24, #26, #32, #65, and #276) and failed to treat a resident with respect for 1 of 1 residents observed during a general observation (Resident #37). A serious adverse outcome was likely to occur as the facility additionally failed to report and thoroughly investigate all allegations of abuse. One identified staff member whom residents reported an issue with remained actively working with access to all residents. Additionally, without the thorough investigation, it was unknown if other staff members could be identified. There was an immediate need for the facility to take steps to ensure all residents were protected from the risk of abuse. The facility reported a census of 79 residents. On 8/1/23, the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/2/23 after the facility staff completed the following: a. Identification of Residents Affected or Likely to be Affected. b. Administrator and Director of Nursing (DON) in-serviced immediately, on Abuse and Neglect. c. Abuse policies were reviewed/updated to include all sources of abuse. d. Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes. e. Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies. f. Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting. g. Staff member identified to be alleged perpetrator was suspended by the DON and Admin on 8/1/2023. h. Self report completed and submitted to DIAL for review. The scope lowered from L to an F at the time of the survey. Findings Include: 1. The MDS(Minimum Data Set) assessment tool, dated 7/21/23, listed diagnoses for Resident #276 which included dislocation of the right hip and restless leg syndrome. The MDS stated the resident required limited assistance of 2 staff for bed mobility, extensive assistance of 1 staff for dressing and personal hygiene, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for transfers and bathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicating intact cognition. On 7/26/23 at 11:08 p.m., Staff O Certified Nursing Assistant (CNA) stated she worked night shift Mondays-Fridays and was responsible for both the skilled and the 300 hall. She said it was difficult to take care of everyone and stated call lights could remain on for a long time because when she was in one hall a call light may alert in the other hall. She stated she did not know how long the call lights were on because she was in the other hall. She stated she did not have time to get to everyone in a timely manner and stated the residents in the skilled hall were in pain and were needy. On 7/27/23 at 2:25 p.m., Staff P CNA stated she was concerned regarding a complaint from Resident #276 that Staff O was rough with her. Staff P stated she turned in a statement to the DON but the DON stated she needed Staff O to cover staffing needs. On 7/27/23 at 2:33 p.m., the surveyor informed the Administrator about the concerns related to Staff O and she stated she would take care of it immediately. She stated staff were now bringing her concerns about staff to her but prior to her time here it was pushed under the rug. She stated no one brought her any concerns related to Staff O prior to this. In email correspondence on 7/27/23 at 3:20 p.m., the Administrator stated Staff JJ Registered Nurse(RN) interviewed the resident and the resident stated Staff O tapped her on the arm. The email did not mention the resident reported the staff member was rough. In email correspondence on 7/31/23 at 1:32 p.m. , Staff JJ stated she met with the resident on 7/27/23 and the resident stated earlier in the week as she slept a CNA entered her room and tapped her on the shoulder and instructed her to roll over so she could provide cares. The resident stated she felt the staff member was rough and felt like the CNA was angry with a bed attitude which concerned her. In email correspondence on 7/27/23 at 4:20 p.m., the Administrator stated she spoke with Staff O and Staff O stated the resident did not share any concerns with her and she had not been rough. The Administrator stated she informed all staff to be mindful when approaching residents not to startle them with a touch. On 7/31/23 at 10:38 a.m., Resident #276 stated that she had an incident where a staff member came into her room at 5:30 a.m. and slapped her on the back and was rough. She stated she informed one of the CNAs about it a couple of nights later. The resident stated this was uncalled for. In a phone interview on 7/31/23 at 3:30 p.m., Staff P stated she submitted a statement to the Social Worker and the DON regarding Staff O. She stated she submitted the note sometime in July and dated the note. She stated there was no follow-up completed related to her concerns. In email correspondence on 8/1/23, the Administrator stated they would discuss the process for reporting care concerns or roughness and stated the DON conducted staff interviews and no staff reported residents sharing concerns of staff being rough. The facility lacked documentation of resident interviews or further investigation conducted as of 8/1/23 related to allegations of staff roughness. On 8/1/23 at 11:05 a.m., the resident clarified that the staff member did not slap her but tapped' her on the back but was very rough when turning her. On 8/1/23 at 12:40 p.m. , Staff E Licensed Practical Nurse(LPN) stated Staff O worked the night shift on 7/31/23-8/1/23. Employee Time Card Reports revealed Staff O worked 21 shifts in July of 2023 from 7/2/23-7/29/23. An additional Time Card report revealed Staff O worked 7/31/23. On 8/1/23 at approximately 5:10 p.m., the Administrator stated the facility suspended Staff O. In a phone interview on 8/8/23 at 11:08 a.m., Staff O stated she was never rough with residents and never hit or slapped a resident. She stated she could not remember who Resident #276 was. 2. The Quarterly MDS assessment tool, dated 6/19/23, listed diagnoses for Resident #32 which included Alzheimer's disease, non-Alzheimer's dementia, and depression. The MDS stated the resident required extensive assistance of 2 staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene, and completely depended on 2 staff for bathing. The MDS listed her BIMS score as 5 out of 15, which indicated severely impaired cognition. A Care Plan entry, dated 3/3/22, stated the resident required assistance with Activities of Daily Living(ADLs). On 7/25/23 at 9:19 a.m., Resident #32 stated she had trouble with a black guy who was tall and slender (Staff Q CNA). She stated if she did not move as fast as he wanted her to he yanks at her and this made her feel bad. She stated someone came in and talked to her about the situation but she did not know who this was. She stated after this he was not supposed to care for her but he did. She stated there were other staff also who jerk you around. She stated Staff Q wanted her to go to bed at 6:30 p.m. but she wanted to go to bed at 9:30 p.m. She stated she loses every night. On 7/26/23 at 10:21 a.m., Staff E stated residents complained that staff were rude, primarily on the night shift. She stated residents had been manhandled by the night shift. She stated residents asked to stay up late and the night shift told them they had to go to bed now. She stated she heard from Resident #32 that Staff Q was rude and condescending. She stated there were residents that he was not allowed to care for. Staff E stated she questioned why he was working here and stated they needed to get him out of here. She stated she spoke to the DON about it and informed her staff had been rough. On 7/26/23 at 10:33 a.m., Staff D CNA stated 2 weekends ago, there was a complaint related to Staff Q and Resident #32. Staff D stated the resident told her Staff Q was not nice. She stated Staff Q was not supposed to go in her room because they clash. The resident told her that she didn't want to go to bed at 7:00 p.m. and Staff Q stated they were putting everyone to bed. Staff D stated she informed Staff W LPN about the situation. In a phone interview on 7/26/23 at 11:36 a.m., Staff C LPN stated that she recently turned in a statement related to Staff FF CNA. Staff GG CNA informed her that Resident #32 told her Staff FF was rough with her. Staff C stated Staff GG wrote out a statement and put it in the DON's door. She stated she thought the facility fired her. Staff C stated she did not work with Staff Q much but that he was rude to the residents. On 7/26/23 at 12:42 p.m., Staff GG CNA stated Resident #32 thanked her for being here instead of Staff FF and the resident stated Staff FF was rough and rude with her. Staff GG stated she informed Staff C and wrote out a statement and taped it to the DON's door. On 7/26/23 at 10:46 a.m., Staff CC CNA stated there were a few residents down the 200 hall who preferred not to work with Staff Q. She stated Resident #32 reported to her that Staff Q cussed at her and made her go to bed right after dinner. On 7/26/23 at 4:07 p.m., the resident stated when staff were rough with her she felt terrible. On 8/1/23 at 8:06 a.m., Staff II Social Services Assistant stated she was not sure of the time but staff had reported concerns to her about other staff. She stated a CNA came to her one morning and stated that Resident #32 stated one of the overnight staff would not provide her toileting assistance before they assisted her to bed and stated she alerted her call light around midnight and the staff member came in and took her oxygen off and pulled her call light out of the wall. She stated she completed a concern form and gave it to the DON and the Administrator at the time. In a phone interview on 8/1/23 at 4:00 p.m., Staff W LPN stated Resident #32 told her staff entered her room and turned the call light off. She stated she believed she left a note for the DON. An Employee Time Card Report revealed Staff Q worked 13 shifts in July of 2023 with his final shift 7/24/23. A review of Staff Q's employee file revealed no disciplinary actions or concern forms related to resident complaints prior to 7/24/23. On 7/25/23 at 11:02 a.m., the DON stated she heard complaints of staff being rude but received no other reports of staff being rough. She stated Resident #32 never complained about Staff Q and there was never a rule that he couldn't care for her. 3. The Quarterly MDS assessment tool, dated 7/20/23, listed diagnoses for Resident #26 which included kidney disease, Alzheimer's disease, and seizure. The MDS stated the resident required extensive assistance of 1 staff member for bed mobility, dressing, and personal hygiene, depended completely on 1 staff for toilet use, and depended completely on 2 staff for transfers. The MDS listed the resident's BIMS score as 10 out of 15, indicating moderately impaired cognition. Care Plan entries, dated 2/2/23, stated the resident required assistance with ADLs due to weakness. On 7/24/23 at 1:29 p.m., Resident #26 stated there were staff on all of the shifts who were rough when they changed her incontinent brief. On 7/26/23 at 1:24 p.m., when asked how it felt when staff were rough with her, Resident #26 held up her thumb and index finger to indicate she felt small. 4. The Quarterly MDS assessment tool, dated 7/19/23, listed diagnoses for Resident #7 which included anxiety disorder, depression, and muscle weakness. The MDS stated the resident required limited assistance of 1 staff for transfers and extensive assistance of 1 staff for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS listed the resident's cognition as 15 out of 15, indicating intact cognition. A Care Plan entry, dated 12/2/20, stated the resident had an ADL deficit related to fatigue, chronic pain, and vision deficit. A 7/12/23 Night Shift Meeting Notes stated Resident #7 stated night staff was rude and she asked a CNA not to be so rough when touching her back and she acted like she did not hear her. Resident #7 asked her what her name was and she ignored her. A 7/12/23 Grievance Form stated Resident #7 reported there was a night shift staff who was rude to her and she would not tell her her name. The Grievance Form Official Follow-up stated she had a meeting with the night shift and went over resident interviews that the nurse manager carried out. A 7/12/23 Night Shift Meeting Notes documented the following: a. Resident #7 stated night staff was rude and she asked a CNA not to be so rough when touching my back and she acted like she did not hear her. Resident #7 asked her what her name was and she ignored her. b. Resident #40 stated an overnight worker was rude to him and they talked on the phone with ear buds in and did not engage with him during care. c. Resident #9 stated the overnight shifts are very loud and sat outside the resident rooms and talked on the phone. She stated staff did not answer call lights in a timely manner and when the CNAs come in to respond tot he call lights they say what do you want? like they were inconvenienced by the residents need. d. Resident #36 stated one aide did no want to work with her and stated when she worked with her friends she came in to change her incontinent brief and her conversation was loud and it was a personal conversation. She stated it was so rude. The facility lacked documentation of follow-up actions related to the 7/12/23 meeting concerns. A 7/17/23 Employee Disciplinary Form stated residents down two different hallways named Staff FF in 2 concerns, being rude and rough while providing cares. The form also stated that Staff FF told residents to mind your own business. The form stated the resident would be suspended. A 7/17/23 Grievance Form stated that Resident #7 reported that the aide was in her room again and she said the same thing as before and she was Staff FF. The form stated that the staff member would be terminated. On 7/25/23 at 10:19 a.m., Resident #7 stated that the girls, mostly the overnight staff, were rough when they took care of her. On 7/26/23 at 1:37 p.m., she stated when staff were rough with her she didn't understand why they would do that to elderly people. 5. The MDS assessment tool, dated 5/26/23, listed diagnoses for Resident #24 which included coronary artery disease, kidney disease, and diabetes. The MDS stated the resident required extensive assistance of 2 staff for bed mobility, dressing, toilet use, and personal hygiene, and depended completely on 2 staff for transfers. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. A Care Plan entry, dated 5/20/22, stated the resident required assistance with ADLs. On 7/24/23 at 1:47 p.m., Resident #24 stated that 50% of staff were horrible. She stated they said mean things and were rough when changing her. She stated they also hurt her bottom when they cleansed her with a washcloth. On 7/26/23 at 1:31 p.m., the resident stated she was scared of staff when they were rough because she could not get away. 6. The Quarterly MDS assessment tool, dated 5/19/23, listed diagnoses for Resident #65 which included coronary artery disease, stroke, and low back pain. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene and dressing, extensive assistance of 2 staff for bed mobility, transfers, and toilet use, and depended completely on 2 staff for bathing. The MDS documented that the resident scored a 13 out of 15 for the Brief Interview for Mental Status (BIMS), which indicated intact cognitive skills. Care Plan entries, dated 12/12/22 stated the resident needed assistance with ADLs related to weakness and decreased mobility. A 2/12/23 concern/Recommendation stated Resident #65 pulled his call light on the night shift 2/12/23 and did not have his urinal so he wet his bed. When the 2 aides came in to change him, they insisted he roll to be changed and when he said he couldn't because of his arm they got rough with him tossing(rolling) him back and forth, tugging and pulling on his bad arm. The facility lacked any follow-up to this concern form. On 8/1/23 at 8:06 a.m., Staff II Social Services Assistant stated Resident #65 had been here a year and he continuously did not get the help he deserved. She said he would scream when his call light was on and stated there could be multiple staff members at the nursing station and they just sat there and did not answer his light. She stated this was 4-5 months ago. 7. The Admission MDS assessment tool, dated 5/1/23, listed diagnoses for Resident #10, which included end stage renal (kidney) disease, diabetes, and arthritis. The MDS stated the resident required extensive assistance of 1 staff for dressing and personal hygiene and extensive assistance of 2 staff for bed mobility, and transfers. The MDS listed the resident's BIMS score as 15 out of 15, which indicated intact cognition. A 5/1/23 Care Plan entry stated the resident had a self-care performance deficit. On 7/26/23 at 10:44 a.m., Staff U LPN stated she wrote a statement regarding Resident #10 regarding his complaint about Staff HH being rough with him in the Hoyer. She stated she thought she either wrote a statement or called the DON regarding the issue. She stated Staff HH returned to work after the allegation. Staff HH's file contained no disciplinary action or information related to Resident #10's complaint. 8. The Resident Council Meeting minutes for May 2023 stated all residents agreed staff had a bad attitude and were rude, mainly the newer staff. Resident Council Meeting minutes for July 2023 stated residents felt that overnight staff did not check on them frequently enough to ensure their needs were met. Resident council Meeting minutes for June 2023 stated staff are mean and disrespectful. The facility policy Abuse Prevention, Identification, Investigation, and Reporting, revised 4/20/22, defined abuse to include verbal abuse and mental abuse, and mistreatment of a resident and stated resident must not be subjected to abuse by anyone. On 7/25/23 at 9:54 a.m., the Administrator stated she had received no allegations of abuse. On 7/26/23 at 10:13 a.m., Staff L CNA stated staff verbally abuse the residents and talk to them in a rude way. She said half of the staff are rude. She stated when she arrived at the facility at 6:00 a.m. for her shift, residents were soaking wet. She stated there was a resident which they made to go to bed early. On 7/27/23 at 9:14 a.m. the Administrator stated there were residents who had complaints about Resident Council and they had an in-service. She stated it sounded like there was resolution and then the issue occurred again. She stated they eliminated staff including Staff Q, FF, and HH. She stated she didn't handle anything related to staff being rough with Resident #10. On 7/27/23 at 1:01 p.m., the Administrator stated she did not have anything additional related to follow-ups for Resident Council other than the emails she sent on 7/26/23. In email correspondence, sent on 7/27/23 at 4:06 p.m., the DON stated she did not receive any specific staff grievances with the exception of the complaint about Staff FF from Resident #7. On 7/31/23 at 4:52 p.m., the Administrator stated if a resident complained of staff being rough more questions would be asked. On 8/1/23 at 8:03 a.m., the Social Worker stated no one submitted any concerns to her about any staff but stated Staff II handled concerns regarding staff. On 8/10/23 at 8:38 a.m., the Administrator stated staff should treat residents with dignity and respect and should not be utilizing their phones while providing cares. On 8/2/23 at 1:53 p.m., the DON stated she expected to be informed about allegations of abuse. She stated they would suspend the alleged perpetrator, report to the State Agency, and complete an investigation. 47079 9. Observation on 7/24/23 at 4:25 PM, Resident #44 ambulated down the hall with her walker and asked to get some Kleenex. Staff Y, Certified Nurse Aide (CNA) stated OK, I'll get you but did not turn around to face the resident. The resident repeated her request and added it was for her and her roommate. Staff Y said, ok without facing the resident. Another staff member heard the request and walked away. Staff Y was advised to tend to the resident's needs. Staff Y walked into a storage room in close proximity to the resident. Staff Y returned and stated to the resident there was no Kleenex in the storage room. Staff Z, CNA, approached the resident and, while chewing gum with an opened mouth, asked the resident what she wanted. She was then told by the staff member who initially walked away that the delivery truck had not delivered any supplies yet. Staff Z looked at the resident and told the resident the facility didn't have any Kleenex. The resident asked inquisitively, you don't have any Kleenex? Why? Staff Z continued to chew gum in the same manner and replied because the delivery truck hasn't come yet! The resident asked when she could get some Kleenex and Staff Z said in an abrupt tone, in about 3 days! The resident initially responded oh, OK as she turned around to walk away. She furrowed her eyebrows with a bewildered look, turned back toward Staff Z and said, Three days? Why would it take three days to get Kleenex? Staff Z exclaimed, lam not telling you a story! in a defensive tone (similar to someone accused of lying). He turned to his right, pointed in the direction of the resident with his left thumb over his left shoulder, walked away and said aloud someone come tell her I'm not telling her any stories. He did not turn around toward the five staff members, one visitor, or two other residents in the hall. On 7/24/23 at 4:45, the Director of Nursing (DON) stated that Staff Z's behavior toward the resident was not acceptable. On 7/24/23 at 5:15 PM, Resident #44 stated that Staff Z's response made her feel as though he was telling her to fend for herself. She said she felt it was rude and he shouldn't talk to anyone like that. On 7/25/23 at 9:05 AM, the Administrator stated Staff Z's behavior was not acceptable.

Based on clinical record review, policy review, staff interview, and resident interview, the facility staff failed to ensure 5 allegations were reported to the Administrator and the State Agency (SA). Five residents reported allegations of staff being rough with cares (Residents #7, #10, #32, #65, and #276). Staff interviews confirmed that staff were aware of residents verbalizing allegations of roughness during cares with no evidence the allegations were reported to the SA. A serious adverse outcome was likely to occur as the facility failed to report and thoroughly investigate all allegations of abuse. One identified staff member whom residents reported an issue with remained actively working with access to all residents. Additionally, without the thorough investigation, it was unknown if other staff members could be identified. There was an immediate need for the facility to ensure all allegations of abuse were reported to management and the SA per regulatory timeframes so interventions could be taken to protect all residents from the potential for physical abuse. The facility reported a census of 79 residents. On 8/1/23 at 1:00 p.m. the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/2/23 after the facility staff completed the following: a. Disciplinary action was taken with staff member accused of abuse. b. All Federal and State protocols were followed in investigating and reporting the abuse allegation(s). c. Residents with Brief Interview for Mental Status (BIMS) scores of 8 or higher were interviewed/assessed by Social Services Director and/or Nursing Supervisors to identify if they felt safe and if they had experienced abuse while living at the facility. d. All Residents with a BIMS of 7 or lower, the Power of Attorney (POA) was called to identify any concerns. e. Abuse policies were reviewed. f. Reviewed the Iowa Healthcare Association; Nursing facility abuse prevention, identification, investigation, and reporting Policy. g. Education / Review of Iowa Healthcare Association; Compliance with reporting allegations of abuse and neglect. h. Abuse investigation procedure and documentation process were reviewed and revised. i. Director of Nursing (DON) and designees educated all staff on facility abuse policies. j. DON and designees educated all staff on abuse prevention and reporting. k. The DON or designee reviewed facility abuse policies and procedures with any agency staff prior to their shift. l. Staff members were not permitted to work a shift until education completed. m. The Administrator, DON, and Social Services Director received education from a Regional Director of Operations Compliance with reporting to the Administrator and the State Agency (SA) n. The Regional Consultant team member would visit the facility weekly to provide oversight, audits, and additional training as needed. o. The Activities Director held a Resident Council meeting in which the residents were educated on the facility's abuse policies and procedures. p. The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference (upon admission). q. The Administrator or designee would continue to interview residents with BIMS scores of 8 or higher on a monthly basis to ensure they have not experienced abuse. The findings of these interviews would be presented to the Quality Assurance(QA) committee as a Performance Improvement Plan (PIP) project. The scope lowered from L to an F at the time of the survey. Findings include: 1. The MDS (Minimum Data Set) assessment tool, dated 7/21/23, listed diagnoses for Resident #276 which included dislocation of the right hip and restless leg syndrome. The MDS stated the resident required limited assistance of 2 staff for bed mobility, extensive assistance of 1 staff for dressing and personal hygiene, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for transfers and bathing. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 15, which indicated intact cognition. On 7/26/23 at 11:05 p.m., Staff O Certified Nursing Assistant (CNA) stated she worked night shift Mondays-Fridays and was responsible for both the skilled and the 300 hall. She said it was difficult to take care of everyone and stated call lights could remain on for a long time because when she was in one hall a call light may alert in the other hall. She stated she did not know how long the call lights were on because she was in the other hall. She stated she did not have time to get to everyone in a timely manner and stated the residents in the skilled hall were in pain and were needy. On 7/27/23 at 2:25 p.m., Staff P CNA stated she was concerned regarding a complaint from Resident #276 that Staff O was rough with her. Staff P stated she turned in a statement to the DON but the DON stated she needed Staff O to cover staffing needs. On 7/27/23 at 2:33 p.m., the surveyor informed the Administrator about the concerns related to Staff O and she stated she would take care of it immediately. She stated staff were now bringing her concerns about staff to her but prior to her time here it was pushed under the rug. She stated no one brought her any concerns related to Staff O prior to this. In email correspondence on 7/27/23 at 3:20 p.m., the Administrator stated Staff JJ Registered Nurse (RN) interviewed the resident and the resident stated Staff O tapped her on the arm. The email did not mention the resident reported the staff member was rough. In email correspondence on 7/31/23 at 1:32 p.m. , Staff JJ stated she met with the resident on 7/27/23 and the resident stated earlier in the week as she slept a CNA entered her room and tapped her on the shoulder and instructed her to roll over so she could provide cares. The resident stated she felt the staff member was rough and felt like the CNA was angry with a bed attitude which concerned her. In email correspondence on 7/27/23 at 4:20 p.m., the Administrator stated she spoke with Staff O and Staff O stated the resident did not share any concerns with her and she had not been rough. The Administrator stated she informed all staff to be mindful when approaching residents not to startle them with a touch. On 7/31/23 at 10:38 a.m., Resident #276 stated that she had an incident where a staff member came into her room at 5:30 a.m. and slapped her on the back and was rough. She stated she informed one of the CNAs about it a couple of nights later. The resident stated this was uncalled for. In a phone interview on 7/31/23 at 3:30 p.m., Staff P stated she submitted a statement to the Social Worker and the DON regarding Staff O. She stated she submitted the note sometime in July and dated the note. She stated there was no follow-up completed related to her concerns. In email correspondence on 8/1/23, the Administrator stated they would discuss the process for reporting care concerns or roughness and stated the DON conducted staff interviews and no staff reported residents sharing concerns of staff being rough. The facility lacked documentation of resident interviews or further investigation conducted as of 8/1/23 related to allegations of staff roughness. On 8/1/23 at 11:05 a.m., the resident clarified that the staff member did not slap her but tapped' her on the back but was very rough when turning her. On 8/1/23, Staff E Licensed Practical Nurse(LPN) stated Staff O worked the night shift on 7/31/23-8/1/23. Employee Time Card Reports revealed Staff O worked 21 shifts in July of 2023 from 7/2/23-7/29/23. An additional Time Card report revealed Staff O worked 7/31/23. On 8/1/23 at approximately 5:10 p.m., the Administrator stated the facility suspended Staff O. In a phone interview on 8/8/23 at 11:08 a.m., Staff O stated she was never rough with residents and never hit or slapped a resident. She stated she could not remember who Resident #276 was. 2. The Quarterly MDS assessment tool, dated 6/19/23, listed diagnoses for Resident #32 which included Alzheimer's disease, non-Alzheimer's dementia, and depression. The MDS stated the resident required extensive assistance of 2 staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene, and completely depended on 2 staff for bathing. The MDS listed her BIMS score as 5 out of 15, indicating severely impaired cognition. A Care Plan entry, dated 3/3/22, stated the resident required assistance with Activities of Daily Living(ADLs). On 7/25/23 at 9:19 a.m., Resident #32 stated she had trouble with a black guy who was tall and slender(Staff Q CNA). She stated if she did not move as fast as he wanted her to he yanks at her and this made her feel bad. She stated someone came in and talked to her about the situation but she did not know who this was. She stated after this he was not supposed to care for her but he did. She stated there were other staff also who jerk you around. She stated Staff Q wanted her to go to bed at 6:30 p.m. but she wanted to go to bed at 9:30 p.m. She stated she loses every night. On 7/26/23 at 10:21 a.m., Staff E stated residents complained that staff were rude, primarily on the night shift. She stated residents had been manhandled by the night shift. She stated residents asked to stay up late and the night shift told them they had to go to bed now. She stated she heard from Resident #32 that Staff Q was rude and condescending. She stated there were residents that he was not allowed to care for. Staff E stated she questioned why he was working here and stated they needed to get him out of here. She stated she spoke to the DON about it and informed her staff had been rough. On 7/26/23 at 10:33 a.m., Staff D CNA stated 2 weekends ago, there was a complaint related to Staff Q and Resident #32. Staff D stated the resident told her Staff Q was not nice. She stated Staff Q was not supposed to go in her room because they clash. The resident told her that she didn't want to go to bed at 7:00 p.m. and Staff Q stated they were putting everyone to bed. Staff D stated she informed Staff W LPN about the situation. In a phone interview on 7/26/23 at 11:36 a.m., Staff C LPN stated that she recently turned in a statement related to Staff FF CNA. Staff GG CNA informed her that Resident #32 told her Staff FF was rough with her. Staff C stated Staff GG wrote out a statement and put it in the DON's door. She stated she thought the facility fired her. Staff C stated she did not work with Staff Q much but that he was rude to the residents. On 7/26/23 at 12:42 p.m., Staff GG CNA stated Resident #32 thanked her for being here instead of Staff FF and the resident stated Staff FF was rough and rude with her. Staff GG stated she informed Staff C and wrote out a statement and taped it to the DON's door. On 7/26/23 at 10:46 a.m., Staff CC CNA stated there were a few residents down the 200 hall who preferred not to work with Staff Q. She stated Resident #32 reported to her that Staff Q cussed at her and made her go to bed right after dinner. On 7/26/23 at 4:07 p.m., the resident stated when staff were rough with her she felt terrible. On 8/1/23 at 8:06 a.m., Staff II Social Services Assistant stated she was not sure of the time but staff had reported concerns to her about other staff. She stated a CNA came to her one morning and stated that Resident #32 stated one of the overnight staff would not provide her toileting assistance before they assisted her to bed and stated she alerted her call light around midnight and the staff member came in and took her oxygen off and pulled her call light out of the wall. She stated she completed a concern form and gave it to the DON and the Administrator at the time. In a phone interview on 8/1/23 at 4:00 p.m., Staff W LPN stated Resident #32 told her staff entered her room and turned the call light off. She stated she believed she left a note for the DON. An Employee Time Card Report revealed Staff Q worked 13 shifts in July of 2023 with his final shift 7/24/23. A review of Staff Q's employee file revealed no disciplinary actions or concern forms related to resident complaints prior to 7/24/23. On 7/25/23 at 11:02 a.m., the DON stated she heard complaints of staff being rude but received no other reports of staff being rough. She stated Resident #32 never complained about Staff Q and there was never a rule that he couldn't care for her. 3. The Quarterly MDS assessment tool, dated 7/19/23, listed diagnoses for Resident #7 which included anxiety disorder, depression, and muscle weakness. The MDS stated the resident required limited assistance of 1 staff for transfers and extensive assistance of 1 staff for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS listed the resident's cognition as 15 out of 15, which indicated intact cognition. A Care Plan entry, dated 12/2/20, stated the resident had an ADL deficit related to fatigue, chronic pain, and vision deficit. A 7/12/23 Night Shift Meeting Notes stated Resident #7 stated night staff was rude and she asked a CNA not to be so rough when touching her back and she acted like she did not hear her. Resident #7 asked her what her name was and she ignored her. A 7/12/23 Grievance Form stated Resident #7 reported there was a night shift staff who was rude to her and she would not tell her her name. The Grievance Form Official Follow-up stated she had a meeting with the night shift and went over resident interviews that the nurse manager carried out. A 7/12/23 Night Shift Meeting Notes documented the following: a. Resident #7 stated night staff was rude and she asked a CNA not to be so rough when touching my back and she acted like she did not hear her. Resident #7 asked her what her name was and she ignored her. b. Resident #40 stated an overnight worker was rude to him and they talked on the phone with ear buds in and did not engage with him during care. c. Resident #9 stated the overnight shifts are very loud and sat outside the resident rooms and talked on the phone. She stated staff did not answer call lights in a timely manner and when the CNAs come in to respond tot he call lights they say what do you want? like they were inconvenienced by the residents need. d. Resident #36 stated one aide did no want to work with her and stated when she worked with her friends she came in to change her incontinent brief and her conversation was loud and it was a personal conversation. She stated it was so rude. The facility lacked documentation of follow-up actions related to the 7/12/23 meeting concerns. A 7/17/23 Employee Disciplinary Form stated residents down two different hallways named Staff FF in 2 concerns, being rude and rough while providing cares. The form also stated that Staff FF told residents to mind your own business. The form stated the resident would be suspended. A 7/17/23 Grievance Form stated that Resident #7 reported that the aide was in her room again and she said the same thing as before and she was Staff FF. The form stated that the staff member would be terminated. On 7/25/23 at 10:19 a.m., Resident #7 stated that the girls, mostly the overnight staff, were rough when they took care of her. On 7/26/23 at 1:37 p.m., she stated when staff were rough with her she didn't understand why they would do that to elderly people. 4. The Quarterly MDS assessment tool, dated 5/19/23, listed diagnoses for Resident #65 which included coronary artery disease, stroke, and low back pain. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene and dressing, extensive assistance of 2 staff for bed mobility, transfers, and toilet use, and depended completely on 2 staff for bathing. Care Plan entries, dated 12/12/22 stated the resident needed assistance with ADLs related to weakness and decreased mobility. A 2/12/23 concern/Recommendation stated Resident #65 pulled his call light on the night shift 2/12/23 and did not have his urinal so he wet his bed. When the 2 aides came in to change him, they insisted he roll to be changed and when he said he couldn't because of his arm they got rough with him tossing(rolling) him back and forth, tugging and pulling on his bad arm. The facility lacked any follow-up to this concern form. On 8/1/23 at 8:06 a.m., Staff II Social Services Assistant stated Resident #65 had been here a year and he continuously did not get the help he deserved. She said he would scream when his call light was on and stated there could be multiple staff members at the nursing station and they just sat there and did not answer his light. She stated this was 4-5 months ago. 5. The Admission MDS assessment tool, dated 5/1/23, listed diagnoses for Resident #10, which included end stage renal(kidney) disease, diabetes, and arthritis. The MDS stated the resident required extensive assistance of 1 staff for dressing and personal hygiene and extensive assistance of 2 staff for bed mobility, and transfers. The MDS listed the resident's BIMS score as 15 out of 15, which indicated intact cognition. A 5/1/23 Care Plan entry stated the resident had a self-care performance deficit. On 7/26/23 at 10:44 a.m., Staff U LPN stated she wrote a statement regarding Resident #10 regarding his complaint about Staff HH being rough with him in the hoyer. She stated she thought she either wrote a statement or called the DON regarding the issue. She stated Staff HH returned to work after the allegation. Staff HH's file contained no disciplinary action or information related to Resident #10's complaint. 6. The Resident Council Meeting minutes for May 2023 stated all residents agreed staff had a bad attitude and were rude, mainly the newer staff. Resident Council Meeting minutes for July 2023 stated residents felt that overnight staff did not check on them frequently enough to ensure their needs were met. Resident council Meeting minutes for June 2023 stated staff are mean and disrespectful. The facility policy Abuse Prevention, Identification, Investigation, and Reporting, revised 4/20/22, defined abuse to include verbal abuse and mental abuse, and mistreatment of a resident and stated resident must not be subjected to abuse by anyone. The facility policy Abuse Prevention, Identification, Investigation, and Reporting, revised 4/20/22, stated all allegations of abuse would be reported to the State Agency within 24 hours of the alleged incident. On 7/25/23 at 9:54 a.m., the Administrator stated she had received no allegations of abuse. On 7/26/23 at 10:13 a.m., Staff L CNA stated staff verbally abuse the residents and talk to them in a rude way. She said half of the staff are rude. She stated when she arrived at the facility at 6:00 a.m. for her shift, residents were soaking wet. She stated there was a resident which they made to go to bed early. On 7/27/23 at 9:14 a.m. the Administrator stated there were residents who had complaints about Resident Council and they had an in-service. She stated it sounded like there was resolution and then the issue occurred again. She stated they eliminated staff including Staff Q, FF, and HH. She stated she didn't handle anything related to staff being rough with Resident #10. On 7/27/23 at 1:01 p.m., the Administrator stated she did not have anything additional related to follow-ups for Resident Council other than the emails she sent on 7/26/23. In email correspondence, sent on 7/27/23 at 4:06 p.m., the DON stated she did not receive any specific staff grievances with the exception of the complaint about Staff FF from Resident #7. On 7/31/23 at 4:52 p.m., the Administrator stated if a resident complained of staff being rough more questions would be asked. On 8/1/23 at 8:03 a.m., the Social Worker stated no one submitted any concerns to her about any staff but stated Staff II handled concerns regarding staff. On 8/2/23 at 1:53 p.m., the DON stated she expected to be informed about allegations of abuse. She stated they would suspend the alleged perpetrator, report to the State Agency, and complete an investigation. On 8/10/23 at 8:38 a.m., the Administrator stated staff should treat residents with dignity and respect and should not be utilizing their phones while providing cares. She stated the facility should report allegations of abuse to the State Agency within 2 hours.

Based on clinical record review, policy review, staff interview, and resident interview, the facility staff failed to thoroughly investigate all allegations of abuse, and separate an possible abuser from residents. Five residents reported staff were rough during cares(Residents #7, #10, #32, #65, and #276). The facility lacked documentation of thorough investigations. The facility failed to conduct resident and staff interviews to determine the extent of the allegations, if other residents and/or staff involved. A serious adverse outcome was likely to occur as the facility failed to report and thoroughly investigate all allegations of abuse. One identified staff member whom residents reported an issue with remained actively working with access to all residents. Additionally, without the thorough investigation, it was unknown if other staff members could be identified. There was an immediate need for the facility to ensure all allegations of abuse are thoroughly investigated to protect all residents from the potential for physical abuse. On 8/1/23, the Iowa Department of Inspections, Appeals, and Licensing(DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/2/23 after the facility staff completed the following: a. Disciplinary action was taken with staff member accused of abuse. b. All Federal and State protocols were followed in investigating and reporting the abuse allegation(s) c. Residents with BIMS scores of 8 or higher were interviewed/assessed by Social Services Director and/or Nursing. Supervisors to identify if they felt safe and if they had experienced abuse while living at the facility. All Residents with a BIMS of 7 or lower, the Power of Attorney (POA) was called to identify any concerns. Resident nurses notes were updated to reflect interventions, physician and family notification. e. Abuse policies were reviewed. f. Abuse investigation procedure and documentation process were reviewed and revised. The Administrator implemented a new abuse investigation checklist to ensure investigations were initiated and completed thoroughly. g. The DON and Administrator educated all staff on these changes. h. DON and designees educated all staff on facility abuse policies. i. DON and designees educated all staff on abuse prevention and reporting. j. The DON or designee reviewed facility abuse policies and procedures with any agency staff prior to their shift. k. Staff members were not permitted to work a shift until education has been completed. l. The Administrator, DON, and Social Services Director received education from a Regional Director of Operations on timely and thorough abuse investigations, and reporting protocol, and initiation of the abuse investigation checklist. m. The regional/corporate/hired consultant team member will visit the facility weekly to provide oversight, audits, and additional training as needed. n. The Activities Director held a Resident Council meeting in which the residents were educated on the facility's abuse policies and procedures. o. The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference (upon admission). p. The Administrator or designee will continue to interview residents with BIMS scores of 8 or higher on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the Quality Assurance(QA) Committee as a Performance Improvement Project(PIP) project. The scope lowered from L to an F at the time of the survey. Findings: 1. The MDS(Minimum Data Set) assessment tool, dated 7/21/23, listed diagnoses for Resident #276 which included dislocation of the right hip and restless leg syndrome. The MDS stated the resident required limited assistance of 2 staff for bed mobility, extensive assistance of 1 staff for dressing and personal hygiene, extensive assistance of 2 staff for toilet use, and depended completely on 2 staff for transfers and bathing. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 15, indicating intact cognition. On 7/26/23 at 11:05 p.m., Staff O Certified Nursing Assistant(CNA) stated she worked night shift Mondays-Fridays and was responsible for both the skilled and the 300 hall. She said it was difficult to take care of everyone and stated call lights could remain on for a long time because when she was in one hall a call light may alert in the other hall. She stated she did not know how long the call lights were on because she was in the other hall. She stated she did not have time to get to everyone in a timely manner and stated the residents in the skilled hall were in pain and were needy. On 7/27/23 at 2:25 p.m., Staff P CNA stated she was concerned regarding a complaint from Resident #276 that Staff O was rough with her. Staff P stated she turned in a statement to the DON but the DON stated she needed Staff O to cover staffing needs. On 7/27/23 at 2:33 p.m., the surveyor informed the Administrator about the concerns related to Staff O and she stated she would take care of it immediately. She stated staff were now bringing her concerns about staff to her but prior to her time here it was pushed under the rug. She stated no one brought her any concerns related to Staff O prior to this. In email correspondence on 7/27/23 at 3:20 p.m., the Administrator stated Staff JJ Registered Nurse(RN) interviewed the resident and the resident stated Staff O tapped her on the arm. The email did not mention the resident reported the staff member was rough. In email correspondence on 7/31/23 at 1:32 p.m. , Staff JJ stated she met with the resident on 7/27/23 and the resident stated earlier in the week as she slept a CNA entered her room and tapped her on the shoulder and instructed her to roll over so she could provide cares. The resident stated she felt the staff member was rough and felt like the CNA was angry with a bed attitude which concerned her. In email correspondence on 7/27/23 at 4:20 p.m., the Administrator stated she spoke with Staff O and Staff O stated the resident did not share any concerns with her and she had not been rough. The Administrator stated she informed all staff to be mindful when approaching residents not to startle them with a touch. On 7/31/23 at 10:38 a.m., Resident #276 stated that she had an incident where a staff member came into her room at 5:30 a.m. and slapped her on the back and was rough. She stated she informed one of the CNAs about it a couple of nights later. The resident stated this was uncalled for. In a phone interview on 7/31/23 at 3:30 p.m., Staff P stated she submitted a statement to the Social Worker and the DON regarding Staff O. She stated she submitted the note sometime in July and dated the note. She stated there was no follow-up completed related to her concerns. In email correspondence on 8/1/23, the Administrator stated they would discuss the process for reporting care concerns or roughness and stated the DON conducted staff interviews and no staff reported residents sharing concerns of staff being rough. The facility lacked documentation of resident interviews or further investigation conducted as of 8/1/23 related to allegations of staff roughness. On 8/1/23 at 11:05 a.m., the resident clarified that the staff member did not slap her but tapped' her on the back but was very rough when turning her. On 8/1/23, Staff E Licensed Practical Nurse(LPN) stated Staff O worked the night shift on 7/31/23-8/1/23. Employee Time Card Reports revealed Staff O worked 21 shifts in July of 2023 from 7/2/23-7/29/23. An additional Time Card report revealed Staff O worked 7/31/23. On 8/1/23 at approximately 5:10 p.m., the Administrator stated the facility suspended Staff O. In a phone interview on 8/8/23 at 11:08 a.m., Staff O stated she was never rough with residents and never hit or slapped a resident. She stated she could not remember who Resident #276 was. 2. The MDS assessment tool, dated 6/19/23, listed diagnoses for Resident #32 which included Alzheimer's disease, non-Alzheimer's dementia, and depression. The MDS stated the resident required extensive assistance of 2 staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene, and completely depended on 2 staff for bathing. The MDS listed her BIMS score as 5 out of 15, indicating severely impaired cognition. A Care Plan entry, dated 3/3/22, stated the resident required assistance with Activities of Daily Living(ADLs). On 7/25/23 at 9:19 a.m., Resident #32 stated she had trouble with a black guy who was tall and slender(Staff Q CNA). She stated if she did not move as fast as he wanted her to he yanks at her and this made her feel bad. She stated someone came in and talked to her about the situation but she did not know who this was. She stated after this he was not supposed to care for her but he did. She stated there were other staff also who jerk you around. She stated Staff Q wanted her to go to bed at 6:30 p.m. but she wanted to go to bed at 9:30 p.m. She stated she loses every night. On 7/26/23 at 10:21 a.m., Staff E stated residents complained that staff were rude, primarily on the night shift. She stated residents had been manhandled by the night shift. She stated residents asked to stay up late and the night shift told them they had to go to bed now. She stated she heard from Resident #32 that Staff Q was rude and condescending. She stated there were residents that he was not allowed to care for. Staff E stated she questioned why he was working here and stated they needed to get him out of here. She stated she spoke to the DON about it and informed her staff had been rough. On 7/26/23 at 10:33 a.m., Staff D CNA stated 2 weekends ago, there was a complaint related to Staff Q and Resident #32. Staff D stated the resident told her Staff Q was not nice. She stated Staff Q was not supposed to go in her room because they clash. The resident told her that she didn't want to go to bed at 7:00 p.m. and Staff Q stated they were putting everyone to bed. Staff D stated she informed Staff W LPN about the situation. In a phone interview on 7/26/23 at 11:36 a.m., Staff C LPN stated that she recently turned in a statement related to Staff FF CNA. Staff GG CNA informed her that Resident #32 told her Staff FF was rough with her. Staff C stated Staff GG wrote out a statement and put it in the DON's door. She stated she thought the facility fired her. Staff C stated she did not work with Staff Q much but that he was rude to the residents. On 7/26/23 at 12:42 p.m., Staff GG CNA stated Resident #32 thanked her for being here instead of Staff FF and the resident stated Staff FF was rough and rude with her. Staff GG stated she informed Staff C and wrote out a statement and taped it to the DON's door. On 7/26/23 at 10:46 a.m., Staff CC CNA stated there were a few residents down the 200 hall who preferred not to work with Staff Q. She stated Resident #32 reported to her that Staff Q cussed at her and made her go to bed right after dinner. On 7/26/23 at 4:07 p.m., the resident stated when staff were rough with her she felt terrible. On 8/1/23 at 8:06 a.m., Staff II Social Services Assistant stated she was not sure of the time but staff had reported concerns to her about other staff. She stated a CNA came to her one morning and stated that Resident #32 stated one of the overnight staff would not provide her toileting assistance before they assisted her to bed and stated she alerted her call light around midnight and the staff member came in and took her oxygen off and pulled her call light out of the wall. She stated she completed a concern form and gave it to the DON and the Administrator at the time. In a phone interview on 8/1/23 at 4:00 p.m., Staff W LPN stated Resident #32 told her staff entered her room and turned the call light off. She stated she believed she left a note for the DON. An Employee Time Card Report revealed Staff Q worked 13 shifts in July of 2023 with his final shift 7/24/23. A review of Staff Q's employee file revealed no disciplinary actions or concern forms related to resident complaints prior to 7/24/23. On 7/25/23 at 11:02 a.m., the DON stated she heard complaints of staff being rude but received no other reports of staff being rough. She stated Resident #32 never complained about Staff Q and there was never a rule that he couldn't care for her. 3. The MDS assessment tool, dated 7/19/23, listed diagnoses for Resident #7 which included anxiety disorder, depression, and muscle weakness. The MDS stated the resident required limited assistance of 1 staff for transfers and extensive assistance of 1 staff for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS listed the resident's cognition as 15 out of 15, indicating intact cognition. A Care Plan entry, dated 12/2/20, stated the resident had an ADL deficit related to fatigue, chronic pain, and vision deficit. A 7/12/23 Night Shift Meeting Notes stated Resident #7 stated night staff was rude and she asked a CNA not to be so rough when touching her back and she acted like she did not hear her. Resident #7 asked her what her name was and she ignored her. A 7/12/23 Grievance Form stated Resident #7 reported there was a night shift staff who was rude to her and she would not tell her her name. The Grievance Form Official Follow-up stated she had a meeting with the night shift and went over resident interviews that the nurse manager carried out. A 7/12/23 Night Shift Meeting Notes documented the following: a. Resident #7 stated night staff was rude and she asked a CNA not to be so rough when touching my back and she acted like she did not hear her. Resident #7 asked her what her name was and she ignored her. b. Resident #40 stated an overnight worker was rude to him and they talked on the phone with ear buds in and did not engage with him during care. c. Resident #9 stated the overnight shifts are very loud and sat outside the resident rooms and talked on the phone. She stated staff did not answer call lights in a timely manner and when the CNAs come in to respond tot he call lights they say what do you want? like they were inconvenienced by the residents need. d. Resident #36 stated one aide did no want to work with her and stated when she worked with her friends she came in to change her incontinent brief and her conversation was loud and it was a personal conversation. She stated it was so rude. The facility lacked documentation of follow-up actions related to the 7/12/23 meeting concerns. A 7/17/23 Employee Disciplinary Form stated residents down two different hallways named Staff FF in 2 concerns, being rude and rough while providing cares. The form also stated that Staff FF told residents to mind your own business. The form stated the resident would be suspended. A 7/17/23 Grievance Form stated that Resident #7 reported that the aide was in her room again and she said the same thing as before and she was Staff FF. The form stated that the staff member would be terminated. On 7/25/23 at 10:19 a.m., Resident #7 stated that the girls, mostly the overnight staff, were rough when they took care of her. On 7/26/23 at 1:37 p.m., she stated when staff were rough with her she didn't understand why they would do that to elderly people. 4. The MDS assessment tool, dated 5/19/23, listed diagnoses for Resident #65 which included coronary artery disease, stroke, and low back pain. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene and dressing, extensive assistance of 2 staff for bed mobility, transfers, and toilet use, and depended completely on 2 staff for bathing. Care Plan entries, dated 12/12/22 stated the resident needed assistance with ADLs related to weakness and decreased mobility. A 2/12/23 concern/Recommendation stated Resident #65 pulled his call light on the night shift 2/12/23 and did not have his urinal so he wet his bed. When the 2 aides came in to change him, they insisted he roll to be changed and when he said he couldn't because of his arm they got rough with him tossing(rolling) him back and forth, tugging and pulling on his bad arm. The facility lacked any follow-up to this concern form. On 8/1/23 at 8:06 a.m., Staff II Social Services Assistant stated Resident #65 had been here a year and he continuously did not get the help he deserved. She said he would scream when his call light was on and stated there could be multiple staff members at the nursing station and they just sat there and did not answer his light. She stated this was 4-5 months ago. 5. The MDS assessment tool, dated 5/1/23, listed diagnoses for Resident #10, which included end stage renal(kidney) disease, diabetes, and arthritis. The MDS stated the resident required extensive assistance of 1 staff for dressing and personal hygiene and extensive assistance of 2 staff for bed mobility, and transfers. The MDS listed the resident's BIMS score as 15 out of 15, which indicated intact cognition. A 5/1/23 Care Plan entry stated the resident had a self-care performance deficit. On 7/26/23 at 10:44 a.m., Staff U LPN stated she wrote a statement regarding Resident #10 regarding his complaint about Staff HH being rough with him in the hoyer. She stated she thought she either wrote a statement or called the DON regarding the issue. She stated Staff HH returned to work after the allegation. Staff HH's file contained no disciplinary action or information related to Resident #10's complaint. 6. The Resident Council Meeting minutes for May 2023 stated all residents agreed staff had a bad attitude and were rude, mainly the newer staff. Resident Council Meeting minutes for July 2023 stated residents felt that overnight staff did not check on them frequently enough to ensure their needs were met. Resident council Meeting minutes for June 2023 stated staff are mean and disrespectful. The facility policy Abuse Prevention, Identification, Investigation, and Reporting, revised 4/20/22, defined abuse to include verbal abuse and mental abuse, and mistreatment of a resident and stated resident must not be subjected to abuse by anyone. The facility policy Abuse Prevention, Identification, Investigation, and Reporting, revised 4/20/22, stated all allegations of abuse would be reported to the State Agency within 24 hours of the alleged incident. The facility policy Abuse Prevention, Identification, Investigation, and Reporting, revised 4/20/22, stated the facility would carry out an investigation of alleged allegations of abuse and complete documentation and collect supporting documents related to the alleged incident. The investigation should include resident assessments, notifications to the provider, and witness statements. The policy stated during the investigation, the facility would immediately implement measures to prevent further potential abuse by separating the employee accused of abuse from all residents. On 7/25/23 at 9:54 a.m., the Administrator stated she had received no allegations of abuse. On 7/26/23 at 10:13 a.m., Staff L CNA stated staff verbally abuse the residents and talk to them in a rude way. She said half of the staff are rude. She stated when she arrived at the facility at 6:00 a.m. for her shift, residents were soaking wet. She stated there was a resident which they made to go to bed early. On 7/27/23 at 9:14 a.m. the Administrator stated there were residents who had complaints about Resident Council and they had an in-service. She stated it sounded like there was resolution and then the issue occurred again. She stated they eliminated staff including Staff Q, FF, and HH. She stated she didn't handle anything related to staff being rough with Resident #10. On 7/27/23 at 1:01 p.m., the Administrator stated she did not have anything additional related to follow-ups for Resident Council other than the emails she sent on 7/26/23. In email correspondence, sent on 7/27/23 at 4:06 p.m., the DON stated she did not receive any specific staff grievances with the exception of the complaint about Staff FF from Resident #7. On 7/31/23 at 4:52 p.m., the Administrator stated if there were allegations of roughness, she expected staff interviews and resident interviews to be conducted and they would carry out a physical assessment. She stated they would ask more questions if there was an allegation of roughness. On 8/1/23 at 8:03 a.m., the Social Worker stated no one submitted any concerns to her about any staff but stated Staff II handled concerns regarding staff. On 8/2/23 at 1:53 p.m., the DON stated she expected to be informed about allegations of abuse. She stated they would suspend the alleged perpetrator, report to the State Agency, and complete an investigation. On 8/10/23 at 8:38 a.m., the Administrator stated staff should treat residents with dignity and respect and should not be utilizing their phones while providing cares. She stated the facility should report allegations of abuse to the State Agency within 2 hours and the facility would suspend the alleged perpetrator.

Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for a change in condition for 3 of 4 residents reviewed (Resident #77, #56, & #32). The facility failed to identify Resident #77 had developed sores and scratches on her arms. A family member discovered them and alerted staff. The resident then saw the Advanced Registered Nurse Practitioner (ARNP) and received orders for a steroid, an antibiotic, and to notify her if no improvement by the next week. The facility failed to assess/reassess the wounds to determine if they improved. The resident developed additional signs of a problem, and was hospitalized in the intensive care unit. The facility reported a census of 79 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #77 scored 7 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required supervision with transfer and ambulation. The resident's diagnoses included Alzheimer's disease. The Care Plan revised 7/12/22 identified the resident had (potential for) impaired skin integrity and was at risk for edema, skin/tissue color changes, sensitivity towards heat/cold, swelling and pain. The interventions included: a. Avoiding scratching and keeping hands and body parts from excessive moisture, b. Keeping fingernails short, c. Encouraging good nutrition and hydration in order to promote healthier skin, d. Keeping skin clean and dry, e. Using lotion on dry skin, f. Monitoring/documenting location, size and treatment of skin injury, g. Reporting abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to MD, h. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, any exudate and any other notable changes or observations. A General Chemistry report dated 1/6/23 documented the resident had results of potassium 4 (reference range 3.5-5), anion gap 8 (reference range 4-14), BUN 15 (reference range 5-23), and Creatinine 1.8 (reference range 0.4-1.10). Emails from the resident's family member and power of attorney (POA) included: 1. On 2/6/23 at 9:42 a.m. an email from the resident's family member to the previous Administrator documented she had a very big concern about the resident. When she visited the resident the previous afternoon they were shocked at the sight of her arms. The resident had multiple open sores and she picked at them. She was so stunned by this and couldn't believe no one had called her about it. The family member questioned why they did not notify her, the resident had to be uncomfortable. 2. On 2/6/23 at 2:14 p.m. an email response documented the Administrator could understand the family member's frustration and concern. The Director of Nursing (DON) and Assistant (A)DON were included on the email. The email asked if they could speak to her concerns, and if they had something documented on it. The previous ADON responded she wanted to say she was sorry the resident's arms were so scratched up. The ADON went and looked at her and she did have some much smaller areas on her shins but not on her stomach, back or head. The resident told the ADON she didn't itch and they were nothing. Obviously, there were quite a few. The ADON could suggest having some Eucerin lotion applied to help keep her skin hydrated and prevent her from itching. She could also have a doctor visit set up with her to look at the area and see if there were any further interventions to help heal the area up. 3. On 2/6/23 at 2:50 p.m. the family member responded she wanted the resident to have a doctor come and see her as soon as possible. They would like to know once that had been scheduled. The family member wrote if they knew the resident, she would never tell them if something bothered her. She would always say she's fine, The resident had Alzheimer's so she didn't remember things. When the family member visited with the resident she scratched and picked at her arms. The family member stated this did not happen overnight and she still had not received an answer why she was not notified or if there were any documentation on her sores in her daily records. 4. On 2/26/23 at 5:51 p.m. the new Director of Nursing DON replied she would be talking to the staff and doing some 1:1 education. She would have staff meetings the next week and bring the issue up. They would be doing some education. She did not have an answer to why staff never called, all she could do moving forward was hold staff accountable and let them know this was an expectation. 5. On 2/7/23 at 9:19 a.m. the family member responded she appreciated the response. She was glad to hear they would do 1:1 training so something like that did not happen again and just get ignored. The Progress Notes dated 2/6/23 at 2:14 p.m. documented the tenant had large areas of multiple scabs to her bilateral upper extremities. The resident denied itching or irritation. The areas were small and non bleeding, and family had concerns. Questioned an order for Eucerin cream, and having the resident placed on the provider visit list for it. The Progress Notes dated 2/7/23 dated 9:24 p.m. documented the receipt of an order for Eucerin Cream 2 times a day to the bilateral upper extremities until healed, then as needed for dryness, and would see at the next visit. The resident's POA notified. An Encounter note dated 2/9/23 documented the physical exam included the resident had widespread abrasions and scratches on the bilateral upper extremities and upper chest wall. Some with surrounding erythema. Dermatitis added to the list of diagnoses. New orders included Prednisone (steroid, anti-inflammatory) and Keflex (antibiotic), monitor rash and notify if no improvement by the next week. The Progress Notes dated 2/10/23 at 3:08 a.m. documented the Encounter form received with new orders. Point Click Care (PCC, facility electronic health record) updated, faxed to pharmacy, and POA aware. At 2/10/2023 at 12:49 p.m. the resident's family member updated on new orders for prednisone and Keflex. The clinical record lacked any additional documentation regarding the areas to her upper extremities and upper chest wall. The Progress Notes dated 2/14/20 at 7:20 p.m. documented a certified nursing assistant (CNA) was ambulating the resident to the dining area, then suddenly the resident began jerking, and staff lowered her down on the floor. The nurse thoroughly assessed the resident and no concern for symptoms/indication noted at the time. The resident alert and oriented x 3 (person, place, time) and stated she was fine, she did not feel sick at all, and said she jerked sometimes. Staff helped her get up. VS: Temperature (T) 97.4, Pulse (P) 87, Respirations (R) 18, Blood Pressure (BP) 134/68, Pulse Oximetry (PO) 97% on room air (RA). The resident ate and socialized with peers/staff without any difficulty. The clinical record lacked an incident report, follow up of the incident, or documentation of physician/family notification of the incident or the the jerking. The Progress Notes dated 2/15/23 at 4:09 p.m. documented the resident had emesis at 4 p.m. A general assessment done. The resident alert and oriented x 2-3. She stated not sick at that time, cream for itching had been given. The Progress Notes dated at 2/15/23 at 9:21 p.m. documented the resident has symptom of jerking and unable to walk. She had a brownish vomiting in the evening, and a general assessment done. T 97.8, P 79, R 18, BP 129/79, PO 96% RA. Lung sounds clear all lobes, no cough/shortness of breath (SOB)/respiratory distress noted at the time, please advise. The Progress Notes dated 2/16/23 at 3:05 a.m. documented staff alerted the nurse to the resident's room. The resident noted in bed twitching, would open her eyes when the nurse called her name but quickly shut her eyes. She could not answer the nurses' questions. She had a small brown emesis in her hair and on the bed sheets. Last bowel movement 2 days ago. Vitals obtained T 98.8, P 77, R 18, BP 142/88, PO 96% on RA. Call placed to the doctor on call and received orders to send to the emergency room (ER) for evaluation. Call placed to the family member to inform her of the situation, and to go to the ER. The ambulance arrived and the resident left the building at 3:03 a.m. A hospital History and Physical dated 2/16/23 at 9:18 a.m. documented the resident came to the ER for altered mental status (AMS), difficulty walking, and twitching. She had recently finished an antibiotic and steroid for rash. She was not making any urine and had jerky movements. She answered when aggressively stimulated and called her name, but would not answer any questions. The principal problem acute renal failure. An intensive care unit (ICU) progress note dated 2/16/23 at 6 p.m. documented the acute problems included acute kidney failure, anuria (failure of the kidneys to produce urine), urine in the blood, severe AGMA (anion gap metabolic acidosis, can be caused by kidney disease). Patient with BUN 224, and Creatinine 27. No history of renal disease. Blood gas shows metabolic acidosis, anion gap 36. Lasix given without response. Consult to nephrology for HD (hemodialysis), HD cath placed, 1 liter fluid bolus given, with little change to creatinine, hyperkalemia (high potassium (K)). The resident presented with K of 7.8 The resident received medical therapies and K down to mid 6's today, planned for dialysis On 07/27/23 at 10 a.m. Staff B Licensed Practical Nurse (LPN) stated he looked at his charting and thinks they actually lowered her to a chair (on 2/14/23) . He did not witness the incident himself. He did not notify the physician or family because the resident said she did that. He said then he did send a fax to the provider the next day (2/15/23 late evening). On 7/27/23 at 10:10 a.m. Staff D CNA stated the day they eased the resident to the floor, she had jerking movements and she would have fallen if not assisted. She said it could have been to the chair. She said if it was to the chair she reported it because it was not normal for her. On 7/26/23 at 11:47 a.m. Staff C LPN stated she had been told at report that the resident had not been feeling well and not acting right. A night CNA said the resident was shaking and not responding. Staff C called the physician right away and had her transferred to the hospital. She called the hospital later and they told her she was in kidney failure, and the wounds she had were the toxins the kidneys could not excrete coming out through the skin. On 7/27/23 at 7:55 a.m. the resident's family member stated the facility had moved the resident about two weeks before (she noticed the areas on her arms), into another room because she was incontinent. She didn't really understand that but she went along with it. The resident had Alzheimer's and would not say if something bothered her. The family member went to visit the resident in the new room and she sat in a chair and she wore a T-shirt, which was unusual for her. She usually wore long sleeves. She noticed the resident had redness and scratches on her arms. The family member stated surprise to see that. She had not been notified about these areas. She sent an email to the administrator asking about these areas, why she had not been informed about them, and what caused them. She heard back from them and they said they would get the resident an appointment with the provider the next visit. The family member said absolutely, that's what she wanted. The night the resident went to the hospital they called her about 2 to 2:30 a.m. They sent her to the hospital because she was not able to walk. Nobody called her and told her she was having difficulty walking. She said they went to the hospital and were told the sores the resident had were caused from kidney failure, and she would need to have dialysis or she wouldn't make it. The family member noted sores on her face that were not there when she last saw her. On 7/31/23 at 1:10 p.m. Staff A Certified Medication Aide (CMA) stated she worked the day shift and evening shift before the resident went to the hospital. She said the resident kept puking and she had hadn't eaten. She said the resident had been going downhill. Before she moved from one hall to the other she was independent, and after she moved, she declined. On 7/31/23 at 1:17 p.m. Staff CC CNA stated she recalled the resident scratching and having areas on her arms but she didn't really recall anything else. On 7/31/23 at 2:19 p.m. Staff DD CNA stated she didn't realize the resident had anything wrong with her because half the time they didn't get report from the previous shift. The night the resident went to the hospital she breathed heavy and not alert, not her old self. They knew something was not right. On 7/31/23 at 2:39 p.m. Staff EE CNA stated the night the resident went to the hospital she had been sleeping earlier in the shift and then when she went to check on her, she had a coffee ground emesis. Staff EE said she didn't think she had gotten report on the resident that night so she didn't know there were any issues prior to that. On 8/1/23 at 3:30 p.m. Staff S Advanced Registered Nurse Practitioner (ARNP) stated she did not she did not remember the resident. She said that based on the information, if they had called earlier about her symptoms of the jerking and difficulty walking she would have ordered lab including a basic metabolic panel (BMP)(includes kidney function tests and potassium), complete blood count (CBC) and a urine analysis (UA). So they may have identified issues prior to her hospitalization . She could not say if it would have changed anything including the outcome. The resident was such an acute case. 35434 2. The MDS assessment tool, dated 5/31/23, listed diagnosis for Resident #56 which included stroke, diabetes, and muscle weakness. The MDS stated the resident required extensive assistance of 1 staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. The MDS stated the activity of bathing did not occur during he 7-day look back period. The MDS listed the resident's BIMS score as 13 out of 15, indicating intact cognition. On 8/8/23 at 8:58 a.m., Resident #56 stated that on Saturday 8/5/23 Staff R (Certified Nursing Assistant)CNA assisted her and noticed that her toenail had been ripped off. She stated Staff R then informed Staff B Licensed Practical Nurse (LPN) around noon but stated Staff B did not address the toe. She stated Staff R informed Staff E about it also but she could not assist because she was working down another hallway. She stated it was not until her daughter arrived and asked Staff B about it did he do anything. She stated Staff B then acted like he did not know anything about it prior to then. On 8/9/23 at 1:21 p.m., Staff E LPN stated on 8/5/23, Staff R CNA informed her that Resident #56's toenail had come off. Staff E stated this was around noon and she told Staff R to let Resident #56's nurse know. During an interview on 8/9/23 at 12:30 p.m., Staff R CNA stated that when he was helping Resident #56 last weekend he noticed that her sock had blood on it and when he took the sock off the toenail was bent back. He stated he notified the nurse Staff B LPN about it around noon. He stated he also informed Staff E but she was working down another hallway. The resident's Progress notes lacked documentation of an assessment of the resident's toe on 8/5/23. The resident's clinical record lacked an assessment of the toe. 3. The MDS assessment tool, dated 6/19/23, listed diagnoses for Resident #32 which included Alzheimer's disease, non-Alzheimer's dementia, and depression. The MDS stated the resident required extensive assistance of 2 staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene and completely depended on 2 staff for bathing. The MDS listed her BIMS score as 5 out of 15, indicating severely impaired cognition. On 7/26/23 at 8:39 a.m., Staff L and Staff M Certified Nursing Assistants(CNAs) entered the residents room and the resident stated she had diarrhea. When Staff L and Staff M opened the resident's incontinent brief the staff commented that the resident did have diarrhea. The resident had loose stool on her front and back perineal areas. The staff members cleansed her and put on a new brief. On 8/10/23 at approximately 8:30 a.m., the resident stated that she still had diarrhea and that staff had not done anything about it. Progress Notes from 7/26/23-8/10/23 lacked documentation of follow-up regarding the resident's diarrhea. On 8/10/23 at 8:38 a.m. the Administrator stated that if a resident had a toe injury, the nurse should carry out an assessment. On 8/10/23 at 10:22 a.m., the Director of Nursing(DON) stated if a resident had diarrhea, the nurse should carry out an assessment. The facility policy Notification of Changes, revised 1/2023, directed staff to notify the provider when there was a change requiring notification.

Based on observation, clinical record review, policy review,and staff interview, the facility failed to implement and carry out interventions to prevent avoidable pressure ulcers for 2 of 3 residents reviewed for pressure ulcers (Residents #26 and #230). This resulted in harm to these two residents who developed pressure ulcers. The facility reported a census of 79 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The 1/23/23 5-day Admission Minimum Data Set(MDS) listed diagnoses for Resident #26 which included kidney disease, non-Alzheimer's dementia, and difficulty walking. The MDS stated the resident required limited assistance of 1 staff for transfers, walking, and personal hygiene, and extensive assistance of 1 staff for bed mobility, dressing, and toilet use. The MDS stated the resident did not have a pressure ulcer and stated the resident was at risk for developing pressure ulcers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 10 out of 15, which indicated moderately impaired cognition. The facility policy Pressure Injury Prevention Guidelines, revised 1/2023, stated the purpose of the policy was to prevent the formation of avoidable pressure injuries and to promote the healing of existing pressure injuries. The policy stated the facility would utilize prevention devices such as heel flotation devices and carry out documentation of compliance with interventions. The [Company name redacted] Admission Assessment/Readmission Bundle Section G Baseline Care Plan, dated 1/18/23, stated the resident's skin was intact. The Baseline Care Plan lacked documentation of interventions to prevent the development of a pressure ulcer. A 1/22/23 [Company redacted] Braden Scale for Predicting Pressure Sore Risk, dated 1/22/23, stated the resident was at risk for developing pressure ulcers. [Company name redacted]-Pressure Wound-Weekly Assessment Tool(s) revealed the following: a. 2/14/23 The resident had a Suspected Deep tissue Injury(SDTI-a localized are of discolored intact skin or blood-filled blister due to the damage of underlying soft tissue from pressure an/or shear)pressure ulcer to the left heel, acquired 2/14/23. The document included the measurement as follows; length 20 millimeters (mm), width 18 mm, depth 1 mm b. 2/14/23 The resident had a Stage 2 (partial thickness loss of skin) pressure ulcer to the right heel, acquired 2/14/23. The document included the measurement as follows; length 4 mm, width 4 mm, depth 1 mm. Wound Treatment Plans, documented by the wound doctor, revealed the following: a. A 2/28/23 note stated the resident reported her left heel was slightly tender and had boots to her bilateral feet. The note stated the resident had a State 2 pressure ulcer to the right heel 0.3 centimeters(cm) x 0.3 cm x 0.1 cm(length x width x depth) and an unstageable pressure ulcer of the left heel 2.0 x 1.5 x 0.1 cm. b. A 3/7/23 note stated the resident wore Prevalon boots to the bilateral feet during this visit. The note stated the resident's right heel wound measured 0.3 x 0.2 x 0.1 and the left heel wound measured 1.6 x 1.5 x 0.1 cm. c. A 3/21/23 note stated the resident's right heel ulcer was 0.3 cm x 0.3 cm x 0.1 cm and her left heel ulcer was 0.5 cm x 0.1 cm x 0.1 cm. d. A 3/28/23 note stated the resident's right heel ulcer was 0 x 0 x 0 resurfaced(healed) and her left heel ulcer was 0.5 x 0.1 x 0.1 cm. The Prevalon boots were not on today but she allowed application of the boots at conclusion of visit. e. A 7/18/23 note stated the resident had a left heel Stage 3 pressure ulcer 0.2 x 0.5 cm x 0.1 cm. mechanical debridement 4/12/23 Care Plan entries stated the resident had a Stage 3 pressure ulcer to the left heel related to decreased mobility, and directed staff to administer L-Arginine oral tablet(helps promote wound healing) twice daily, monitor nutritional status, and place Prevalon boots to bilateral feet as tolerated at bedtime, and teach the importance of changing positions for the preventions of pressure ulcers. The entries stated the resident should not wear shoes until the pressure ulcer was healed but could wear slippers. The Care Plan lacked any prior interventions related to the prevention of the heel pressure ulcers. On 7/25/23 at 1:01 p.m., the resident stated she had a sore on her left foot. The resident wore a boot on her left foot but did not wear a boot on the right foot. On 7/25/23 at 2:56 p.m. and 4:02 p.m., the resident laid in bed with a boot on her left foot but no boot on her right foot. On 7/26/23 at 9:05 a.m. the resident laid in bed and wore a boot on her left leg. She did not have a boot on her right foot and wore only a gripper sock. The resident's right heel was in direct contact with the mattress. Staff E Licensed Practical Nurse(LPN) measured a dark red area on the inside portion of the resident's left heel as 2 cm x 2 cms (length x width) and a smaller red area inside of the dark red area as 0.5 cm x 0.3 cm. Staff E then cleansed the area with betadine and wrapped it with gauze. During the dressing change, the resident stated that her right foot now hurt. Staff E felt the area and stated her right heel was boggy and she would get a pillow to float her heel. On 7/26/23 at 10:21 a.m., Staff E LPN stated Resident #26's heel ulcers developed here at the facility and the implementation of the boots occurred after the wounds developed. She stated there were times when the resident would not wear the boots but that had improved. She stated until today, she just wore the boot on the right foot. On 8/2/23 at 1:53 p.m., the Director of Nursing(DON) stated if a resident was at risk for the development of pressure ulcers, they would implement an intervention and stated they would implement boots to prevent heel ulcers. 46873 2. The Admission MDS of Resident #230 dated 7/16/23 identified an admitted [DATE]. The MDS identified Resident #230 had a BIMS score of 13 which indicated cognition intact. The MDS recorded the resident had no pressure ulcers present. The Admission assessment dated [DATE] documented the resident's skin as follows; skin warm and dry and skin color is within normal limits. Skin turgor is normal. Mucous membranes are moist. There are no open areas. The Baseline Care Plan dated 7/13/23 documented the resident's skin as being intact. The Comprehensive Care Plan of Resident #230 documented a focus area dated 7/24/23 as follows; the resident has the potential for pressure ulcer development related to decrease in mobility, poor nutrition and urinary incontinence. The Care Plan directed staff to follow facility policies and protocols for the prevention and treatment of skin breakdown. The History and Physical from the hospital, dated 6/22/23 documented under the physical exam several excoriations (scraped or abraded) noted on upper and lower extremities, also the presence of a Stage 1 pressure ulcer to the sacrum (the base of the spine). Wound care had been seeing the resident. The Encounter Note from authored by Staff S, Nurse Practitioner, dated 7/13/23 documented the resident had right hip and sacral wounds and would be referred to the wound care physician. The Wound Treatment Plan note dated 7/25/23 by the wound physician documented the resident had a Stage 3 pressure ulcer to the right greater trochanter (hip) measuring 0.7 cm x 0.5 cm x 0.1 cm. The wound status was documented a new. The note also documented the physician found the resident wearing a foam dressing from the right hip during her visit which she removed to assess and clean the wound. The Treatment Administration Record of Resident #230 for July of 2023 documented treatment orders for the pressure wound were initiated on 7/25/23. No prior treatment was noted. The Pressure Ulcer Weekly Assessment Tool dated 7/25/23 documented the initial assessment of the wound was 7/25/23, and was documented as a stage three pressure ulcer. On 7/27/23 at 11:53 am Staff B, LPN stated he completed the admission assessment for Resident #230 on 7/11/23 and the resident's skin was intact upon his assessment. The facility policy Pressure Injury Prevention Guidelines, revision date 1/2023 documents: In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders Compliance with interventions will be documented in the medical record. - For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting.

Based on record review, staff interview and facility policy review, the facility failed to properly screen all contracted agency staff employees to ensure eligibility to work to prevent abuse. A concern was identified when (Resident #1) expressed concern regarding an agency staff during the night shift. There were 4 agency staff (Staff L, N, O, P) who did not have complete background checks. The facility identified a census of 78 residents. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 6/26/18 indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) (cognitive test) score of 12 out of 15 (15 is highest cognitive function), required extensive assistance of staff with bed mobility, transfers and toilet use, as non-ambulatory and occasionally incontinent of bowels and bladder. A Care Plan had focus areas the included self-care deficit related to [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. limitations and CKD. The interventions/tasks included the following: -Assistance of one staff member for transfers. -The resident required extensive assistance of 1 staff for toileting. -Toilet schedule as prompted. -The resident used large disposable pull ups. Change as needed (PRN) A Skilled Level of Care Progress Note form dated 7/4/18 at 5:30 a.m. indicated the resident as alert and oriented x 3 (person, place and time). During an interview on 7/5/18 at 2:46 p.m., with Resident #1, the resident stated the night in question she put on the call light and a tall black man answered the light and said he had another resident on a bedpan and would return but never came back. The resident then put her call light on again and he returned. The man mouthed off and left the room and never returned. The resident indicated the staff member had been rude and she felt scared so she laid in urine all night which left her cold and stinking. In the morning a little old man (Staff M, Registered Nurse (RN) came in and helped her get cleaned up. During another interview on 7/24/18 at 1:34 p.m., Resident #1 remained consistent in her recollection of events. She stated the night of the incident a male staff member came into the room, turned off the call light and left the room. The resident then put the call light right back on and he returned. He told her he had someone on the stool with a tone that made the resident scared. The resident stated no one else was working so she never called for assistance again because he scared her so she laid in urine all night which felt dirty. During an interview 7/24/18 at 3:13 p.m., Staff L Certified Nursing Assistant (CNA) indicated he did not do anything wrong. The staff member stated he answered the resident's call light and assisted her onto the bedpan 4 different times. He indicated at 5 a.m. the resident pulled the call light so the charge nurse answered the light while he performed rounds with the other residents. A Documentation Survey Report form dated (MONTH) (YEAR), failed to provide documentation on 7/4/18 on the 10 p.m. to 6 a.m. shift that Resident #1 had been toileted or any elimination status information. Staff M, RN provided the following written statements as dated: -7/4/18 at 6:53 a.m. - I checked the resident's Jackson Pratt (JP) tube, oxygen saturation and oxygen tank around the start of the shift. Later he observed the resident's call light as on and pointed it out to the CNA. Staff M had been in the nursing office when he heard a yell. He went into the hallway and asked the CNA what happened. The CNA stated the resident yelled at him to keep the room door open which he closed. When the staff member went into the resident's room and emptied the JP tube and check the blood sugar in the morning the resident stated the CNA refused to help her and the resident thought he said something smart. The resident stated she had been too scared to put on the call light so she laid in urine all night. The resident's brief was soaked as well as the bed pad and sheet. The staff member cleaned up the resident and changed the bedding. The resident denied the staff member hurt her physically but said they shouldn't let a man in here. Staff M point out that he was a man and the resident replied yes, but you won't hurt me. -b. 7/4/18 at 7:22 a.m. - Staff L had been called into the nursing office on skilled to share his side of the story regarding the allegations A Weekly Timesheet form indicated Staff L worked at the facility 7/4/18 from 10 p.m. until 6:30 a.m. Review of a Single Contact License & Background Check form dated 5/16/18 at 8:58 a.m. indicated Staff L, Certified Nursing Assistant (CNA) required further research related to his criminal history background check. A Record Check Evaluation form had not been returned to the agency from the Department of Human Services (DHS) which would have given the agency/facilities approval for the staff member to be employed. A Iowa Criminal History form dated 5/17/18 indicated the staff member had been arrested on 4 separate occasions with the last arrest categorized as domestic abuse assault impeding flow of air/blood and disorderly conduct - loud or raucous noise on 10/25/16 with a penalty of suspended jail time and probation extended until 4/8/18. During an interview with the DHS on 8/2/18 at 8:17 a.m. and 8/3/18 at 9:58 a.m. revealed the last record check evaluation on 9/1/16. Weekly Timesheet forms indicated Staff L worked at the facility on the following dates and times: a. 5/19/18 - 6 a.m. until 10 p.m. b. 5/20 - 11 a.m. - 10 p.m. c. 5/26, 5/31, 6/2, 6/3, 6/7 and 6/25 - 2 p.m. - 10 p.m. d. 5/27 - 6 a.m. - 10 p.m. e. 5/28 - 6:30 a.m. -10 p.m. f. 5/29, 6/5 - 6 a.m. - 10 p.m. g. 6/9 - 6 a.m. - 8 a.m. h. 6/10 and 7/3 - 6 a.m. - 2 p.m. i. 6/18 and 6/19 - 2 p.m. - 6:30 a.m. j. 6/23 - 3 p.m. - 10 p.m. k. 6/27 - 10 p.m. - 6 a.m. l. 7/2 - 6:30 a.m. - 2 p.m. m. 7/4 - 10 p.m. - 6:30 a.m. 2. Review of a Single Contact License & Background Check form dated 5/7/18 at 12:16 p.m. indicated Staff N, CNA required further research related to his criminal history background check. A Record Check Evaluation form had not been returned to the agency from DHS. An Iowa Criminal History form dated 5/9/18 indicated the staff member was arrested for interfering with official acts and operating while under the influence 1st offense. Weekly Timesheet forms indicated the CNA worked at the facility on the following dates and times: a. 7/9/18, 7/10, 7/17, 7/23, 7/24, 7/25 and 7/27 - 6 a.m. - 2:15 p.m. b. 7/11 and 7/26 - 6 a.m. - 2:10 p.m. c. 7/12, 7/16, 7/18 and 7/20 - 6 a.m. - 2:20 p.m. d. 7/13 - 6 a.m. - 2:05 p.m. e. 7/19 - 6 a.m. - 2:50 p.m. 3. Review of a Single Contact License & Background Check form dated 11/1/17 at 9:12 p.m. indicated Staff O, CNA required a further research related to his criminal history background check. A Record Check Evaluation form had not been returned to the agency from DHS. An Iowa Criminal History form dated 11/2/17 indicated the CNA as arrested for operating while under the influence 1st offense. Weekly Timesheet forms indicated the CNA worked at the facility on the following dates and times: a. 6/10/18 - 1 p.m. - 6:30 a.m. b. 6/11 - 2 p.m. - 10:15 p.m. c. (date unknown) - 6 a.m. - 2:25 p.m. 5. Review of a Single Contact License & Background Check form dated 6/15/18 at 3:32 p.m. indicated Staff P, CNA required a further research related to her criminal history background check. A Record Check Evaluation form had not been returned to the agency from DHS. An Iowa Criminal History form dated 6/19/18 indicated the CNA as arrested as follows: a. Theft in the 5th degree. b. Interference with official acts. c. Theft in the 4th degree. d. Possession of marijuana. e. Theft in the 3rd degree. f. Fraudulent practice in the 2nd degree. g. Possession with an intent to deliver h. Possession with an intent to deliver crack cocaine. i. OWI first offense and possession of a controlled substance. During an interview 8/1/18 at 3:35 p.m., the Director of Nursing and Administrator confirmed the owner of the staffing agency who employed the above 3 staff members confirmed he failed to complete the last step of the criminal background checks by sending the Record Check Evaluation form to DHS for approval to work with the elderly/dependent adults. An Abuse Prevention, Identification, Investigation and Reporting form revised 4/1/17 included the following: b. The facility would conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged who provided services to residents, prior to hire in the manner prescribed under 481 Iowa Code. On 8/1/2018, the facility abated the immediate jeopardy (IJ) after developing a policy to include screening for agency employees. The facility removed agency staff from the schedule whose criminal checks were not completed. The facility also had the agencies send all checks over to the facility prior to allowing an agency employee work within the facility. These findings lowered the IJ from a L severity level to an F with ongoing monitoring to ensure agency staff are thoroughly screened.

Based on clinical record review, observation, resident and staff interviews, and facility protocol the facility failed to provide care, implement interventions to prevent the development and promote healing of pressure ulcers for 4 out 8 residents with pressure ulcers (Resident #4, #37, #60 and #24). The facility identified a census of 78 [MEDICATION NAME] residents. Findings include: 1. The 8/31/17 admission Minimum Data Set (MDS) for Resident #4 included [DIAGNOSES REDACTED]. The MDS further recorded a Brief Interview for Mental Status score of 11 out of 15 indicating moderately impaired cognition. The 3/2/18 quarterly MDS for Resident #4 included [DIAGNOSES REDACTED]. The MDS further recorded a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition and 2 stage 2 pressure ulcers with 11/27/17 for the oldest stage 2 pressure ulcers. Resident #4 Care Plan dated 9/7/17 identified a focus area of a Stage 2 pressure ulcer on the right gluteal and updated 2/14 18 with two new areas on the left gluteal. The care plan included interventions to administer treatments and monitor for effectiveness and to follow policies/protocols for the prevention /treatment of [REDACTED]. The facilities Protocol to Follow for Pressure Ulcers dated 10/20/10, included the following information that risk factors should be identified and document in the nursing notes. Risk factors would include nutritional status, mobility, activity, sensory perception, incontinence and friction/shear factor. The Braden scale should be done with identified pressure ulcers. Documentation should include interventions implemented, physician order [REDACTED]. Resident #4 Braden Scale for Predicting Pressure Sore Risk dated 8/25/17 scored 18 that indicated the Resident #4 at risk for pressure scores. Resident #4 Braden Scale for Predicting Pressure Score Risk dated 12/1/17 scored 21. Resident #4 Braden Scale for Predicting Pressure Sore Risk dated 2/26/18 scored 16 that indicated the Resident #4 at risk for pressure scores. A Progress Note dated 12/4/2017 at 10:51 recorded, Communication with Physician the situation: Occupational Therapy (OT) needed for positioning and cushion needs. The Occupational Therapy Outpatient Discharge Summary recorded therapy dates from 12/14/17 through 1/4/18 with a clinical reasoning stage 1-2 pressure wound to buttock. The Treatment Administration Record (TAR) dated (MONTH) (YEAR) directed: Allevyn adhesive pad apply to right gluteal fold every 3 days or as needed. Cleanse wound with house cleanser pat dry apply skin prep to area around wounds and allow to dry. Apply solsite to wounds and cover with allevyn dressing. (MONTH) change as needed (PRN). Start date 12/19/17 discontinued date 2/5/18. The (MONTH) (YEAR) TAR recorded to check placement of Allevyn pad and replace as necessary, with a start date of 12/19/17. The (MONTH) (YEAR) TAR recorded Triad [MEDICATION NAME] Wound Dress Paste apply to Right and Left gluteal clefts topically two times a day for treatment to wound twice a day until healed ,with a start date 2/27/18. The TAR lacked documentation of the treatment of [REDACTED]. The Facilities Wound/Skin Healing Record recorded the following: 11/18/17 right gluteal fold 0.7 cm x 0.5 cm x 0.1 cm depth stage 2 surrounding tissue pink. 11/20/17 right gluteal fold 1 cm x 0.8 cm x 0.1 cm depth stage 2 wound bed with [MEDICATION NAME] tissue. 11/12/17 right gluteal fold 2 cm x 1 cm x 0.1 cm depth stage 2 wound bed with [MEDICATION NAME] tissue. 12/4/17 right gluteal fold 1.3 cm x 1 cm x 0.1 cm depth stage 2 wound bed normal for skin. 12/13/17 right gluteal fold 1.5 cm x 0.6 cm x 0.1 cm depth stage 2 wound bed normal for skin. 12/18/17 right gluteal fold 1 cm x 0.7 cm x 0.1 cm depth stage 2 wound bed normal for skin. 12/29/17 right gluteal fold 0.1 cm x 0.1 cm x 0.1 cm depth stage 2 wound bed normal for skin. 1/3/18 right gluteal fold 0.1 cm x 0.1 cm x 0 cm depth stage 2 wound bed normal for skin. 1/8/18 right gluteal fold 0.1 cm x 0.1 cm x 0 cm depth stage 2 wound bed normal for skin. 1/18/18 right gluteal fold resolved. 11/27/17 3 areas middle one right gluteal fold 0.5 cm x 0.5 cm x 0.1 cm depth pressure area wound bed normal for skin. 12/4/17 3 areas middle one right gluteal fold 0.5 cm x 0.5 cm x 0.2 cm depth pressure area wound bed normal for skin. 12/13/17 3 areas middle one right gluteal fold 0.6 cm x 0.4 cm x 0.1 cm depth pressure area wound bed normal for skin. 12/18/17 3 areas middle one right gluteal fold 1.2 cm x 0.5 cm x 0.1 cm depth pressure area wound bed normal for skin. 12/29/17 3 areas middle one right gluteal fold 0.6 cm x 0.1 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/3/18 3 areas middle one right gluteal fold 0.4 cm x 0.1 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/8/18 3 areas middle one right gluteal fold, 0.3 cm x 0.1 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/18/18 3 areas middle one right gluteal fold, 0.1 cm x 0.1 cm x 0 cm depth pressure area wound bed normal for skin. 1/22/18 3 areas middle one right gluteal fold, 0.1 cm x 0.6 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/29/18 3 areas middle one right gluteal fold, 0.5 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 2/5/18 3 areas middle one right gluteal fold, 0.5 cm x 0.3 cm x 0.1 cm depth pressure area wound bed normal for skin. 2/14/18 3 areas middle one right gluteal fold, 1.0 cm x 1.1 cm x 0.1 cm depth pressure area wound bed normal for skin. 2/22/18 Resident in Hospital 2/26/18 3 areas middle one right gluteal fold, 0.1 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 3/14 18 3 areas middle one right gluteal fold 0.7 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 11/27/17 3 areas bottom one right gluteal fold, 0.5 cm x 0.5 cm x 0 depth pressure area wound bed normal for skin. 12/4/17 3 areas bottom one right gluteal fold, 0.5 cm x 0.5 cm x 0 depth pressure area wound bed normal for skin. 12/13/17 3 areas bottom one right gluteal fold, 1.0 cm x 0.8 cm x 0.1 cm depth pressure area wound bed normal for skin. 12/18/17 3 areas bottom one right gluteal fold, 0.7 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 12/29/17 3 areas bottom one right gluteal fold, 0.9 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/3/18 3 areas bottom one right gluteal fold, 0.5 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/8/18 3 areas bottom one right gluteal fold, 0.4 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/15/18 3 areas bottom one right gluteal fold, 0.5 cm x 0.5 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/22/18 3 areas bottom one right gluteal fold, 0.1 cm x 0.1 cm x 0.1 cm depth pressure area wound bed normal for skin. 1/29/18 3 areas bottom one right gluteal fold, 0.7 cm x 0.7 cm x 0 cm depth pressure area wound bed normal for skin. 2/5/18 3 areas bottom one right gluteal fold, 0.3 cm x 0.3 cm x 0 cm depth pressure area wound bed normal for skin. 2/14/18 3 areas bottom one right gluteal fold healed 2/14/18 left gluteal fold 2 areas 0.6 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 2/22/18 Hospital 2/26/18 left gluteal fold 2 areas 0.5 cm x 0.2 cm x 0.1 cm depth pressure area wound bed normal for skin. 3/14/18 left gluteal fold 2 areas 1.5 cm x 0.6 cm x 0.1 cm depth pressure area wound bed normal for skin. Mobile Wound Solution document dated 3/21/18 recorded Right buttock 1.14 cm x 0.52 cm x 0.1 cm pressure ulcer stage 3, with a scant amount of serosanguinous drainage and the peri-wound excoriated. Change treatment to cleanse with facility choice apply collagen pad to wound moisten with saline cover with foam to change dressing daily and as needed for soiling. A new order for occupational therapy (OT) to evaluate and treat for Roho cushion in recliner During an observation on 3/20/18 at 1:23 PM Staff P Certified Medication Aide/ Certified Nursing Aide (CMA/CNA) placed Triad wound paste into medication cup, Staff P went to Resident #4 room and knocked on door. Staff P let the resident know what they were going to. Staff P pulled the curtains washed his hands and donned gloves. He then wet a washcloth. Staff P helped Resident #4 stand and pulled down Resident #4's pants. Staff P applied Triad on the wound area, removed his gloves and pulled up the resident's pants. Resident #4 sat down on recliner. Staff P washed his hands. During an observation and interview on 3/21/18 7:45 AM with The Mobile Wound Solutions doctor (DPN), helped Resistant #4 stand, pulled down brief and took a picture to measure the wound area 1.42 cm x 0.52 cm x 0.1 cm deep stage 3 pressure ulcer per DPN explained she ordered collagen pad treatment and thought the air mattress on the bed to be a good air mattress is good. The DPN acknowledged she wanted to talk to therapy about a different cushion for her chair. The DPN explained she would have a report today before she left the building. When interviewed on 3/21/18 at 10:21 AM the Director of Nursing (DON) reported her expectation would be for nursing staff to follow the facilities policies and protocols. 2. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #37 had a [DIAGNOSES REDACTED]. The MDS indicated the resident required limited assistance of one staff for bed mobility and transfers, and had limited range of motion in her upper extremities. The MDS revealed the resident had a risk for pressure ulcers, and had no pressure ulcers or skin impairments. The MDS assessment dated [DATE] documented the resident required extensive assistance of 2 staff for bed mobility, and had total dependence on 2 staff for transfers. The MDS revealed the resident had a risk for pressure ulcer and had an unhealed, unstageable pressure ulcer. The admission assessment and skin and body assessment dated [DATE] revealed the resident had no pressure areas or wounds. The admission care plan dated 5/12/17, and revised on 10/19/17, revealed the resident at risk for altered skin integrity related to fragile skin, diabetes, and prone to reddened skin folds. The care plan interventions included encourage mobility and shifting weight in recliner, keep skin clean and dry, notify the physician of altered skin integrity, and treatments as ordered. The care plan dated 3/17/18 revealed a stage 2 pressure ulcer to the gluteal's. The staff directives and interventions included assistance to shift weight in recliner every 2 hours, air mattress on the bed, treatments as ordered, monitor wound healing at least weekly, collaborate with hospice, educate the resident and family on causes of skin breakdown including positioning, good nutrition, and frequent repositioning. The functional maintenance program established by the Occupational Therapist (OT) 9/25/17, documented the resident needed a Roho Cushion on at all times. The resident's care plan updated on 10/19/17 and 3/17/18, did not address the use of a Roho cushion. The Care Sheet (pocket care plan) updated 3/20/18, did not address the resident's need for a Roho Cushion. The Braden Scale for predicting pressure sore risk, dated 8/1/17, revealed a score of 18 which indicated the resident at risk for pressure sore development. The Braden Scare dated 1/12/18, revealed a score of 14, which indicated the resident at moderate risk for pressure sore development. A communication to the physician on 11/11/17 at 5:17 PM, revealed bilateral gluteal's had discolored blanchable areas. Staff L, Licensed Practical Nurse (LPN), requested [MEDICATION NAME] ointment twice a day (BID) for 7 days, then re-evaluate the area. A communication to the physician on 2/21/18 at 8:18 PM, documented the resident had a 1.7 cm x 0.5 cm open area on the right gluteal, and a reddened, nonblanchable area on the coccyx, right gluteal, and left gluteal area. Staff J, LPN, requested an order for [REDACTED]. The physician's telephone order dated 3/2/18 included triad to open areas on right gluteal area BID, up in recliner no more than 2 hrs, and a cushion in recliner at all times. The wound/skin assessment record dated 2/21/18 revealed a Stage 2 pressure wound on the left gluteal and coccyx areas without drainage and two Stage 2 pressure wounds on the right gluteal area. The wounds had been identified on 2/21/18. The weekly wound assessment record revealed the following: Left Gluteal 2/21/18, 5.2 cm length (L) x 2.0 cm width (W) x 0.0 cm depth (D) 2/26/18, 4.5 cm (L) x 1.5 cm (W) x 0 cm (D) 3/5/18, 4.4 cm (L) x 2.0 cm (W) x 0 cm (D) 3/12/18, 4.0 cm (L) x 1.8 cm (W) x 0 cm (D) 3/19/18, 3.6 cm(L) x 1.6 cm (W) Coccyx 2/21/18, 7.0 cm (L) x 5.0 cm (W) x 0 cm (D) 2/26/18, 6.4 cm (L) x 4.0 cm (W) x 0 cm (D) 3/5/18, 6.2 cm (L) x 2.0 cm (W) x 0 cm (D) 3/12/18, 5.4 cm (L) x 1.5 cm (W) x 0 cm (D) 3/19/18, 6.0 cm (L) x 1.8 cm (W) x 0 cm (D) Right Gluteal -wound #1 2/21/18, 7.5 cm (L) x 0.9 cm (W) x 0 cm (D) 2/26/18, 5.5 cm (L) x 1.5 cm (W) x 0 cm (D) 3/5/18, 5.2 cm (L) x 0.8 cm (W) x 0 cm (D) 3/12/18, 5.0 cm (L) x 0.8 cm (W) x 0 cm (D) 3/19/18, 4.8 cm (L) x 0.8 cm (W) x 0 cm (D) Right Gluteal - wound #2 2/21/18, 1.7 cm (L) x 0.5 cm (W) x 0 cm (D) 2/26/18, 1.6 cm(L) x 0.8 cm (W) x 0 cm (D) 3/5/18, 1.7 cm (L) x 0.8 cm (W) x 0 cm (D) 3/12/18, 1.4 cm (L) x 0.6 cm (W) x 0 cm (D) 3/19/18, 1.4 cm (L) x 0.6 cm (W) x 0 cm (D) The Treatment Administration Record (TAR) 3/1-3/31/17 revealed [MEDICATION NAME] to coccyx area every day (2/23 - 3/4/18) and Triad to open area on right gluteal twice daily (BID) for wound healing. The TAR had no entry marked on 3/6 at bedtime (HS) or 3/9 for morning (AM) or HS Triad treatment. Observations revealed the following: 3/19/18 at 9:15 AM Resident #37 sat in a recliner in room and had legs elevated. A Roho cushion sat in a high back wheelchair (w/c) in the room. No cushion in recliner. 3/20/18 at 8:28 AM Resident #37 sat in a recliner in room with legs elevated. No Roho cushion under the resident. 3/21/18 at 12:34 PM Resident #37 sat in recliner with feet elevated. A Roho cushion sat in the w/c in the room. 3/21/18 at 2:10 PM Resident #37 sat in a recliner in room with legs elevated and had no cushion in recliner. Observed a lift pad under the resident. Observation on 3/21/18 at 7:19 AM with the wound physician, wound nurse, and Staff J, LPN, revealed a wound on the resident's bottom located on the coccyx and upper left gluteal area which measured 1.8 cm x 2.1 cm x 0.1 cm. The wound physician advised Staff J of the treatment plan for collagen with a foam dressing to the area. Staff J acknowledged the resident acquired the wound while at the facility. Staff J reported the resident usually sat in recliner, and rarely sat in the wheelchair. The wound Dr stated the Roho cushion needed placed in recliner in order for the resident to offload pressure on bottom. 03/22/18 10:20 AM Resident #37 sat in a recliner with legs elevated. A Roho cushion sat in the w/c across the room from the recliner. In an interview on 3/22/18 at 8:05 AM, the Director of Nursing (DON) stated a Braden assessment completed on every resident at admission. A resident deemed high risk for pressure ulcers if the Braden score 12 or below, and an order for [REDACTED]. The DON reported preventative measures implemented such as heels floated or pillows used for positioning. If a resident had wounds, staff followed the treatment orders. The DON reported they had no policy for pressure ulcer prevention, but had a policy for what to do if a resident had a pressure wound. The DON reported they had a skin performance improvement team (PIP) who met once a month and reviewed process for skin breakdown, nutrition, high protein snacks and supplements recommended, and provided staff education on positioning. The DON acknowledged Resident #37 had no wound on bottom when she admitted to the facility, but had developed a pressure wound while in the facility. During an interview on 3/22/18 at 8:20 AM, the MDS/Care plan Manager reported she updated the care plan when a new order received or if had changes in resident ADL assistance or care needs. If the resident had therapy recommendations, the information would be updated on the care plan. 3. The admission MDS assessment dated [DATE], identified Resident #60 had [DIAGNOSES REDACTED]. The MDS revealed the resident had a BIMS score of 3 out of 15, which indicated cognition severely impaired. The MDS revealed the resident had total dependence on 2 staff for bed mobility and transfers. The MDS revealed the resident had a risk for pressure ulcers, but had no pressure ulcers or wounds. The Admission skin and body assessment dated [DATE], revealed no pressure wounds or skin breakdown. The Braden scale assessment dated [DATE] revealed a score of 12, which indicated the resident at high risk for pressure sores. The MDS assessment dated [DATE], identified the resident had total dependence on 2 staff for bed mobility and transfers. The MDS revealed the resident had a risk for pressure ulcers, and had one Stage 2 and one Stage 3 pressure ulcer, with the oldest stage 2 pressure ulcer dated 8/28/17. The Care Plan dated 11/28/17 and revised on 3/18/18, revealed Resident #60 had a Stage 2 pressure ulcer on the coccyx due to decreased mobility and disease, a self-care deficit related to multiple medical problems, and had total dependence on staff for ADL's. The care plan directives included treatments as ordered, monitor wound healing, reposition side to side in bed, air mattress on bed, and a cushion in the w/c. The Wound/Skin Record revealed a Stage 3 pressure wound to the left gluteal fold, with onset date unknown. The wound/skin record revealed the following measurements: 8/26/17, 2.0 cm (L) x 1.0 cm (W) x 0.1 cm (D) 9/1/17, 1.75 cm (L) x 1.0 cm (W) x 0.1 cm (D) 9/13/17, 1.2 cm (L) x 0.5 cm (W) x 0.1 cm (D) 9/20/17, 1.1 cm (L) x 0.6 cm (W) x 0.1 cm (D) 10/3/17, 1.2 cm (L) x 0.5 cm (W) x 0.2 cm (D) 10/9/17, 1.0 cm (L) x 0.4 cm (W) x 0.1 cm (D) 10/23/17, 0.6 cm (L) x 0.2 cm (W) x 0.1 cm (D) 11/2/17, 1.0 cm (L) x 0.4 cm (W) x 0.1 cm (D) 11/6/17, 1.0 cm (L) x 0.5 cm (W) x 0.1 cm (D) 11/30/17, 0.8 cm (L) x 0.2 cm (W) x 0.1 cm (D) 12/4/17, 1.0 cm (L) x 0.5 cm (W) x 0.1 cm (D) 12/18/17, 0.4 cm (L) x 0.2 cm (W) x 0.1 cm (D) 1/3/18, 0.2 cm (L) x 0.2 cm (W) x 0 cm (D) 1/10/18, 0.5 cm (L) x 0.2 cm (W) x 0.1 cm (D) 2/2/18, 0.8 cm (L) x 0.3 cm (W) x 0.1 cm (D) 2/7/18, 1.0 cm (L) x 0.2 cm (W) x 0.1 cm (D) 2/19/18, 1.0 cm (L) x 0.4 cm (W) x 0.1 cm (D) 3/12/18, 1.0 cm (L) x 0.2 cm (W) x 0.2 cm (D) 3/19/18, 1.0 cm (L) x 0.2 cm (W) x 0.2 cm (D) On 3/21/18 at 07:05 AM, observation with the wound physician, and Staff J, LPN, revealed a wound on the resident's left gluteal/coccyx area. The wound measured 0.3 cm (L) x 0.9 cm (W) x 0.1 cm (D). The wound Dr classified the wound as a pressure wound. In an interview 3/22/18 at 8:05 AM, the DON confirmed Resident #60 had a wound on bottom which had developed while the resident resided at the facility. 4. The MDS assessment dated [DATE] for Resident #24 identified a BIMS score of 14 without signs/symptoms of [MEDICAL CONDITION]. A score of 14 indicated intact cognition. The MDS revealed the resident totally dependent upon 1 person for bed mobility, dressing, eating, personal hygiene and 2 persons for transfers, and toilet use. The MDS coded impairments in functional range of motion on both sides of upper and lower extremities. The MDS documented [DIAGNOSES REDACTED]. the course of the nerve). The MDS identified the presence of 1 Stage II pressure ulcer at the time of the assessment. The care plan focus area revised 9/29/17 identified an impaired physical mobility related to multiple [DIAGNOSES REDACTED]. The care plan focus area revised 11/28/17 identified the resident had a Stage 2 pressure ulcer on her coccyx related to history of ulcers and immobility as evidenced by total assistance provided by staff. The care plan interventions included staff to: administer treatments as ordered; monitor for effectiveness; assess/record/monitor wound healing weekly reporting any improvements or declines to the MD (medical director); and float the resident's heels with a wedge cushion. The Progress Notes dated 11/13/17 at 11:44 a.m. documented the ankle wound resolved, pink scar tissue remained, and staff continued to elevate feet on heel wedge float. The Progress Notes dated 12/30/2017 at 8:49 p.m. documented a Social Services Quarterly Progress Note. The entry recorded the resident had physically continued to decline. The note recorded the resident couldn't move her limbs on her own. The Progress Notes dated 1/4/18 at 9:17 a.m. documented a nutrition/dietary note. The note recorded the resident at risk for skin impairment as evidenced by a Braden score (tool used to measure the risk of developing pressure sores) of 13 = to moderate risk. The Progress Notes dated 1/10/18 at 8:50 a.m. documented communication with the physician that the area on the coccyx healed. The note recorded a request for an order of [MEDICATION NAME] (an ointment that acts as a barrier to protect skin from moisture and irritating substances) to coccyx BID (twice a day) as [MEDICATION NAME] treatment. The Progress Notes dated 1/11/18 at 3:20 p.m. documented the resident had a new order for the treatment. The Progress Notes dated 1/19/18 at 2:00 p.m. documented communication to the physician that the resident had 4 open areas on the coccyx and asked for an order of sacral [MEDICATION NAME] (type of foam dressing that absorbs fluids) to the areas, change TID (3 times a day) and PRN (as needed) UTH (until healed). The Progress Notes dated 1/20/18 at 4:21 p.m. documented the resident had a new order for [MEDICATION NAME] to coccyx wound. The Progress Notes dated 1/27/18 at 10:15 a.m. documented a new order to monitor debrided loose scab to left ankle as needed for old wound daily. The Progress Notes dated 2/1/18 at 11:29 p.m. documented the areas to coccyx measured, see skin sheet; new dressing applied. The Progress Notes dated 2/7/18 at 10:55 a.m. documented communication with the physician the 3 areas on coccyx are now one. The note recorded a request for an order to discontinue sacrum patch and apply Solosite (gel used to create a moist wound environment which assists debridement of necrotic tissue), cover with [MEDICATION NAME] adhesive, change every day (QD) and PRN UTH. The Progress Notes dated 2/7/18 at 6:00 p.m. documented a new order for Solosite and [MEDICATION NAME] adhesive. The Treatment Administration Record (TAR) for (MONTH) (YEAR) documented entries for the following treatments: a. Sacral [MEDICATION NAME] to areas on coccyx, change every 3 days and PRN. The treatment not signed as completed on 2/1. b. Apply Solosite to wound bed and cover with [MEDICATION NAME] adhesive, change QD and PRN UTH. The treatment not signed as completed on 2/16. The Progress Notes dated 3/5/18 at 9:14 a.m. documented communication with the physician and request to discontinue Solosite to area on the coccyx. The note recorded a request to have an order to apply Triad (zinc oxide-based [MEDICATION NAME] paste that absorbs moderate levels of wound exudate) to area on coccyx and cover with [MEDICATION NAME] adhesive, change QD and PRN UTH. The Progress Notes dated 3/7/18 at 3:07 a.m. documented an order received to discontinue Solosite and start Triad to coccyx and cover with [MEDICATION NAME]. The Progress Notes dated 3/7/18 at 1:32 p.m. documented a skin/wound note for a coccyx assessment. The note recorded the area treated with Triad cream onto wound then applied [MEDICATION NAME]. The note reported dressing changed QD and the area not improved since last assessment. The note recorded the wound a Stage 2 pressure ulcer measured 2.5 cm (centimeter) by 1.5 cm with 0.1 cm depth. The note documented treatment completed and drainage yellow in color. The Progress Notes dated 3/7/18 at 3:56 p.m. documented a new treatment order received. The Progress Notes dated 3/16/18 at 2:59 p.m. documented verbal consent received for mobile wound solutions to see and treat the resident if needed. The TAR for (MONTH) (YEAR) documented the following treatments: a. Apply Solosite to wound bed and cover with [MEDICATION NAME] adhesive, change QD and PRN until healed (UTH). review of the (MONTH) (YEAR) TAR revealed the treatment not signed as completed on 3/3, 3/4. b. Apply Triad to area on coccyx and cover with [MEDICATION NAME] adhesive, change daily and PRN UTH. Review of the (MONTH) (YEAR) TAR revealed the treatment not signed as completed on 3/10, 3/16. The TAR for (MONTH) (YEAR) documented a entry started 1/27/18 for a PRN treatment of [REDACTED]. The entry contained no signatures for completion on any day of the month. The (MONTH) (YEAR) and (MONTH) (YEAR) TARs contained the same entry and also contained no signatures for completion on any day of the month. The Progress Notes lacked any documentation of skin assessments or monitoring of the debrided loose scab to the left ankle. In an interview on 3/19/18 at 11:00 a.m., Resident #24 reported she did have a pressure ulcer on her tailbone she acquired while living at the facility and it sounded like it was a pretty bad sore. She stated she thought she had the pressure sore for 6 weeks. Observation revealed the resident had an approximate 3 inch pummel cushion under her in the wheelchair. Resident #24 reported she did not feel staff repositioned her every 2 hours on the weekends; she felt they took longer than 2 hours. Resident #24 stated she felt if the facility had more nursing staff they could have prevented her pressure sores. She reported the staff were supposed to do a treatment to her tailbone every day but they did not get the treatment completed everyday. She reported the area very sore, and staff gives her something to treat the pain. Observation on 3/21/18 at 8:59 a.m. revealed Staff S, Certified Nurse Aide (CNA), and Staff I, CNA, assisted the resident with incontinent cares while Resident #24 laid in bed; the Director of Nursing, (DON), present also to observe cares. With Resident #24's approval socks removed and observation revealed the left outer ankle bone contained a nickel sized black scabbed area, with surrounding skin color pale white. Staff removed the resident's brief and rolled to reveal the coccyx area covered with a piece of 4 by 4 gauze folded in half held in place with a piece of tape, wound not visible. The DON confirmed the dressing gauze with tape and reported the mobile wound clinic in the facility for the first time ever that morning. The DON stated the mobile wound clinic assessed the area at approximately 6:30 a.m. and placed the temporary dressing until supplies received for a new treatment. Staff placed a blue wedge cushion under the resident's calves, to float the heels, Observation revealed the resident's legs naturally rotated outward so the area on the left outer ankle could come in contact with the blue wedge cushion. The mobile wound clinic note titled Tissue Analytics recorded a wound evaluation on 3/21/18 at 11:32 a.m. The note documented new unstageable pressure ulcer on the coccyx that measured 3.22 cm by 2.68 cm by 1.20 cm; 0.95 cm 2 (squared) red, 2.15 cm 2 black, 2.83 cm 2 yellow, 0.37 cm 2 pink, and 0.06 cm 2 other. The assessment documented the presence of extensive slough, 100% with moderate amount of serosanguinous (thin, bloody) drainage. The note documented to discontinue current treatment and start to clean with a wound cleanser, apply Vaseline gauze, Santyl ([MEDICATION NAME] agent), apply nickel thick layer to wound bed, cover with bordered gauze. The note recorded a pre-debridement [DIAGNOSES REDACTED]. In an interview on 3/22/18 at 10:15 a.m., with Staff U, LPN, and Staff P, CMA, Staff U, stated she worked mostly weekends 3 to 4 times a week. She reported she worked the 200 hall and had to rushed to get everything done. She stated they need another medication aide because the medication aide did the top of 200 hall and 300 hall. Staff P, CMA stated he thought a lot of skin occurrences because residents would not get off their bottoms. Staff P reported a lot of times he completed the treatments at the end of the day because there were so many medications to give. He reported if staff didn't get their treatments done they had to stay over. The facility instructed them if they did not get treatments completed they were supposed to pass them on to the next shift for them to complete. Staff P reported he only left the TAR blank if he didn't complete the treatment. Staff U and Staff P confirmed if the resident refused a medication or treatment it would be documented on the MAR (Medication Administration Record) or TAR, which then generated a progress note.

Based on observation, record review, and resident and staff interviews, the facility failed to provide the care and treatment necessary to prevent pressure sore development in 3 of 5 residents reviewed with facility-acquired pressure sores (Resident's #1, #4 and #5), and failed to provide treatment consistent with professional standards of practice to promote healing and prevent infection of the identified pressure sores. The facility reported a census of 78 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/22/17. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 9 out of 15. A score of 9 indicated the resident had cognitive impairments. The MDS had [DIAGNOSES REDACTED]. The MDS indicated the resident required 2 or more people for repositioning in bed and with transfers, personal hygiene and toilet use. The MDS indicated the resident had impairments of both upper and lower extremities, had an indwelling Foley catheter and experienced bowel incontinence episodes. The MDS identified the resident at risk for the development of pressure sores and had 1 unhealed Stage III pressure ulcer that measured 2.0 cm (centimeters) by 1.5 cm by 0.1 cm depth. The MDS identified the resident had a pressure reducing device on the bed and chair, turning and repositioning program, nutrition or hydration interventions, pressure ulcer care, application of ointments and nonsurgical dressings. The Care Plan identified an impaired skin integrity problem on 4/1/15. The interventions directed the staff to do the following: Pressure reduction devices to bed and wheel chair, initiated on 4/1/15. Administer treatments as ordered, initiated 11/19/15. Assist to reposition in bed every 2 hours, initiated 3/23/16. Encourage and assist to remove shoes when in bed, initiated 3/29/17. Boot to left foot when in bed, initiated on 7/20/17. Float bilateral heels when in bed, initiated 10/3/17. The Care Card, available on 10/3/17, directed the staff members to float heals in bed, no shoes, pressure reduction boot to left foot while in bed and to turn approximately every 2 hours when in bed. The resident's Wound/Skin Healing Record identified a scab on the left malleolus (ankle bone) on 6/20/17. The area measured 0.6 cm by 0.9 cm. Additional wound conditions, measurements and dates are described: 6/27/17 - 1.0 cm by 1.0 cm, without depth or drainage. 7/3/17 - 1.0 cm by 1.0 cm scab, without drainage. 7/25/17 - 1.0 cm by 1.8 cm by 0.2 cm depth, no drainage with slough tissue. 8/4/17 - 1.5 cm by 1.3 cm by 0.2 cm, scant drainage with [MEDICATION NAME] tissue. 8/9/17 - 1.0 cm by 2.0 cm by 0.2 cm, scant drainage with [MEDICATION NAME] tissue. 8/14/17 - 2.0 cm by 1.8 cm by 0.2 cm, scant drainage with [MEDICATION NAME] tissue. 8/22/17 - 1.5 cm by 1.5 cm by 0.2 cm, without drainage and with [MEDICATION NAME] tissue. 8/30/17 - 2.0 cm by 1.5 cm by 0.2 cm, without drainage, slough tissue. 9/5/17 - 1.0 cm by 1.0 cm by 0.2 cm, without drainage, slough tissue. 9/13/17 - 1.0 cm by 1.0 cm by 0.2 cm, with drainage, granulation tissue. 9/18/17 - 1.5 cm by 1.5 cm, without drainage, granulation tissue. 9/27/17 - 2.0 cm by 1.5 cm by 0.1 cm, scant serous drainage, slough tissue. On 10/3/17 at 6:20 a.m. observation with Staff A, licensed practical nurse (LPN), identified the resident positioned in bed, without heels floated/suspended. Staff A removed the gauze cover dressing, the [MEDICATION NAME] Blue dressing adhered to the skin, Staff A used an opened bottle of normal saline with approximately 30 to 50 milliliters in it and in 1 lateral motion, applied the entire surface of the bottle opening to the skin around the dressing. Staff A then removed the [MEDICATION NAME] Blue that was then wet by the process. Observation identified a wound approximately 1.0 by 2.0 cm by 0.2 cm depth wound on the left lateral malleolus. The wound was located at the normal resting position of the ankle's contact with the mattress. Observation identified the wound with white slough tissue; an approximate 0.2 cm border of slightly darker pink tissue surrounded the wound opening. The wound had no visible drainage noted. Staff A replaced the cap to the saline bottle. Physician orders [REDACTED]. 6/23/17 - Apply Allevyn patch to scabbed area on the left malleolus. Change every 3 days for 15 days, then reassess. This order was discontinued on 6/28/17 per physician. 6/28/17 - Cleanse area on left ankle with normal saline (NS), pat dry, apply [MEDICATION NAME] to wound bed daily, cover with [MEDICATION NAME] gauze and rolled gauze daily for 7 days. Reassess (end of orders 7/5/17). 7/12/17 - (7 days without wound care orders or wound treatment) Apply [MEDICATION NAME] Ag (silver) to wound area, secure with rolled gauze in figure 8, change daily for 14 days then reassess. 7/27/17 Cleanse wound with NS, apply Skin Prep to peri wound, allow to dry. Apply small amount [MEDICATION NAME] to wound base, cover with 2 inch by 2 inch gauze and secure with [MEDICATION NAME] (clear adhesive dressing), change every other day. 8/24/17 Skin Prep to peri wound, allow to dry completely, calcium alginate cut to fit wound bed, moisten with scant amount of NS and cover with 2 inch by 2 inch island dressing, change daily for 14 days then reassess (end of orders 9/7/17). 9/12/17 - (5 days without wound care orders or wound treatment) Cleanse left foot ulcer daily with NS, pat dry, apply Skin Prep to peri wound, moisten calcium alginate with scant amount of NS and cover with 2 inch by 2 inch island dressing. 9/13/17 -Cleanse wound with NS, cut [MEDICATION NAME] Blue to fit wound bed, cover with island dressing, change daily for 14 days (end of orders 9/27/17). 10/3/17 - (5 days without wound care orders or wound treatment) Cleanse left foot ulcer with NS, pat dry, apply Skin Prep to peri wound, moisten calcium alginate with scant amount of NS and cover with 2 inch by 2 inch island dressing daily for 7 days then reassess. Observations of the resident identified the following: 9/20/17 at 6:58 a.m., in bed and awake, heels floated with a blue pillow device. 9/21/17 at 10:28 a.m., in bed, eyes closed and covered with blanket, legs appear elevated on a device to float heels, covered with blanket. 10/3/17 at 5:44 a.m., CNA (certified nursing assistant) left the resident's room and said the resident was asleep. Observations from the hall revealed the resident's feet on the mattress, not floated, and the blue flotation pillow on the floor by the closet 10/3/17 at 6:20 a.m., resident's feet remained directly on the mattress, the blue flotation pillow remained on the floor, the resident was awake and stated staff had not floated her heels all night, and they were supposed to. On 9/21/17 at 7:42 a.m., the Director of Nursing (DON) stated the resident's pressure sore on the heel probably resulted because staff had not floated her heels as they should have. The DON stated the resident was repositioned about every 2 hours and would have had the opportunity to float the resident's heels with each reposition. On 10/4/17 at 1:25 p.m., the DON stated they had tried the blue boots on the resident a while ago and the resident didn't care for the boots. The DON stated the staff are to float the resident's heels with the blue pillow when in bed. 2. Resident #5 had a MDS assessment with a reference date of 9/8/17. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance of at least 1 staff member for repositioning in bed and need 2 or more staff to help with transfers. The resident depended upon staff for personal hygiene, toilet use, eating and dressing. The resident always had bowel and bladder incontinence and at risk for the development of pressure ulcers. The MDS identified the resident had no pressure ulcers at the time of the assessment and the facility used only a pressure reducing device in the chair (not in bed). The Care Plan identified on 7/24/13, an impaired skin integrity problem. The interventions included and directed the staff to do the following for the problem: Assist to reposition in bed approximately every 2 hours, initiated 6/9/17. Discourage being up in wheel chair for prolonged periods of time and assist to reposition, initiated 6/9/17. Pressure reduction device to bed and wheel chair as appropriate, initiated 7/24/13. Provide treatments as ordered, initiated 7/24/13. The Care Card directed the staff to change the resident, reposition every 2 hours, and lay the resident down between meals. The Centers for Medicare and Medicaid Services (CMS) identify the following stages of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. A Wound/Skin Healing Record identified the resident had a Stage I pressure sore, located on the upper coccyx on 9/13/17. The Stage I pressure ulcer measured 2.5 centimeters (cm) by 1.0 cm, without drainage, [MEDICATION NAME] tissue present in wound bed and normal colored surrounding tissue. The next assessment, completed 9/27/17 identified the area measured 2.3 cm by 1.0 cm by 0.1 cm depth, without drainage, [MEDICATION NAME] tissue present and normal colored surrounding tissue (Stage II). Observation on 9/28/17 at 9:35 a.m. identified the DON present as Staff O, CNA removed the resident's urine soiled brief. Observation identified an approximate 1.0 cm to 1.0 cm circular open area that appeared as a dark purple or brown colored tissue. The peri-wound had a margin of bright red tissue that extended approximately 1.0 to 1.5 cm from the eschar edge, centrally located on the coccyx area. Physician orders [REDACTED]. 9/14/17 - Apply [MEDICATION NAME] ointment (Aluminum [MEDICATION NAME]) to coccyx wound 3 times a day for 14 days, then reassess (end of orders 9/27/17). 10/3/17 - Cleanse wound with wound cleanser, pat dry, apply [MEDICATION NAME] ointment 2 times daily for 14 days then reassess (5 days without wound care orders or treatment). Observations of the resident revealed: 9/20/17 at 6:36 a.m., dressed and seated in wheel chair in the hallway. 9/20/17 at 7:53 a.m., remained seated in wheel chair in the hallway, transported to the assisted dining room. 9/20/17 at 8:10 a.m., remained seated in wheel chair, in assisted dining room for breakfast. 9/20/17 at 9:09 a.m., remained seated in wheel chair in hallway near room, head slumped forward. 9/20/17 at 9:27 a.m., staff pushed resident in wheel chair into his/her room for care and transfer to bed. 9/21/17 at 6:40 a.m., resident dressed and seated in wheel chair in hallway. 9/21/17 at 7:14 a.m., remained seated in wheel chair. 9/21/17 at 7:50 a.m., seated in wheel chair in the assisted dining room. 9/21/17 at 8:25 a.m., seated in wheel chair in the assisted dining room. 9/21/17 at 8:48 a.m., returned from the dining room, remained in wheel chair. 9/21/17 at 9:11 a.m., remained seated in wheel chair in room next to bed, head slumped forward. 9/21/17 at 9:32 a.m., remained seated in wheel chair in room. 9/21/17 at 9:44 a.m., resident in bed. 3. Resident #1 had a MDS assessment with a reference date of 8/25/17. The MDS indicated the resident had [DIAGNOSES REDACTED]. and depression. The MDS indicated the resident had severe cognitive impairments and depended upon 1 staff person for repositioning in bed, and 2 or more staff persons with transfers and toileting. The MDS identified the resident always experienced bowel and bladder incontinence. The MDS identified the resident to be at risk for pressure sore development and had 1 Stage II pressure ulcer on 8/12/17. The MDS indicated the pressure relieving device on the chair seat only. The MDS did not address nutrition or hydration, turning and repositioning or a relieving device on the bed. The Care Plan indicated the resident had the potential for impaired skin integrity problem on 7/22/13. The interventions included and directed the staff to do the following: Assist to position to avoid prolonged periods of time in a wheel chair, initiated 12/8/16. Assist to reposition in bed approximately every 2 hours, initiated 12/8/16. Pressure reduction device to bed and wheel chair as appropriate, initiated, revised on 4/18/14 A Pressure Skin Condition Report dated 8/12/17 described a fluid filled blister on the lateral aspect of the right heel that measured 3.0 centimeters (cm) by 2.8 cm without depth. The report described on 8/17/17 the blister opened, measured 4.0 cm by 1.5 cm, without depth or drainage, granulation tissue present. On 8/25/17 the wound measured 2.8 cm by 2 cm with 0.05 cm depth, without drainage, granulation tissue present. On 9/1/17 the wound measured 1.0 cm by 1.0 cm by 0.1 cm depth, without drainage. On 9/8/17 the wound measured 1.0 cm by 0.8 cm by 0.1 cm, scant drainage, [MEDICATION NAME] tissue present, pain level of 2 determined by facial signs with 0 to 10 scale used, 10 described as worst pain, resident received scheduled pain medication. On 9/17/17 the wound measured 0.5 cm by 0.5 cm by 0.1 cm depth, scant drainage, and [MEDICATION NAME] tissue present. On 9/22/17 the wound measured 0.6 cm by 1.0 cm by 0.2 cm depth, without drainage, [MEDICATION NAME] tissue present. On 9/27/17 the wound measured 0.5 cm by 1.0 cm without depth, no drainage, area scabbed. Observation of wound care with the DON on 9/28/17 at 10:32 a.m. revealed the resident in bed, fully clothed with shoes on. Staff C, licensed practical nurse (LPN), removed the right shoe and sock that revealed no dressing on the wound. The wound area appeared dry, pink tissue, surrounding tissue also pink, foot warm, and measured 1.2 cm diameter, with open area 0.7 cm by 0.9 cm and approximate 0.2 to 0.3 cm depth. Physician orders [REDACTED].>8/12/17 - Apply [MEDICATION NAME] to right lateral heel blister daily until opened, then apply [MEDICATION NAME] daily until healed. The order was not implemented as documented on the Treatment Administration Record (TAR). 8/12/17 - Keflex (a strong antibiotic) 500 milligrams (mg) administered 3 times daily for 7 days related to wound. 8/20/17 - Cleanse wound right ankle area with normal saline, pat dry, apply Skin Prep to peri wound and allow to dry. Apply Solosite to wound bed and cover with 2 inch by 2 inch gauze, secured with rolled gauze in figure 8, change 2 times daily for 15 days. 8/31/17 - Continue same wound care 2 times daily for 15 days (order ended 9/15/17). 9/22/17 - (7 days without wound care orders or treatment) Apply Allevyn adhesive pad to right heel wound daily for 7 days. The facility document titled Protocol To Follow for Pressure dated 10/20/10, included and directed staff to do the following: 1. Complete assessment required when a pressure sore is first identified. 2. Documentation should include interventions implemented, orders received, and family/responsible party notification. 3. Documentation should also include use of pressure relieving devices, such as pillows to elevate heels off the bed, positioning devices, and padding to bony prominences. 4. Documentation should include repositioning if resident is unable to reposition self. 5. Weekly skin assessments are to be initiated for any pressure sore, completed by the nurse assigned to the area. Resident observations: On 9/19/17 at 10:14 a.m., the resident sat in a wheel chair in room, fully dressed with white tennis shoes on feet. On 9/20/17 at 7:21 a.m., fully dressed with white tennis shoes on, lying towards right side on bed with lift sling under the resident. Continuous observation from the hall from 7:21 a.m. until 8:05 a.m. revealed the resident in bed, without staff intervention. Staff D, certified nursing assistant (CNA) and certified medication aide (CMA) and Staff J, restorative aide (RA), and transferred the resident to a wheel chair, transported to the dining room for breakfast. On 9/20/17 at 9:36 a.m., the resident remained seated in the wheel chair with shoes on. On 9/21/17 at 9:52 a.m. the resident sat in the wheel chair, dressed with shoes on as staff transferred her to bed. The shoes were removed and the blue foam boot placed on right foot. On 10/3/17 at 9:20 a.m., seated in wheel chair, dressed with blue foam boots on both feet. Staff D, CMA, stated resident is supposed to have the blue boots on at all times now. Staff D provided the current Care Card for the resident's hall that did not provide direction about the resident's feet, boots or wound. During an interview on 10/4/17 at 1:25 p.m., the DON stated the blue boots can be applied as a preventive measure, no order was required, and no product information was available as the product varied depending on when it was ordered and from what company. The DON stated the facility laundered the boots for use with other residents and some of the boots were older but remained in use if intact and cushioned in the desired area. The DON stated that she was the designated wound nurse until approximately 1 month ago. The facility transferred the responsibility to the MDS nurse at that time. The DON stated she resumed the responsibility on 10/1/17 and did not have specialized wound care education other than some in-services.

Based on record review, family and staff interviews, the facility failed to provide an appropriate and timely intervention related to a change in cognition, behaviors and a critically low temperature assessment for one out of six residents reviewed (Resident #1). The facility reported a census of 78 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] listed stroke and [MEDICAL CONDITION] as [DIAGNOSES REDACTED]. The MDS also noted Resident #1 had memory problems, a moderately impaired ability to make decisions and only sometimes understood others and made him/herself understood. The MDS assessment revealed Resident #1 was independent with all activities of daily living (bed mobility, transfers, walking in the room or the corridor, walking on/off the unit, dressing and eating ), however the resident required oversight/encouragement support from staff for toilet use. The MDS revealed Resident #1's balance as steady when walking or for transitions (with a walker/cane). The MDS revealed Resident #1 occasionally incontinent (less than 7 episodes of incontinence). The Care Plan dated [DATE] noted Resident #1 had a self-care deficit that required the assistance of one for dressing, and had impaired cognition related to dementia and stroke. A revision of the Care Plan dated [DATE] instructed staff to notify the family and physician if significant changes in nutritional status occurred. Another revision dated [DATE] instructed staff to notify the physician of signs and/or symptoms of acute confusion or changes in cognition as needed. According to the revision dated [DATE], the physician should be notified of altered vital signs. Another revision dated [DATE] noted that assistance should be provided to Resident #1 for peri-care upon request or as needed. The [DATE] revision also instructed staff to observe for signs and/or symptoms of urinary tract infections [MEDICAL CONDITION] and notify the physician as needed. A nursing note dated [DATE] at 9:10 a.m. and authored by Staff A, Licensed Practical Nurse (LPN), documented, an Aide reported Resident #1 had not gotten dressed or had been doing his/her own cares like h/she usually did. Staff A completed the following assessment: Blood Pressure (BP) ,[DATE], Pulse (P) 71, Temp (T) 95.0 Fahrenheit (F), and Respirations (R) 17. The LPN documented that Resident #1 would be added to the 24 hour sheet for staff to follow-up with Activities of Daily Living (ADLs), vital signs (VS) and behaviors for 3 days. The 24 hour sheet dated [DATE] noted that staff should document the findings of their assessments of Resident #1's overall behaviors, VS, ability to do ADLs on the 6:00 a.m. to 2:00 p.m. (first), 2:00 p.m. to 10:00 p.m. (second) and 10:00 p.m. to 6:00 a.m. (third) shifts for three consecutive days. A nursing note dated [DATE] at 2:00 p.m. and authored by Staff A noted Resident #1 refused breakfast and lunch. A behavior note dated [DATE] at 3:29 a.m. noted Resident #1 had not demonstrated behavioral issues or expressed complaints of pain or discomfort during the shift. The 24 hour report dated [DATE] documented 0 behaviors for the first and second shifts and 0 issues on the third shift. Under the third shift column, instructions to document behaviors for two more days had also been noted. A nursing note dated [DATE] at 10:00 p.m. and authored by Staff B, LPN, noted Resident #1 had not demonstrated any behavioral issues during the shift. A behavior note dated [DATE] at 5:23 a.m. and authored by Staff B, noted Resident #1 had not demonstrated any behavioral issues during the shift. The 24 hour report dated [DATE] documented 0 behaviors, will not go to meals for first shift, put on doctor's list, not coming out of room for second shift and 0 behaviors noted under the sole instruction to check behaviors on the third shift. A nursing note dated [DATE] at 9:43 p.m. and authored by Staff D, LPN, noted Resident #1 refused to come out of his/her room during the shift. According to the document, the resident ate 25% of his/her supper and had not expressed any complaints of pain or discomfort. Staff D documented she left a note for the Patient Care Manager (PCM) to put Resident #1 on the list to be seen by the doctor in the morning. A behavior note dated [DATE] at 4:06 a.m. noted Resident #1 had not demonstrated any behavioral issues. A telephone order dated [DATE] at 10:30 a.m. ordered a CBC, BMP (blood tests) and UA (urine test) on Resident #1. A telephone order dated [DATE] at 11:30 a.m. ordered for Resident #1 to be transported to the hospital by ambulance. The 24 hour report dated [DATE] noted hospital for the first shift, nothing for the second shift and instructions to monitor behaviors, VS and if going to meals for the third shift. A nursing note dated [DATE] at 11:42 a.m. and authored by Staff A revealed a new order had been obtained for lab work and a urinalysis (UA). The document noted that two attempts to draw blood were unsuccessful and the resident had not urinated before a second order had been obtained to transport Resident #1 to the ER because of unsuccessful attempts to draw blood and the resident's family requested for him/her to be seen that day. A nursing note dated [DATE] at 11:20 p.m. noted that the hospital called to inform them Resident #1 had been admitted with a [DIAGNOSES REDACTED]. A document from the ER dated [DATE] at 12:36 p.m. noted Resident #1 arrived by ambulance accompanied by his/her daughter with the chief complaint of dehydration. According to the document, the nurses at Fountain West said Resident #1 had been lethargic, unwilling to eat, seemed dehydrated and tried to drink out of his/her urinal that day. The physical examination noted a decreased temperature of 96.9 F, somnolent (sleepy), arousal to verbal stimuli but did not follow commands. UA results indicated Resident #1's urine was cloudy with critical levels of red and white blood cells (RBC, WBC) and bacteria. The CBC and differential (blood test) noted an elevated number of WBC and the basic metabolic panel (BMP (blood test)) documented elevated levels of sodium, glucose, BUN (blood urea nitrogen) and Creatinine (sometimes indicative of dehydration).The Impression and Disposition noted the clinical impression as acute [MEDICATION NAME] (bladder inflammation) and hematuria (blood in the urine) with instructions to admit to the telemetry floor (heart monitoring). A document titled Unity Point Internal Medicine History and Physical (H&P) noted Resident #1 arrived with the chief complaint of [MEDICAL CONDITION] (general term meaning brain disease, damage or malfunction) and presented to their facility from Fountain West on [DATE] because of a change in mental status. The resident could not provide any history, his/her daughter said she arrived at Fountain West and found him/her to be lethargic. According to one of Fountain West's nurses, Resident #1 had not eaten any meals two days ago, but she could not account for his/her status over the weekend. According to the family member, Resident #1 only slept and looked weak, both of which were not typical of him/her. The family member also stated that Resident #1's overall appearance seemed similar to how h/she acted when h/she had UTIs in the past. Considering the abnormal behaviors, lab values and decreased temperature, Resident #1 had been admitted for further evaluation and treatment. The physical exam also indicated Resident #1 had a dry oral mucosa (inside mouth). A Flow sheet Note dated [DATE] and authored by an RN noted: - At 8:27 p.m. she notified a doctor of a critical lactic acid level of 6.2 (caused when carbohydrates break down as a result of a low oxygen level) - At 9:20 p.m. she notified a doctor because Resident #1 met the criteria for [MEDICAL CONDITION] (the body's overwhelming and life threatening response to infection) due to decreased temperature, high WBC count and critical lactic acid. - At 11:54 p.m. she notified a doctor of a critical lactic acid level of 19.6 and a decreasing BP. The family had been notified and asked to come to the hospital at the doctor's request. The RN clarified with the durable power of attorney (DPOA) that they wanted to escalate the care up to and including transfer to intensive care unit (ICU). A document titled H&P/Consult dated [DATE] at 2:03 a.m. and authored by a Dr. indicated Resident #1 had moved to MICU (medical intensive care unit) for impending shock. According to the document, the resident had been admitted to the medical floor that day for [MEDICAL CONDITION] attributed to UTI. The H&P also noted Resident #1 was hypothermic (abnormally low temperature), and normotensive (normal BP). Gradually his/her BP decreased, WBC, lactic acid and creatinine increased and had E coli (intestinal bacteria) in the urine. A progress note dated [DATE] at 3:45 p.m. documented that an extensive discussion with family concluded that care would be withdrawn and comfort measures would be started. An untitled document authored by the previous Director of Nursing (DON) noted: - 24 Hour Report Books on [DATE] are to be started for charting purposes and to replace the orange sheets effective immediately. - These books are to be shared with all nursing staff. - Subjective, Objective, Assessment, Plan (SOAP) charting started on the 2:00 p.m. to 10:00 p.m. shift on [DATE]. - Any faxed communication to any Physician will be written in SOAP format. - S - what you heard. - O - what you know to be true. - A - what you are going to do about it. Unfortunately there will be times when things get missed. Our new motto is you see it, you own it. This means you take care of it. Things being ignored without a nurse assessment will not be accepted. If you do not know much about it you need to investigate it. Talk to staff, look in the chart, ask the resident. You would be surprised what cognitively impaired residents may tell you. - P - Then write or call the doctor. What is the intervention or treatment or what do you need to get the effect you want? A Certificate of Death filed on [DATE] documented Resident #1 died on [DATE] at 11:45 p.m. from [MEDICAL CONDITION] (severe infection in the blood) due to or a consequence of UTI. An interview on [DATE] at 10:30 a.m. with Staff A revealed that Resident #1 was very meticulous about everything and took very good care of him/herself. The LPN said h/she had been acting kind of depressed about a week before being sent to the hospital, but seemed to improve. According to Staff A, on [DATE] h/she seemed sick and had not been acting like him/herself. Staff A said she had been noticing urine on the floor. She also noticed Resident #1 started staying in bed, wetting the bed and not taking care of him/herself. Staff A said she put the information on the 24 hour sheet so other shifts would monitor his/her vital signs, ability to do ADLs and overall behaviors for 3 days. The LPN said Resident #1's daughter had been visiting on [DATE] and declined the offer to send him/her to ER. According to the LPN, she returned to work after having the weekend off and noticed h/she had been acting lethargic. The LPN said she obtained a doctor's order for lab work on [DATE]. She said she unsuccessfully attempted to draw the resident's blood twice before another order had been obtained to send Resident #1 to ER. The LPN said she attributed the unsuccessful lab draws to the resident being dehydrated. An interview on [DATE] at 11:41 a.m. with Resident #1's 1st family member revealed observations she made when she visited her father/mother at Fountain West. According to the family member, she tried to visit every Monday and at least another day out of the week. She said she noticed that Resident #1 did not have a water pitcher in his/her room when she visited on [DATE]. Resident #1's family member #1 also noticed h/she did not have a water pitcher in his/her room when she visited again on [DATE]. On that day she said she told a nurse. According to the daughter, the nurse said the resident should have a water pitcher and went and got him/her one. Resident #1's 1st daughter said she got an email from her sister saying that she visited their father/mother on [DATE] and said h/she had not been eating, not getting out of bed and was in bad shape. The 1st family member said she went to visit her father/mother the next day on [DATE]. She said she found him/her curled up in bed and his/her breakfast tray had not been touched. Resident #1's family member #1 also recalled how cold his/her room felt. According to the family member, she went and told the nurse that h/she looked terrible. The resident's daughter said the nurse acknowledge she already knew and said h/she had not been eating well on Friday or Saturday. The daughter said she and the nurse went to Resident #1's room; at which time the nurse said it's freezing in here. At that time, Resident #1's family member said she told the nurse to speak with the on call doctor. According to the family member, she went out to her car to call her sisters. When she went back into the facility, the nurse said she spoke to someone that ordered a UA. The daughter remembered the urine in her father/mother's urinal looked as dark as any she had ever seen. According to the daughter, the nurse told her she also figured out the room felt so cold because the air conditioner had been on. She said the nurse told her she had not been able to successfully draw a blood sample and asked if the family wanted their father/mother to go to the doctor or the hospital and if they wanted to transport him/her or go by ambulance. Family member #1 (daughter) told the nurse she wanted her father/mother transported to the hospital by ambulance. Resident #1's family member said at that time she saw staff leaving Resident #1's room and walking him/her down the hall. According to the family member, a staff member said her father/mother drank out of his/her urinal. The daughter also said staff told her they had removed his/her water pitcher so h/she would not urinate in it. A subsequent interview on [DATE] at 12:22 p.m. with Resident #1's 1st family member revealed she had not visited her father/mother on Friday [DATE] when this surveyor inquired about a family member that supposedly declined a nurse's offer to send their father/mother to ER that day. She said she spoke with her sister, Resident #1's 2nd family member who also said she did not believe she visited on [DATE] either. She said her sister said regardless if she visited or not, she could say with absolute certainty that she had not declined an offer to send her father/mother to the hospital. The 1st family member said her other sister had been wintering in Florida at that time and their brother lived in Arizona, and neither of them visited on [DATE]. An interview on [DATE] at 1:25 p.m. with Staff D, revealed that typically Resident #1 played cards with his/her family when they visited. Staff D said Resident #1 came out to meals sometimes too. According to Staff D, h/she stayed in his/her room more during the weekend before being sent toER on [DATE]. Staff D said his/her family thought h/she had been acting more depressed so she left a note for the PCM to add Resident #1 to list of people to see the doctor. Staff D said Resident #1 had not appeared sick from what she remembered. When asked if she assessed Resident #1's vital signs that weekend, she said she could not recall, but would have documented them in Point Click Care if she had. She said if the information to assess vital signs did not get added to the 24 hour sheet they probably got overlooked. An interview on [DATE] at 2:44 p.m. with Staff F, CNA, revealed that she no longer worked at Fountain West. According to her, she remembered seeing Resident #1 drinking from his/her water pitcher that smelled like urine. The CNA thought the resident had used the pitcher as a urinal. Staff F said she just cleaned the cup out and refilled it with fresh ice water. According to the CNA, the resident did it all the time and everybody knew about it. The CNA said she never tried to educate the resident because of a hearing impairment. According to Staff F, she told the nurse. She said the nurse acknowledged that she understood her, but doubted they did anything about it. An interview on [DATE] at 3:45 p.m. with Staff E, CNA said she left Fountain West in February 2017 because they eliminated her position. Staff E said she only worked there for about one and a half to two months, but recalled knowing Resident #1. According to the CNA, she remembered hearing from nurses in report that a resident would drink urine out of his/her urinal if they did not keep it empty. Staff E said she could not recall anything about Resident #1 in particular between [DATE] and [DATE]. A subsequent interview on [DATE] at 8:22 a.m. with Resident #1's 1st family member revealed the facility did not contact any of the family members when their father/mother's condition changed on [DATE]. According to her, none of them realized just how sick their father/mother had been until family member #2 (her sister) visited on [DATE]. An interview on [DATE] at 9:52 a.m. with Staff H, CNA/CMA (certified medication assistant) revealed that she worked as a CMA on the weekend before Resident #1 had been sent toER on [DATE]. The CMA said she could take vital signs and record them on the 24 hour sheet, but other assessments were outside of the scope of her practice. She remembered the 24 hour sheet instructed staff to chart Resident #1's behaviors because h/she had not been coming out to meals and his/her family thought h/she had been acting more depressed. The CNA recalled h/she had not been coming out of his/her room that weekend like he/she usually did. The CMA said she had not done VS because the 24 hour report did not instruct her to. According to the CMA, the overnight shift was responsible to transpose information from one day to the next on the 24 hour report and it only addressed behaviors related to suspected depression. The CMA said she told the charge nurse and the next shift about Resident #1 not coming out of his/her room. Staff H said they had to take the trash can out of Resident #1's room because h/she had been urinating in it. When asked, the CMA said they refilled the resident's pitcher with fresh ice water every shift and she never noticed that it smelled like urine. According to Staff H, Resident #1's room smelled like urine because of urinating in the wastebasket. An interview on [DATE] at 11:10 a.m. with the DON revealed her explanation of how staff failed to follow up on the 24 hour report that had been initiated on [DATE]. According to the DON, the 24 hour report was one of the many new systems that the old DON implemented at about that same time. The DON said they were all trying to get used to those changes. The DON also said apparently there were some bugs in the system, because not all the information got transposed from the initial 24 hour report onto the days that followed. According to the DON, the 95 F. temperature should have been rechecked for accuracy because of being a critical value. The DON said she would have expected that and for everyone else to follow up on the 24 hour report as it was intended. An interview [DATE] at 11:40 a.m. with Staff B revealed that Resident #1's demeanor had changed completely. The LPN said h/she seemed to be very confused. According to Staff B, she thought one of the CNAs caught him/her drinking from his/her urinal. Staff B recalled that after a CNA got Resident #1 ready to send to the hospital on [DATE], h/she started walking out of his/her room, so she and the CNA walked with him/her. Staff B recalled the resident's gait being steady, but they sat him/her in a chair just about the time the ambulance showed up. Staff B remembered one of Resident #1's family members being there and the CNA telling her she wondered if her father/mother drank out of his/her urinal because she saw it in his/her hand and up to his/her mouth. According to Staff B, the CNA had not actually seen the resident drink from it. An interview on [DATE] at 12:15 p.m. with Staff G, CNA revealed that she worked at Fountain West a couple days a week for about two months. Staff G said she remembered getting Resident #1 ready to be transported to ER by ambulance. According to Staff G, Resident #1 had been soaked in urine when she entered his/her room. She recalled seeing the resident reach down to pick the urinal up off the floor and lifted it to his/her mouth. The CNA said she intervened before he/she drank from it and offered the resident a drink of water instead. Staff G also recalled walking with Resident #1 down the hall and being told by someone that h/she probably should not be walking. According to Staff G, she had never heard of Resident #1 drinking from a urinal before. An interview on [DATE] at 9:00 a.m. with Resident #1's 2nd daughter/family member revealed her account of her father/mother's condition when she visited on Sunday [DATE]. According to her, she could tell right away that h/she did not feel well. The family member said she told a nurse who in turn told her they noticed h/she had not been eating or leaving his/her room. Resident #1's family member #2 said the things the nurse mentioned were very uncharacteristic of her father/mother. The daughter said she went back into the room and tried visiting some more. She said Resident #1 had a hard time staying awake so she went and told a nurse that something needed to be done. The nurse said she would put Resident #1 on the list to be seen by the Doctor. According to Resident #1's family member #2, she relied on the nurse's expertise and ability to make good decisions. In hind sight, the family member said she now believed h/she should have been taken to the hospital right away. She recalled when her father/mother had a similar problem when h/she lived with her a few years before. The family member said she took Resident #1 right away and they were able to resolve the UTI. She said Resident #1 did not have a water pitcher in his/her room when she visited on [DATE]. The family member said she visited at least once or twice a week, and noticed frequently towards the end h/she did not have water in his/her room. According to her, h/she developed peculiar urinary habits like urinating in the wastebasket and the facility told her family/sister they removed the water pitcher for that reason. A subsequent interview on [DATE] at 12:15 p.m. with the DON revealed that she did not have any documentation or other evidence to know if the doctor had been called between the time Resident #1 had been assessed with [REDACTED]. According to the DON, since the nurse had not verified the accuracy of the temperature by rechecking it, the doctor should have been notified of the critical value right away. An interview on [DATE] at 1:00 p.m. Resident #1's physician revealed that elderly people's temperatures can run a little bit lower. The doctor said he considered 99.9 F. to be significantly elevated, but agreed that 95 F. was not normal. According to the doctor, he would have expected the facility to notify him about a temperature of 95 F. and a change in Resident #1's ability to perform his/her own ADLs. The doctor said he would have expected them to recheck such a critical value to verify the accuracy and carefully monitor the resident. According to the physician, early intervention with antibiotics and IV fluids were important. An interview on [DATE] at 1:15 p.m. with Staff A revealed that she could not remember calling the doctor on [DATE], and wondered if she should have for some reason. After being informed that her assessment of Resident #1 on [DATE] documented a temperature of 95 F., the LPN said she would have charted the doctor notification in Point Click Care (electronic record) if she had done it.

Based on observation, record review and staff interview, the facility failed to provide adequate nursing supervision to prevent accidents 9 of 13 residents reviewed. Physical Therapy (PT) identified Resident #1, #2, #9, and #43 required assistance with transfers and ambulation (walking). The residents continued to self-transfer and not always use the call light. The facility did not consistently implement interventions to address the residents ' risk of falls resulting in multiple falls and injuries, including hip fractures. Resident #1 died as the result of complications of hip fracture. Resident #11 fell with head injury when he/she attempted to self-transfer. No one heard the resident's alarm. Resident #3 was allowed to self-transfer even though a PT treatment note dated [DATE] revealed PT and nursing both collaborated on Resident #3 requiring one person assist with transfers. After falls, the facility did not implement new interventions. Resident #45's care plan directed the resident required assistance with transfers and ambulation. The facility implemented interventions after most falls, but two (2) of the interventions relied on the resident's memory although he/she experienced persistent cognitive deficits. Resident #7 sustained repeated skin tears to the left elbow from bumping into the wall or doorframe when staff used the EZ stand. Resident #22 was placed in an EZ stand and facility staff then left him/her alone for an extended period of time. The findings constitute an immediate jeopardy to the residents' health and safety. The facility identified a census of ninety-three (93) residents. Findings include: 1. A Minimum Data Set (MDS) assessment tool dated [DATE] revealed Resident #2 had a [DIAGNOSES REDACTED]. The resident displayed the following indicator of delirium that fluctuated through the day: inattention, and had no behavior symptoms identified. The resident required limited staff assistance with bed mobility, transfers and ambulation and extensive staff assistance with toilet use, dressing and personal hygiene. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance. The resident used a walker and wheelchair for mobility and was occasionally incontinent of bladder. Falls: An incident report (IR) dated [DATE] at 6:40 a.m. revealed the resident fell in his/her room. The resident had walked with a glass of water and spilled the water on the floor. He/she then slipped in it, fell on his/her bottom and hit his/her head on the bed frame. The resident complained of head and back pain following the incident. The IR listed the intervention following the incident: encourage reminders and encourage resident not to walk with water in room. Have staff assist with carrying water as appropriate. Following the incident, a transfer form dated [DATE] identified the resident transported to the emergency room (ER) for evaluation. Nursing progress notes dated [DATE] at 12:51 p.m. revealed the facility received a phone call from the hospital ER stating the resident would return to the facility. Labs, spine x-rays and head CT (computerized tomography) were all within normal limits. ER personnel stated they gave the resident 50 mcg (micrograms) of Fentanyl (narcotic) with no further back pain noted. The resident returned to the facility at 1:40 p.m. The resident complained of continued back pain when he/she moved certain ways and continued to have a slight headache. An x-ray report dated [DATE] revealed osteoporosis and an age indeterminate compression fracture of T 11. A CT of the abdomen and pelvis dated [DATE] revealed a T 10 compression fracture with near complete vertebral body height loss. A physical therapy (PT) outpatient discharge form identified the PT end date as [DATE]. The form identified the resident ambulated with contact guard assistance (CGA) of one staff and a front wheel walker, and transferred with limited to extensive assistance of one staff. Nursing progress notes dated [DATE] at 3:07 a.m. revealed the resident apparently walked to their roommate's recliner. The resident did not use the call light. The entry identified the resident required assist of one assist with walker. Nursing progress notes dated [DATE] at 6:05 p.m. revealed there were times the resident ambulated alone and did not use the call light. Staff educated the resident to use the call light to request assistance. An MDS dated [DATE] identified the resident with a BIMS score of 6 (severe cognitive impairment). Nursing progress notes dated [DATE] at 1:27 p.m. revealed staff observed the resident ambulating in his/her room. Staff repeated cues and reeducation regarding the need to call for assistance and safety awareness. Nursing progress notes dated [DATE] at 5:05 p.m. revealed the resident wanted to go to the bank and walked down the hall by themselves without assistance or a walker. Staff reeducated the resident and assisted the resident back to his/her room. Staff also reminded the resident to use the call light and wait for help. Nursing progress notes dated [DATE] at 6:23 a.m. revealed the resident was up without the walker. Staff then assisted the resident to the toilet. A restorative program form dated [DATE] directed staff should ambulate the resident with front wheeled walker and CGA of one staff. A physician encounter note dated [DATE] at 2:08 p.m. identified the resident experienced debility and required increased assistance with transfers and ambulation. An IR dated [DATE] at 5:40 a.m. revealed staff found the resident sitting on the floor in front of the recliner in his/her room. The resident denied pain and did not hit his/her head. The resident sustained [REDACTED]. The IR identified the resident's transfer/ambulation needs as up with assistance of one with front wheeled walker and gait belt. The IR did not identify an intervention placed following the incident. Nursing progress notes dated [DATE] at 2:40 p.m. revealed the resident up and wandering in the hallway a couple times on that shift. Staff talked to the resident about using the call button and need for the walker and staff assistance to prevent falls. The resident voiced understanding but seemed forgetful. A care plan intervention dated [DATE] revealed the resident required limited to extensive assistance of one staff for transfers and toilet use. The resident required contact guard assistance of one staff with a front wheeled walker. (According to PT [DATE] the resident required one staff assistance and walker) The resident was on a prompted toileting plan on [DATE]. Nursing progress notes dated [DATE] at 10:27 a.m. documented the resident required CGA assistance with ambulation and transfers. Nursing progress notes dated [DATE] at 4:53 p.m. identified the resident standing up by themselves in their room. An IR dated [DATE] at 3:15 a.m. revealed staff found the resident sitting on the floor in his/her room with the resident's back against the foot of the bed. The resident did not know how he/she ended up on the floor. The IR identified the intervention following the incident as assure needs are met before leaving room. The care plan intervention box identified this intervention was in place since [DATE]. An IR dated [DATE] at 8:30 p.m. revealed staff found the resident seated on the floor. The resident fell trying to get clothes out of the closet. The resident hit his/her head on the bathroom door. The IR did not identify an intervention following the incident. An IR dated [DATE] at 5:15 a.m. revealed the resident stated he/she came out of the bathroom and fell . Staff found the resident sitting on his/her bottom on the floor in his/her room. The resident said he/she hit their head on the edge of the bed. Staff applied an ice pack to the head. The resident received a hematoma to the right forehead and abrasion to the buttock. The IR did not identify an intervention following the incident. Nursing progress notes dated [DATE] at 9:16 a.m. revealed the resident transferred to the ER for evaluation. Nursing progress notes dated [DATE] at 1:36 p.m. revealed the resident had a 1 centimeter (cm) by 4 cm scrape to the right upper buttock with a scant amount of blood noted, a 2 cm by 0.1 cm scrape on lower buttock with a scant amount of blood noted, and a 5.5 cm by 1 cm scabbed area on the right hip. Staff documented all above areas were due to the resident's previous fall. A physician encounter form dated [DATE] at 4:51 p.m. revealed the resident transferred to theER on [DATE] after a fall. The resident had bruising above and below bilateral (both) eyes as well as to the right forehead. The ER evaluated the resident with laboratory tests, left hand X-rays, and a CT of head. The left hand X-ray showed mild osteopenia and mild degenerative arthritis. The bruising was described as follows: Examination of the head and face revealed hematoma around bilateral eyes and right forehead and tenderness over the right frontal area. The right eyelid showed swelling of the upper eyelid and extensive bruising around bilateral eyes. The resident fell 4 times in the past week. The resident used a walker with assistance and transferred with assistance. The resident used a wheelchair for longer distances. The resident's motor strength revealed the resident displayed weakness in both upper and lower extremities. A CT of the abdomen/pelvis on [DATE] revealed a T 10 compression fracture. A Tinetti assessment tool identified the resident with a combined balance and gait score of ,[DATE]. A score of less than 21 identified the resident at high risk for falls. An IR dated [DATE] at 8 a.m. revealed staff found the resident sitting in the hallway on his/her bottom with the left leg flexed outward with his/her back up against the wheelchair wheel. The foot pedals were in the down position. The resident yelled with range of motion (ROM) and told staff to take him/her to the hospital. A statement dated [DATE] and written by the charge nurse revealed the resident was last seen at 7:30 a.m. At that time, the resident tried to ambulate by themselves. The nurse went to pass medications and left the resident with a CNA (certified nurse aide). At 8 a.m., the charge nurse heard someone fall from the end of the hallway. When she investigated the noise, she observed the resident on the floor with staff beside the resident. A transfer form dated [DATE] identified the resident transferred to the hospital following the incident. The transfer form revealed staff found the resident sitting in the hallway on the floor with his/her back against the wheelchair wheel and wheelchair pedals in the down position. The form identified that there were no witnesses to the incident. Nursing progress notes dated [DATE] at 1:24 p.m. revealed ER phoned and reported Resident #5 had sustained a left femur fracture and would undergo surgery to repair the fracture. A PT discharge summary revealed the resident did not progress significantly with 3 PT sessions prior to hospitalization on [DATE]. The resident continued to exhibit cognitive deficits with poor safety awareness and insight into his/her deficits. The resident continued to self-transfer and be noncompliant with waiting for CNA assistance. Nursing progress notes dated [DATE] at 12:23 a.m. revealed the resident returned to the facility from the hospital at 4:30 p.m. on [DATE]. The resident had some bruises on arms from IV's at the hospital and 25 staples in the left hip incision. The resident utilized the EZ stand and 2 staff for transfers. Nursing progress notes dated [DATE] at 4:20 a.m. revealed the resident showed inadequate awareness of self-limitations and staff anticipated most to all of the resident's needs. A physician visit encounter form dated [DATE] identified the resident sustained [REDACTED]. The resident attempted to stand up from the wheelchair and fell . The resident readmitted to the facility following ORIF (open reduction and internal fixation) repair of the left femoral neck fracture. A hospital trauma daily progress note dated [DATE] identified the resident sustained [REDACTED]. The report also identified the resident exhibited bilateral eye bruising. Nursing progress notes dated [DATE] at 4:20 a.m. revealed the resident sat up to go to the bathroom and slid off the bed to the floor. Staff found the resident on the floor at the bedside. The resident did not use the call light and the resident was barefoot. The resident's brief was wet. The resident did not sustain injury. The intervention on care plan dated [DATE] after the incident directed staff to take the resident to the bathroom on second rounds. Nursing progress notes dated [DATE] at 1:01 a.m. revealed staff checked the resident every 30 minutes and found the resident sitting in his/her recliner chair. The resident did not use the call light and then self-transferred to the recliner. Staff educated the resident to use the call light for assistance. Nursing progress notes dated [DATE] at 9:32 p.m. identified staff saw the resident ambulating in his/her room without assistance. Staff encouraged the resident to call for assistance when he/she wanted to stand up and walk around. The care plan did not contain any new interventions following the [DATE] and [DATE] documentation of self-transfers/ambulation. Nursing notes dated [DATE] at 3:07 a.m. revealed staff continued to check the resident frequently as the resident was noncompliant with call light use. Staff documented reeducation continued without effectiveness due to cognitive decline. Care Plan: The care plan identified an intervention dated [DATE] that directed staff to place the recliner in a safe sitting position when the resident sat in the recliner. The point click care (PCC) care plan box identified staff created the intervention on [DATE]. The care plan identified an intervention dated [DATE] that directed staff to observe resident for signs and symptoms of restlessness during the night time hours. Offer toilet, snack, or relaxing activities if increased restlessness noted. The PCC care plan box revealed staff created the intervention on [DATE]. The care plan identified an intervention dated [DATE] that directed staff to place a call light reminder sign by the resident's bed. The PCC care plan box revealed staff created the intervention on [DATE]. An intervention on the care plan follow facility fall protocol created on [DATE], identified the intervention follow facility protocol had been in place since that date. Review of the facility fall protocol revealed staff would complete a fall assessment on the first day of admission. If the fall assessment identified the resident as at risk for falls, the team leader/case manager would instruct the staff to monitor the resident frequently, answer the call light promptly and add any other safety measures to help protect the resident. Staff Interviews: On [DATE] at 2:34 p.m. Staff E, LPN unit manager stated she worked when the resident fell on [DATE]. Staff heard the resident yelling. When Staff E saw the resident, he/she was sitting on the floor. When Staff E asked the resident if he/she could rotate his/her leg, the resident yelled out in pain. The resident complained of hip pain. Staff E stated she thought the resident did get up without help. On [DATE] at 2 p.m. Staff F CNA stated she worked when the resident fell on [DATE]. She came up the 100 hall and heard someone yell help me. After she finished what she was doing, she went down the 300 hall and saw the resident on the floor. She stated she didn't know where the 300 hall staff were. She started the resident was about 3 feet from the resident room door. The resident complained of knee pain. Staff F called for help and the DON (director of nursing) and ADON (assistant director of nursing) arrived. When asked what was being done for the resident to prevent falls, Staff F stated she couldn't think of anything as the facility was going alarm free. Staff F reported Resident #5 was care planned to get up with staff assistance, was not to be up by him/herself and did not wait for help; reeducation did not help, and staff offered resident things to occupy him/her. Staff F also reported the resident did not use the call light. In Staff F's written statement dated [DATE], she wrote she last saw the resident at 6:30 a.m. standing in the doorway. At that time, Staff F redirected the resident to the recliner and offered the resident the toilet and a drink. The resident refused both. On [DATE] at 3:35 p.m., Staff G CNA stated prior to the [DATE] fracture, the resident got up all the time. Staff G found the resident found Resident #5 transferring or ambulating without assistance in the hallway and in the dining room. On [DATE] at 2:58 p.m. Staff H CNA stated the resident was known to get up without asking for assistance On [DATE] at 8:10 a.m. the DON stated the created date in the point click care plan box was the date the intervention was created. She stated at the end of August a new unit manager (UM) took over and there was miscommunication regarding inputting the new interventions on the care plan. On [DATE] at 10:41 a.m. Staff A, CNA (certified nurse aide) stated the resident tried to stand up constantly - 4 to 5 times a shift. The resident also did not like to use the call light and tried walk to his/her closet or the bathroom as the resident wanted to use the bathroom frequently. On [DATE] at 2:40 p.m. Staff B, LPN (licensed practical nurse) stated the resident was known to get up and not use the call light. Sometimes staff found the resident in the midst of standing up when Staff B walked by the room. On [DATE] at 3:12 p.m. Staff D, LPN stated the resident was known to get up without waiting or using the call light once in a while. On [DATE] at 2:58 p.m. Staff H, CNA stated the resident was known to get up without asking for help. Staff H would ask the resident to sit for a second and 2 minutes later the resident would stand up. When Staff H came back, it would startle the resident. Observation: On [DATE] at 11:35 a.m. observation showed Staff I CNA transferred the resident and placed the resident in the wheelchair without a gait belt. Staff I confirmed he did not use a gait belt, but stated he did use the walker for the transfer. Observation showed the walker by the wall approximately 8 feet from Staff I and the resident. The care plan in place [DATE] contained an intervention dated [DATE] that directed staff to stand pivot transfer the resident with one to two staff, gait belt and front wheeled walker. 2. An MDS dated [DATE] documented Resident #11 had [DIAGNOSES REDACTED]. The MDS also documented the resident did not ambulate and required extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, and personal hygiene. The MDS revealed the resident showed functional range of motion (ROM) limitations of the upper and lower extremities, used a wheelchair for mobility and experienced two or more falls without injury since the previous assessment. A care plan with a completion date of [DATE] identified Resident #11 as at risk for falls related to balance problems, functional ROM problems, osteoarthritis, osteoporosis, severely impaired cognition, incontinence and medication use. The care plan directed staff to encourage the resident to self-propel his/her wheelchair and assist as needed (extensive assist of one staff for locomotion in wheelchair). The care plan also directed staff to assist the resident with transfers to desired destination (bed, recliner, toilet, etc.) shortly after meals. The resident used a sensor alarm in the wheelchair. An IR dated [DATE] at 7:20 p.m. revealed staff found the resident lying on his/her right side in the central hallway with a large bump on the forehead and a bloody nose. The resident reported back pain. The alarm sounded when the resident fell . The investigation portion of the incident report was blank. On [DATE] at 1:55 p.m., Staff K LPN stated Resident #11 was in the central hallway and fell out of the wheelchair. She stated there was a family visiting another resident in the central hall and they alerted staff to the resident's fall. No staff heard the resident's wheelchair alarm. Staff found the resident first on the ground. Staff K called the ambulance and the resident transferred to ER for evaluation. Staff K stated after the incident the resident had black eyes. Nursing progress notes dated [DATE] at 12:08 a.m. revealed the hospital called and informed the facility the resident had a UTI (urinary tract infection) and the resident would return with an order for [REDACTED]. The head CT and chest X-ray were unremarkable. Nursing progress notes dated [DATE] at 8:34 p.m. revealed staff found the resident sitting on the floor in front of the wheelchair. The resident attempted to self-transfer to bed. The notes did not identify if the alarm activated. The resident did not sustain injury. Review of the current care plan revealed no new intervention(s) added following the incident. The incident report dated [DATE] at 8:30 p.m. revealed the alarm failed to sound when the resident attempted to self-transfer. The incident report also revealed staff added no new intervention(s) following the incident. Observation on [DATE] at 1:10 p.m. revealed Staff L CNA transferred the resident to the toilet via the EZ stand. The alarm sounded when Staff L assisted the resident to stand. Staff L stated she took care of the resident on [DATE], but the resident fell after he/she left. The next day the resident had 2 black eyes. 3. An MDS dated [DATE] assessed Resident #3 with a BIMS score of 8 (moderate cognitive impairment). The resident required extensive staff assistance with bed mobility, dressing, toilet use, personal hygiene and bathing. The resident required limited staff assistance with bathing. A balance during transitions and walking test identified the resident as not steady but able to stabilize with staff assistance. The resident used a walker and wheelchair for mobility. The MDS identified the resident received daily anticoagulant medication. A physical therapy (PT) treatment note dated [DATE] revealed the PT and nursing both collaborated on the resident being one person assist. The resident discharged from PT on that date. The resident remained at risk for falls and nursing educated and posted signs in room to wait for staff assistance prior to attempting to transfer. Care plans with completion dates of [DATE] and [DATE] identified the resident as independent to limited staff assistance of one with transfers. Falls: An IR dated [DATE] at 11:30 a.m. revealed staff found the resident seated on his/her bottom with legs stretched out in front of him/her and the resident's back on the wall by the toilet. The resident stated he/she went down easy and fell getting off the toilet. The resident did not sustain injury. The IR identified the intervention after the incident as assure needs are met before leaving room. The [DATE] care plan already had the following intervention in place: anticipate and meet the resident's needs as appropriate dated [DATE]. An IR dated [DATE] at 12:45 a.m. revealed staff found the resident seated on the floor by the bed. The resident did not sustain injury. The IR did not identify an intervention following the incident. An IR dated [DATE] at 2:45 p.m. revealed the resident slipped forward out of the wheelchair when a CNA pushed the resident without foot pedals. The resident hit his/her right temple on the wall and received a small, tender abrasion. Staff assisted the resident back in the wheelchair. The intervention following the incident was to have foot pedals available on the back of the wheelchair and educate employees on proper procedure. The care plan did not contain the intervention. An IR dated [DATE] at 7:10 p.m. revealed staff found the resident lying on his/her side on the floor. The resident received a skin tear from the incident. The intervention following the incident was to educate the resident to use the call light. According to the [DATE] care plan the care plan already contained an intervention that directed staff to ensure the resident's call light was in reach and encourage the resident to use it. Staff needed to answer the call light promptly. An IR dated [DATE] at 7:10 p.m. revealed staff found the resident on the floor seated on his/her bottom in the resident room. The resident stated he/she attempted to transfer from the wheelchair to the bed and fell . The resident hit his/her head on the night stand resulting in a bump measuring 0.7 cm. by 0.7 cm. on the back of the head. The IR did not have an intervention listed following the incident. An IR dated [DATE] at 1:20 a.m. revealed staff heard the resident yell, help me. Staff found the resident on the floor in his/her room between the wheelchair and bed. The resident's head was up and the resident was in a sitting position in his/her room. Staff did not observe injury. The intervention following the incident was call light reminder sign paced on bedside table and assure bedside table is next to resident when in bed. The resident already had a reminder sign in place on [DATE] to wait for staff assistance. The care plan completed on [DATE] continued to contain the intervention that identified the resident as independent to limited staff assistance of one with transfers. An IR dated [DATE] at 7:45 p.m. revealed a fall in the resident room. The resident tried to get to bed without shoes on and fell to the floor. The resident did not sustain injury. The intervention following the incident was to assure the resident wore shoes. An IR dated [DATE] at 6:30 p.m. identified a fall in the resident room. Staff found the resident on the floor lying on his/her back between the bed and window. The wheelchair was at the foot of the bed. Staff did not observe injury. There was no intervention listed following the incident. An IR dated [DATE] at 5:30 a.m. revealed a fall in the resident room. Staff found the resident on the floor next to the bathroom. The resident could not explain what occurred. The IR identified the resident had previously been anxious. The resident sustained [REDACTED]. by 2 cm. The intervention following the incident was to answer the resident promptly when he/she called. (Already in place) and a PT/Occupational therapy (OT) screen. Nursing progress notes dated [DATE] at 5:31 p.m. revealed staff observed a skin tear on the right upper arm with purple discoloration surrounding it. The skin tear measured 0.5 cm. by 6 cm. by 0.1 cm. Staff closed the wound with 6 steri strips. The resident did not know how the injury occurred. There was no incident report for the injury. An IR dated [DATE] at 7:30 p.m. revealed a fall in the resident room. Staff attempted to transfer the resident from his/her wheelchair into bed. The resident's knees buckled and the resident went to the ground. The resident did not have shoes on. The resident did not sustain injury. A hospital report dated [DATE] revealed the resident fell 3 times in the past 3 days. The resident sustained [REDACTED]. The report identified a left wrist skin tear and right bicep skin laceration. On [DATE] at 9:28 a.m. Staff M LPN unit manager confirmed the resident toileted themselves. Observation: Observation showed on [DATE] at 10:20 a.m. the resident in the bathroom. At that time, Staff L CNA stated the resident would take themselves to the bathroom and when he/she wanted off the toilet, the resident would pull the call light. On the same date at 10:35 a.m., the resident transferred themselves to bed. Staff L stated the resident was in the process of transferring when he/she entered the room. The resident did not use the call light. On the same date at 10:55 a.m., the resident transferred themselves from bed to wheelchair. On [DATE] at 11:37 a.m., the resident wheeled themselves using their feet in the wheelchair. Observation showed a large bruised area around the left eye. When asked what happened the resident stated it ' s been like that a long time. The record lacked documentation of a left black eye. The DON supplied documentation on a sheet of legal pad paper, a list of interventions implemented following falls: [DATE] Staff to offer restroom prior to meals. The care plan identified the resident was already on a prompted toileting plan which identified prompted toilet before meals in place since [DATE]. [DATE] assure resident with appropriate position in wheelchair for safety. (This intervention was not on the resident's care plan and the PCC care plan box identified this intervention was created on [DATE]) [DATE] During sleeping hours observe resident for restlessness and if he/she is awake offer drinks, snacks and toilet. The PCC care plan box identified this intervention was created on [DATE] (The resident already had an intervention on the care plan to observe for restlessness and provide calming activities dated [DATE]) [DATE] Provide patient education related to safe sitting/standing when appropriate. (The MDS identified the resident with a BIMS of 8, moderate cognitive impairment) [DATE] Call light reminder sign on bedside table. (PT notes identified the resident already had a sign in place [DATE] to wait for help) [DATE] Staff to assure the resident's wheelchair placed next to bed. The PCC care plan box identified this intervention was created on [DATE]. [DATE] Assure call light answered promptly. According to care plan review, this intervention was already in place since [DATE]. [DATE] Offer snacks and drinks as needed through the day. The PCC care plan box identified this intervention was created on [DATE]. 4. An MDS dated [DATE] assessed Resident #1 with a BIMS score of 9 (moderate cognitive impairment). The resident had no behavior symptoms identified. The resident required extensive staff assistance with bed mobility, dressing, toileting and bathing. The resident required limited assistance of staff with ambulation and personal hygiene. A balance during transitions and walking test identified the resident as not steady but able to stabilize without staff assistance in all areas of testing. The resident used a walker and wheelchair for mobility. The MDS identified the resident admitted to the facility [DATE]. The resident was occasionally incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury since admission. A Tinetti assessment tool identified the resident with a fall risk score of ,[DATE]. A score less than ,[DATE] revealed a high fall risk. The initial care plan dated [DATE] identified the resident as at risk for falls and required assistance of 1 staff with bed mobility, transfers and ambulation. A care plan with completion dated of [DATE] revealed the resident required assistance of one staff with transfers and assistance with toileting. The care plan identified the resident with a risk for falls. The interventions to assist with the prevention of falls and all dated [DATE] included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate resident

Based on observation, record review and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 7 of 7 residents reviewed. Resident #2, #3, #5, #7, #11, #17, and #21. Resident #5 experienced symptoms of stroke that the facility failed to act on in a timely manner. Resident #2, Resident #11 and Resident #3 fell and bruised their faces. The facility failed to assess and document the bruising. Resident #7 had an open area to his/her bottom that the facility failed to measure or document a description of. The facility failed to follow up on Resident #5's skin impairment. Resident #17 [MEDICAL CONDITION] and pain. The resident stated the facility failed to administer pain medications in a timely manner. Resident #21 fell and fractured his/her upper arm (humerus) and the facility failed to document an ongoing assessment. The facility failed to provide a follow up assessment. Facility census was ninety-three (93) residents. Findings include: 1. A Minimum Date Set (MDS) assessment tool dated 3/31/16 assessed Resident #5 with a BIMS score of 5 (severe cognitive impairment) The resident had behavior symptoms of verbal and other behaviors 1 to 3 days out of 7 and did not reject care. The MDS documented the resident required extensive staff assistance with bed mobility, dressing and eating and total assistance with transfers, toileting, personal hygiene and bathing. The MDS also documented Resident #21 did not ambulate and had functional range of motion limitations of one lower extremity, was frequently incontinent of bowel and bladder, and at risk for pressure sores and the resident had pressure sores. The MDS did not identify moisture associated skin damage (MASD) and revealed the resident had [DIAGNOSES REDACTED]. The resident admitted to the facility on [DATE]. Stroke Nursing progress notes dated 7/28/16 at 8:31 p.m. and documented by Staff C RN revealed the resident's granddaughter informed the nurse that the resident had right side facial drooping and could not speak. The resident appeared sleepy. The resident looked at Staff C when staff spoke to him/her. The resident attempted to speak to answer questions but could not say any actual words. The right side of the face had drooping and the right grip was weaker. The resident could move extremities. Temperature was 98 axillary, pulse 84, respirations 16 and blood pressure 128/72. The next nursing progress note entry dated 7/29/16 at 12:45 a.m. and documented by Staff AA LPN revealed Staff C informed her of the resident's symptoms at 12:30 a.m. Staff AA observed the resident lying in bed awake and alert with right side of face drooping. The resident could usually swallow a pill whole. Staff AA had to crush the resident's 12 a.m. [MEDICATION NAME] and the resident could not keep it in his/her mouth. Water and parts of the pill ran out of the right side of the resident's mouth. The resident could follow the nurse with his/her eyes. The resident could not speak. The resident could not grasp with the right hand. The resident's pupils reacted to light. Staff AA notified the resident's daughter at 1 a.m. who gave the OK to notify the physician. Staff AA called the physician's answering service at 1:10 a.m. with no answer. At 1:40 a.m. the ARNP called and gave the OK to transport the resident to ER. At 2:16 a.m. the ambulance arrived and transported the resident to the hospital. Hospital ED (emergency department) HPI (history of present illness) comments, dated 7/29/16 at 2:56 a.m. revealed the resident presented from the nursing home for evaluation of stroke-like symptoms and was noted to develop an acute onset of [MEDICAL CONDITION] with right sided facial droop and right upper extremity weakness around 8:30 p.m. last night. The facility did not send the resident to the ED at that time. Nursing staff at the facility reportedly noted a persistent [MEDICAL CONDITION] and facial droop around 12:30 a.m. this morning as the resident had difficulty taking his/her pills at that time. Therefore EMS (emergency medical services) was finally called around 2 a.m. to transfer the resident to the ED for further evaluation. ED provider notes dated 7/29/16 at 5:26 a.m. revealed the resident continued to have apparent neurological deficits including facial droop and [MEDICAL CONDITION]. The physician suspected the resident's symptoms were related to an acute stroke though the onset and progression of the symptoms. The resident presented well outside the window for any emergent treatment for [REDACTED]. The resident admitted to the hospital for care. A hospital history and physical identified the resident's principal problem as acute ischemic stroke. On 11/22/16 at 2:38 p.m. Staff C RN stated the resident started having symptoms on the 2 p.m. to 10 p.m. shift. The resident was very tired and exhibited unclear speech. Staff C thought it may have to do with the resident being tired. Staff C notified the charge nurse Staff M LPN. The resident's vitals were fine and they continued to monitor the resident. Staff C stated it was up to the charge nurse to make the decision to send the resident to the hospital. On 11/23/16 at 9:28 a.m. Staff M LPN stated she worked on the skilled unit that night. Staff M confirmed she was the charge nurse that shift. Staff M stated a resident readmitted and she helped that resident get to his/her room when she was told Staff C needed her. Staff M asked what was wrong and the resident's family stated the resident was not acting right. Staff M stated she then let Staff C know if she needed help to let her know and she went back to the resident that just returned to the facility. Staff M stated she glanced in the room and Staff C was in there and that's when she told her to let her know if she needed help. She didn't give Staff C any directives on what to do for the resident and she never heard anything more from Staff C. No one told her any specifics other than the resident wasn't acting right. On 12/19/16 at 12:16 p.m. Staff AA LPN stated she came on duty after midnight and Staff C told her the resident's granddaughter had concerns that the resident had signs and symptoms of stroke since 8 or 9 p.m. Staff AA immediately went to the resident's room and the resident had mumbled speech with right facial drooping. Staff AA thought the resident had a stroke so she sent the resident to the hospital. Staff AA stated from what she saw, the resident should have transferred to the hospital a lot sooner. On 12/20/16 at 1 p.m. during phone exit the Administrator identified Staff AA as a disgruntled employee with credibility issues. Skin Impairment Nursing progress notes dated 7/13/16 at 9:48 p.m. revealed a CNA reported the resident had a moderate amount of red blood in his/her brief that appeared to come from the vagina. Assessment of the area revealed a small amount of blood from small nodules and lumps on the labia fold. Staff cleansed the area and patted dry. The resident voiced discomfort to the area. The record lacked follow up of the area. Nursing progress notes dated 7/29/16 at 2:16 a.m. revealed the resident transported to the hospital with stroke symptoms. Hospital records dated 7/29/16 at 2:58 p.m. revealed hospital staff assessed the resident with Stage 2 wounds on the perineal area. The resident had multiple open areas on the outer and inner labia and urethral opening. On 11/28/16 at 4:05 p.m. the Director of Nursing (DON) stated she did not find the facility followed up on the 7/13/16 observation and that the resident did not have a physician encounter that addressed it. 2. An MDS dated [DATE] assessed Resident #2 with a brief interview for mental status (BIMS) score of 5 (severe cognitive impairment). The resident had the following indicator of [MEDICAL CONDITION] that fluctuated through the day: inattention. The resident had no behavior symptoms identified. The MDS documented the resident required limited staff assistance with bed mobility, transfers and ambulation and extensive staff assistance with toileting, dressing and personal hygiene. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance. The resident used a walker and wheelchair for mobility. The resident was occasionally incontinent of bladder. The resident had [DIAGNOSES REDACTED]. An incident report dated 10/16/16 at 5:15 a.m. revealed the resident stated he/she came out of the bathroom and fell . Staff found the resident sitting on his/her bottom on the resident's room floor. The resident said he/she hit their head on the edge of the bed. Staff applied an ice pack to the head. The resident received a hematoma to the right forehead and abrasion to the buttock. The incident report did not identify an intervention following the incident. Nursing progress notes dated 10/16/16 at 9:16 a.m. revealed the resident transported to ER for evaluation. A physician encounter form dated 10/17/16 at 4:51 p.m. revealed the resident was sent toER on [DATE] after a fall. The resident had bruising above and below bilateral eyes as well as the right forehead. ER evaluated the bruising. The bruising was described as follows: Examination of the head and face revealed hematoma around the bilateral eyes and right forehead and tenderness over the right frontal area. The right eyelid showed swelling of the upper eyelid and extensive bruising around the bilateral eyes. The facility failed to document any bruising on the face. Observation showed 11/16/16 at 11:07 a.m. the resident in bed. The resident had visible bruising around both eyes. 3. An MDS dated [DATE] assessed Resident #11 with a BIMS score of 5 (severe cognitive impairment). The resident required extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, and personal hygiene. The resident did not ambulate. The resident had functional range of motion (ROM) limitations of the upper and lower extremities. The resident used a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The resident had two or more falls without injury since the previous assessment. An incident report dated 10/17/16 at 7:20 p.m. revealed staff found the resident laying on the right side in the central hallway. The resident had a large bump on the forehead and a bloody nose. The resident complained of back pain. The alarm sounded when the resident fell . On 11/23/16 at 1:55 p.m., Staff K LPN stated the resident was in the central hallway and fell out of the wheelchair. She stated there was a family visiting another resident in the central hall and they alerted staff to the resident's fall. No staff heard the resident's wheelchair alarm. and found the resident lay face first on the ground. Staff K called the ambulance and the resident transported to ER for evaluation. Staff K stated after the incident the resident had black eyes. Nursing progress notes dated 10/18/16 at 12:08 a.m. revealed the hospital called and informed the facility the resident had a UTI (urinary tract infection) and the resident would return with an order for [REDACTED]. Nursing progress notes on the same date at 1:48 a.m. revealed the resident returned to the facility and had bruising to the forehead and face. There was no further documentation regarding the bruising. Observation showed on 11/23/16 at 1:10 p.m. Staff L CNA transferred the resident to the toilet via the EZ stand. The alarm sounded when Staff L assisted the resident to stand. Staff L stated she took care of the resident on 10/17/16 and the resident fell after she left. The next day the resident had 2 black eyes. On 11/28/16 at 4:05 p.m. the DON stated she could not find any documentation regarding the resident's facial bruising after readmission from ER. 4. An MDS dated [DATE] assessed Resident #3 with a BIMS score of 8 (moderate cognitive impairment). The resident required extensive staff assistance with bed mobility, dressing, toileting, personal hygiene and bathing. The resident required limited staff assistance with bathing. A balance during transitions and walking test identified the resident as not steady but able to stabilize with staff assistance and revealed the resident used a walker and wheelchair for mobility. The MDS identified the resident received daily anticoagulant medication. An IR dated 11/22/16 at 5:30 a.m. revealed a fall in the resident room. Staff found the resident on the floor next to the bathroom. The resident could not explain what occurred. The IR identified the resident had previously been anxious. The resident sustained [REDACTED]. by 2 cm. The intervention following the incident was to answer the resident promptly when he/she called. (Already in place) and a PT/Occupational therapy (OT) screen. A hospital report dated 11/23/16 revealed the resident fell 3 times in the past 3 days. The resident sustained [REDACTED]. The report identified a left wrist skin tear and right bicep skin laceration. Observation: Observation showed on 11/28/16 at 11:37 a.m. the resident wheeled self with feet in the wheelchair. Observation showed a large bruised area around the left eye. When asked what happened the resident stated it ' s been like that a long time. The record lacked documentation of a left black eye after 11/22/16. 5. A MDS with assessment reference date of 8/11/16 assessed Resident #7 with a BIMS score of 13 (no cognitive impairment). The MDS did not identify any behavior symptoms. The MDS documented the resident required extensive staff assistance with bed mobility, transfers and toileting, did not ambulate, was frequently incontinent of bowel and bladder, and used a wheelchair for mobility. The MDS identified the resident had [DIAGNOSES REDACTED]. A care plan completed 8/15/16 identified the resident with potential skin impairment related to risk factors for skin breakdown and incontinence, [MEDICAL CONDITION], impaired mobility and cognition, right hand contracture and noncompliance with right hand splint. The care plan directed staff to encourage and assist the resident to change position frequently, avoid lying or sitting in any one position for extended periods of time. On 11/17/16 at 9:28 a.m. observation revealed a band aide on the resident's left buttock. When staff removed the Band-Aid, there was no open or scabbed area beneath it. On the same date at 11:55 a.m., observation also revealed two scarred healed areas to the upper buttocks and an open horizontal slit at the top of the upper right buttock area. At that time, Staff T LPN confirmed the area was open and applied [MEDICATION NAME] (for skin impairment) to the area. Observation showed on 11/28/16 at 1:48 p.m., the resident in bed on his/her back. The resident remained in a back lying position until 4:42 p.m. (3 hours) Observation revealed on 11/29/16 at 8:08 a.m. the resident up in the wheelchair. The resident remained up in the wheelchair until 1:27 p.m. when Staff Q transferred the resident to bed. Prior to transfer to bed, Staff Q checked and changed the resident. The resident had red areas on the upper buttocks. On 11/29/16 at 1:43 p.m. Staff R CNA stated she and Staff S CNA got the resident up around 7 a.m. to 7:30 a.m. and neither she or Staff S CNA did anything with the resident since they brought the resident back from breakfast and started showers. This indicated the resident sat in the wheelchair approximately 6 hours. On 11/29/16 at 11:12 a.m. the resident stated he/she sat in the wheelchair all morning and he/she didn't want to sit that long. The resident stated no one offered or took him/her to the toilet since he/she got up. Documentation: Nursing progress notes dated 11/16/16 at 2:49 p.m. revealed the resident had two, small thick scar tissue areas to the upper buttocks. The entry identified superficial pinpoint areas on the scar tissue areas. The facility notified the physician and received an order for [REDACTED].>Nursing progress notes dated 11/23/16 at 1:04 p.m. revealed staff documented the resident with skin impairment of the coccyx. (No measurement or description documented). Staff applied [MEDICATION NAME] to the area. Nursing progress notes dated 11/30/16 identified a decrease in the size of the open area on the right gluteal. (no measurement or description) Nursing progress notes dated 12/5/16 at 11:48 a.m. identified the area as healed. On 12/7/16 at 9:10 a.m. the Director of Nursing (DON) stated the facility did not have skin sheets for the area because they only do skin sheets for pressure, stasis and arterial sores. Staff documents in the nursing progress notes. 6. An MDS dated [DATE] assessed Resident #17 with a BIMS score of 15 (no cognitive impairment). The resident was independent with all cares other than supervision for bathing. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with frequent pain and pain that made it hard to sleep at night at a pain level of 3 on a scale of 0 to 10 with 10 being the worst imaginable pain. A care plan dated 10/27/16 identified the resident with a pain/comfort concern related [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The care plan directed staff to encourage the resident to verbalize presence, type and location of pain and administer medications as ordered. On 11/29/16 at 9:08 a.m. the resident stated she waited 2 hours for a pain pill the day before yesterday. (11/27/16). The resident stated he/she pushed the call light at 7:30 a.m. to be able to get a pain pill by 8:30 a.m. The resident stated he/she didn't get the pain pill until 10:15 a.m. when she got both the long acting and short acting pain pills together. The resident stated it was hard to get the pain managed after that. The same day the resident pushed the call light at 1:30 p.m. to get his/her 2 p.m. medication and he/she didn't get it until 3:15 p.m. At 2:15 p.m. the resident pushed the call light again and a nurse aide answered it and said she would tell the nurse the resident wanted his/her 2 p.m. medication. The resident stated he/she could handle the medication 1 hour late but not longer. The resident got up and went to the big nurse ' s station. The resident thought he/she may pass out but the resident made it and got the medication instantly then. The November Medication Administration Record [REDACTED]. The resident had a PRN (as needed) order for [MEDICATION NAME] IR (immediate release) 30 mg. every 4 hours as needed for pain. Narcotic controlled substance record identified the nurse signed out the [MEDICATION NAME] 60 mg SA on 11/27/16 at 9 a.m. and [MEDICATION NAME] IR 30 mg on 11/27/16 at 9:45 a.m., 2:30 p.m., and 6:30 p.m. 7. According to the MDS dated [DATE], Resident #21had [DIAGNOSES REDACTED]. The same MDS documented a Brief Interview of Mental status score of 14 (intact cognition) and revealed the resident, required extensive assistance with transfers and ambulation, did not ambulate in his/her room or the hallway during the assessment period, utilized a wheelchair for mobility and had decreased functional range of motion in one upper extremity. The resident had no falls since the last assessment completed 92 days or less. The care plan problem revised 11/10/16 identified the resident as at risk for falls related to deconditioning and vision and hearing problems and directed staff to provide assist of 1 for transfers from bed. The care plan also directed staff to provide assist of 1 with other transfers upon request, place the call light placed within reach and encourage the resident to use it. The Incident Report dated 1/8/17 documented staff found the resident found lying on the floor on his/her left side at 5:15 PM. The resident stated he/she attempted to go to the bathroom and fell . The resident complained of pain to the left upper arm and the nurse assessed the resident had decreased range of motion in this arm. The progress notes entry in the resident's clinical record completed by Staff WW, RN, dated 1/8/17 at 8:29 PM documented the resident sustained [REDACTED]. The Incident Report documented the resident notified by fax if the incident. The progress notes contained no further assessment of the resident until 1/9/17 at 2:42 PM which documented the resident had a bruise and two abrasions on the left knee, in addition to the left arm skin tear. The entry documented the resident's range of motion within normal limits. The clinical record contained no further information on the resident until 1/10/17 at 1:54 PM which documented the unit secretary told the nurse the resident did not act right and seemed confused. The entry failed to contain any assessment of the resident other than vital signs and blood sugar result. Staff placed a call to the physician's office and called 911 to transport the resident to the hospital. The progress notes entry dated 1/10/17 at 8:08 PM documented the resident admitted to the hospital with [REDACTED]. During interview on 1/12/17 at 4:04 PM the director of nursing (DON) stated staff failed to continue to assess the resident post-fall and she has disciplined the nurses involved.

Based on record review and staff interview, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable; and a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 of 5 residents reviewed. The facility failed to ensure Resident # 5's cast padding was smooth without rolling/bunching on 6/21/16 resulting in a deep tissue injury (DTI) to the right heel. ER (emergency room ) notes dated 6/25/16 identified the resident with a new decubitus on the right foot developed secondary to pressure at the cast site due to the leg hanging in the dependent position. After the cast was removed on 7/15/16, the facility assessed the pressure sores on the right foot. There was no further documentation of assessment of the sores. The resident transferred to the hospital 7/29/16. Staff initialed they provided the ordered [MEDICATION NAME] treatment to the right foot 8 out of 14 days. Facility census was ninety-three (93) residents. Findings include: 1. A Minimum Data Set (MDS) assessment tool dated 3/31/16, assessed Resident #5 with severe cognitive impairment and documented the resident displayed behavior symptoms of verbal and other behaviors 1 to 3 days out of 7, but did not reject care. The resident required extensive staff assistance with bed mobility, dressing, eating and personal hygiene. The resident required total assistance with transfers, toilet use and bathing. The resident did not ambulate. The resident had functional range of motion limitations of one lower extremity. The resident was frequently incontinent of bowel and bladder. The MDS identified the resident at risk for pressure sores and the resident did not have pressure sores. The MDS identified the resident with [DIAGNOSES REDACTED]. The resident admitted to the facility on [DATE]. An MD/nursing communication form dated 6/15/16 at 10:44 a.m. revealed staff notified the resident's primary physician that the resident saw the orthopedic (ortho) physician on 6/14/16 and had the right lower extremity (RLE) cast removed and the resident now wore a splint on the RLE. The resident continued non-weight bearing status. The resident had an order for [REDACTED]. The skin to the toes was intact. The physician signed the order 6/15/16 and agreed to the discontinuation of the [MEDICATION NAME] dressings and cast padding. An MD/nursing communication form dated 6/21/16 at 10:24 a.m. revealed Staff Y LPN (licensed practical nurse) asked Staff Z LPN to assess skin breakdown to the right heel. Staff Y removed the compression wrap used to hold the half cast to do a skin assessment. The cast padding was not smooth and was rolled up in places, especially the heel and achilles area. Staff Z assessed a DTI measuring 2 cm. (centimeter) by 2 cm. and a 0.7 cm. by 0.6 cm. wound with dry yellow exudate just superior to it. Assessment showed extensive desquamation of the skin on the right foot and ankle. The resident did not complain of pain. Staff Z instructed Staff Y to place new cast padding to the half cast and a dressing to the heel. Staff Z requested the following treatment for [REDACTED]. Apply skin prep to surrounding skin allow to dry. Cover with foam dressing and change every 4 days and as needed. The ARNP (advanced registered nurse practitioner) agreed to the order. On 11/29/16 at 10:24 a.m. Staff Y LPN stated on 6/21/16 she discovered the resident had skin breakdown so she got Staff Z to check the areas and that was her only part in that incident. On 11/29/16 at 5 p.m. Staff Z LPN stated the cast padding was rolled up and that could be the cause of the resident's DTI discovered on 6/21/16. A physician encounter form dated 6/21/16 at 11:55 a.m. identified the ARNP saw the resident for an acute wound to the right heel. The resident had a history of [REDACTED]. The ARNP identified the acute wound on the right heel as a pressure ulcer with a soft padded dressing over it. The ARNP identified the heel as difficult to float. The resident was referred to the wound clinic for follow up. Nursing progress notes dated 6/21/16 at 4:30 p.m. revealed the facility attempted to schedule an appointment at the wound center. The wound center stated the first they could see the resident was in 1 to 2 months. Nursing progress notes dated 6/22/16 at 1:11 p.m. revealed the resident's family expressed they did not feel the facility cared for the resident's leg and heel appropriately and tried to take the resident to the orthopedic physician via car and could not get the resident in the car due to immobility to bend leg. An x-ray report identified an x-ray of the RLE completed on 6/22/16 showed no changes from 3/20/16 x-ray. Nursing progress notes dated 6/23/16 at 8:55 a.m. revealed the facility received a phone call from the orthopedic physician office for the resident to come to the office that afternoon to get the RLE recasted. Nursing progress notes dated 6/24/16 at 2:52 p.m. revealed the new cast contained a heel cut out due to the DTI and Stage 3 ulcer. [MEDICAL CONDITION] to the heel caused compression against the cast edges especially at the achilles area. The facility notified the physician on 6/24/16 at 3:56 p.m. of the [MEDICAL CONDITION]. The physician directed staff to elevate the leg as able. An ER (emergency room report) dated 6/25/16 at 9:28 p.m. revealed the resident came to the ER for a cast problem involving an issue with swelling in the right heel and the cast pressing into it. The report identified an ortho tech at the ER opened the cast window more and could visualize a 2 cm. by 1 cm. area of [DIAGNOSES REDACTED] consistent with a new pressure ulcer. ER instructed the family, who arrived with the resident that the resident needed to keep his/her leg elevated. The family stated they tried to elevate the leg but the facility left the leg in the dependent position up to 8 hours at a time. The ER document identified the decubitus developed secondary to pressure at the cast site due to the leg hanging in the dependent position. On 12/19/16 at 11:40 a.m. Staff FF LPN stated she worked with the resident on the first day the resident was at the facility with a cast. She stated the resident did not have a leg extender on the wheelchair and the resident's leg hung in the dependent position and no one did anything about it so she got a leg extender and pillow so she could elevate the leg. On 12/20/16 at 1 p.m. during phone exit the Administrator identified Staff FF as a disgruntled employee with credibility concerns. On 11/23/16 at 1:24 p.m. the orthopedic ARNP stated there was no new injury to the RLE when the RLE was recasted on 6/23/16. The ARNP stated there was nothing the ortho office saw regarding the facility care of RLE that caused concerns. There was a lot of he said/she said. The ortho recasted the leg on 6/23/16 at the family request. Nursing progress notes dated 6/29/16 at 9:52 a.m. staff documented the heel ulcers identified on 6/21/16 as improved. The small superior wound measured 0.6 cm. by 0.3 cm. with [MEDICATION NAME] in the wound bed. The distal DTI measured 2 cm. The entry identified an ill-fitting cast with a large gap between the plantar aspect of the foot and the cast. Staff visualized purple skin to the skin at the right lateral malleolus at the cast edge measuring 2.3 cm. by 0.5 cm. A gray/purple wound at the achilles measured 1 cm. by 2.5 cm. Nurses notes dated 7/1/16 at 1:45 p.m. identified a new full cast in place and pressure wounds covered by the new cast. On 11/28/16 at 4:05 p.m. the Director of Nursing (DON) stated they facility was unable to assess the areas after 6/29/16 due to placement of long cast. A wound center note identified the resident went to the center 7/13/16. A 4 cm. by 2 cm. by 0.1 cm. unstageable pressure ulcer was present on the right posterior heel. A 2 cm. by 1.5 cm. by 0.1 cm. stage 2 pressure ulcer was present on the dorsal aspect of the foot. The wound center directed staff to apply [MEDICATION NAME] and foam dressing daily after the resident got his/her brace fit. Review of the treatment administration record (TAR) identified the facility began the [MEDICATION NAME] treatment on 7/17/16. Nursing progress notes dated 7/15/16 at 10:45 a.m. revealed the resident returned with a brace at that time. On the same date at 2:18 p.m. staff attempted to measure the resident's skin impairments of the RLE. The resident did not cooperate so staff could not measure but just estimated sizes as follows: 1. There was a deep purple color to the right medial heel approximately 5 cm. by 3.5 cm. There was no open skin within the area. 2. There was a wound to the plantar aspect of the right heel approximately 4 cm. by 2 cm. The wound bed had black necrotic tissue. The periwound skin was dry with desquamation. 3. There was an approximate 3 cm. by 3 cm,. nonblanching red wound to the anterior foot. 4. There was an approximate 2.5 cm. by 2.5 cm. wound to the medical aspect of the right heel. There was no skin impairment to the coccyx. The record lacked evidence of any further skin assessments. The resident discharged to the hospital on [DATE]. The TAR identified the facility signed for the [MEDICATION NAME] treatment to the RLE 8 out of 14 days.

Based on record review and resident and staff interviews, the facility failed to ensure Resident #6 was free from abuse from Resident #1. The sample consisted of 2 residents and the facility reported a census of 88 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 5/12/16. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 indicated the resident had no cognitive problems and exhibited no behaviors According to Resident #1's Care Plan, with an initiated date of 6/29/15 and a target goal date of 8/12/16, noted the resident could demonstrate significant mood distress related to health status and placement as manifested by constant complaints, anger and frustration. The interventions directed the staff to do the following: Encourage the resident to try alternative therapies such as music, art, intergenerational, animal interventions, horticulture, and empowerment activities. Refer to qualified professionals as needed, and use open ended questions when talking to the resident and encourage open communication. On 8/16/16 at 3:00 p.m. Resident #6 reported Resident #1 hit his/her thigh. Resident #6 stated he/she reported to the nurses but was unable to recall names or dates. Resident #1 was not abusive until diagnosed with [REDACTED].#6 eventually moved to a new room. According to the 5/12/16 MDS, Resident #6 had intact cognition. On 8/16/16 at 2:50 p.m. Staff B, LPN, stated Resident #6 was moved because Resident #1 was verbally abusive. She stated Resident #6 reported Resident #1 got out of his/her wheelchair and punched his/her stomach. Staff B was aware Resident #1 became agitated at times and known to swing at staff. Staff B stated she was only aware of one instance when Resident #1 hit Resident #6. Staff B stated Resident #6 is alert and oriented. Resident #1 is not allowed to go to Resident #6's new room per Resident #6's request On 8/24/16 at 10:30 a.m. Staff J, CNA, stated a couple months ago Resident #6 reported Resident #1 was abusive. Additionally, one month ago, Resident #6 reported Resident #1 hit him/her. Resident #1 got up at night and demanded Resident #6 assists him/her. Resident #1 punched Resident #6's hip. Resident #6 told Staff J he/she wished Resident #1 would not hit him/her. Staff J reported Resident #6's allegation to Staff B, licensed practical nurse (LPN)/patient care manager. On 8/24/16 at 4:45 p.m. the Administrator and Director of Nursing stated they were not aware Resident #1 hit Resident #6. The Administrator and Director of Nursing stated the staff are trained about the abuse policy and reporting requirements.

Based on record review and staff interview, the facility failed to ensure separation of victim Resident #6 from perpetrator, Resident #1 reviewed with an abuse allegation and failed to report the allegations of abuse to the Iowa Department of Inspections and Appeals within 24 hours. Resident #6 did not get moved/separated to another hall from Resident #1 for several days. The facility reported a current census of 88 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 5/12/16. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 indicated the resident had no cognitive problems and exhibited no behaviors According to Resident #1's Care Plan, with an initiated date of 6/29/15 and a target goal date of 8/12/16, noted the resident could demonstrate significant mood distress related to health status and placement as manifested by constant complaints, anger and frustration. The interventions directed the staff to do the following: Encourage the resident to try alternative therapies such as music, art, intergenerational, animal interventions, horticulture, and empowerment activities. Refer to qualified professionals as needed, and use open ended questions when talking to the resident. On 8/16/16 at 3:00 p.m. Resident #6 reported Resident #1 hit his/her thigh. Resident #6 stated he/she reported to the nurses but was unable to recall names or dates. Resident #1 was not abusive until diagnosed with [REDACTED].#6 had intact cognition. On 8/24/16 at 10:30 a.m. Staff J, CNA, stated a couple months ago Resident #6 reported Resident #1 was abusive. Additionally, one month ago, Resident #6 reported Resident #1 hit him/her. Resident #1 got up at night and demanded Resident #6 assist him/her. Resident #1 punched Resident #6 ' s hip. Resident #6 told Staff J he/she wished Resident #1 would not hit him/her. Staff J reported Resident #6 ' s allegation to Staff B, licensed practical nurse (LPN)/patient care manager. Review of the Department's records identified the facility did not report this allegation of abuse to the Iowa Department of Inspections and Appeals. On 8/24/16 at 4:45 p.m. the Administrator and Director of Nursing were interviewed and stated they were not aware Resident #1 hit Resident #6. The Administrator and the Director of Nursing stated the nursing staff are trained about the abuse policy and the reporting requirements.

The following deficiency relates to incident -I: Based on record review and staff interviews, the facility failed to provide adequate supervision and assistive devices (EZ Stand lift) when transferring a resident in order to mitigate the risk for accidents (Resident #10). The sample consisted of 4 residents and the facility reported a census of 87 residents. Findings include: Resident #10 had an annual Minimum Data Set (MDS) assessment with a reference date of 1/7/16. The MDS indicated the resident had a Brief Interview for Mental Status score of 6. A score of 6 identified the resident as severely cognitively impaired. The MDS indicated the resident required extensive assistance to total dependence with assist of one staff person with transfers, dressing, toilet use and personal hygiene needs. The resident ' s [DIAGNOSES REDACTED]. The Care Plan, revised on 1/12/16, identified Resident #10 had impaired physical mobility and at risk for falls. The interventions directed staff to use the EZ stand with one person assistance with all transfers The Care Guide for Resident #10 included and directed the staff to assist the resident with one staff person with activities of daily living. The Guide identified the resident as non-ambulatory and staff are to use the EZ stand for all transfers. The Progress Notes dated 3/20/16 at 5:24 p.m. indicated Resident #10 was lowered to the floor. No visible signs of injuries noted at this time. Assessed active range of motion. Lower extremities are not bending as much and Resident #10 complained of right leg hurting. No visible injuries noted. The Progress Notes dated 3/20/16 at 5:36 p.m. identified Resident #10 was lowered to the floor during a transfer from bed to wheelchair. No bruises or skin concerns noted. The resident had right knee pain and had active range of motion. The Progress Notes dated 3/20/16 at 8:02 p.m. identified Resident #10 complained of increased right knee pain and the knee to be swollen. The nurse notified the physician and obtained orders for an x-ray of the right knee. The Progress Notes dated 3/20/16 at 10:50 p.m. indicated the nurse received a message to contact the radiologist. The radiologist confirmed the resident had a right distal femur complex comminuted fracture. In an interview on 4/12/16 at 8:00 a.m. the Director of Nursing (DON), stated Staff A was a new CNA (Certified Nursing Assistant) and started at the facility in December 2015. The DON stated Staff A was provided orientation and was aware of the care guides which are available to all staff to provide awareness of each resident's individual care needs. The DON stated Staff A did not use the EZ stand as directed by the Care Plan which resulted in a major injury. In an interview on 4/11/16 at 2:20 p.m. Staff B, CNA, stated each hall has a Care Plan summary sheet for the residents on that hall. The sheets provide care information to CNAs including the level of assistance needed for resident transfers. On 4/12/16 at 8:20 a.m. Staff C, CNA, stated she has worked at the facility about a month. During orientation, she was informed of resident care guides which are kept on each hall. The Care Guides help direct CNA's with each resident's needs, such as assist level, ted hose use, mobility, etc. In an interview on 4/12/16 at 8:30 a.m. Staff D, certified nurse aide, stated she started working at the facility in December 2015. During orientation she was informed of resident care guides which are kept in the 200 hall shower room for 200 hall residents. The care guides specify each resident ' s individual needs and are to assist CNAs with providing cares.

Based on observation, record review, facility staff interview and interviews with 2 staff from another facility, the facility failed to implement services for adequate supervision from hazards to prevent accidents for two of six residents. Observation showed Resident #3's bed contained a 3 inch gap between the mattress and bed. Staff interviews revealed on one occasion (not documented) staff found the resident with his/her head wedged between the mattress and side rail. Record review identified on 8/20/14 Resident #3 ' s head was stuck between the bed side rail, and once the staff removed the resident from the side rail, he/she had abrasions to his/her face, elbow and knee. The care plan did not identify any intervention until after the 8/20/14 incident. Staff transported Resident #13 in a wheelchair without foot pedals which caused the resident's foot to become caught under the wheelchair during transport. Facility census was one hundred eight (108) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 8/12/14 assessed Resident #3 with a brief interview for mental status score of "2" (severe cognitive impairment). The resident required staff assistance with bed mobility and transfers. The resident had [DIAGNOSES REDACTED]. The resident was 64 inches tall and weighed 99 pounds. The resident used antipsychotic medications daily. A side rail assessment, completed on 5/20/14 identified staff observed the resident getting in and out of bed and determined it as safe with staff assistance. The resident used the side rail as a boundary identifier and also an enabler for self-repositioning. The resident used a partial side rail on the right and left sides of the bed. The care plan dated 2/11/14 documented the following interventions: floor mat to floor next to bed when resident in bed; on 3/13/14, mattress alarm sensor placed per family request. The care plan lacked any indication the resident ' s side rail had a wedge on the outside rail until the incident on 8/20/14. An incident report, dated 8/20/14 at 4 a.m. identified staff found Resident # 3 with his/her lower torso on the floor with his/her head stuck between the bed and side rails. Once the resident's head was removed the resident stated he/she had a little headache. Staff observed abrasions to the face and right knee and elbow. The incident report documented the intervention put in place after the fall, side rail wedge placed to outside rail. The progress notes dated 8/20/14 at 4:33 a.m., documented the following: resident was found with alarm in bed, and his/her bed had been in the low position. Resident ' s head was stuck into two side rails. Resident has a partial thickness on the right side of face. Range of motion was good; resident denies pain and stated he/she was trying to get up. The note identified " right knee and elbows, " without further explanation of what that meant. A fax to the physician dated 8/20/14 at 12:45 p.m. revealed staff notified the physician of the incident. The fax identified staff went to the resident room to answer the alarm and found the resident with his/her legs on the floor and the resident's top half was against the bed with head between mattress and side rail. In the fax the facility identified the following injuries: small abrasion to right cheek and abrasions to the bilateral knees. Staff placed a Tegaderm on the right knee. The physician wrote it was Ok to use Tegaderm to the right knee for 7 days and Bacitracin to the other abrasions twice per day until healed. Another fax sent on the same date at 1:05 p.m. identified the resident right eye as red with increased watery drainage. The upper and lower lid were slightly swollen and the lower lashes were beginning to have some mattering. The resident stated the eye burned. Staff asked the physician to order antibiotic eye drops. The physician responded by ordering Gentamycin (antibiotic) drops 2 drops to both eyes four times a day for 7 days. Progress notes dated 8/25/14 at 9:30 p.m. identified the resident's family member arrived and questioned staff about the bruising the resident received (from the 8/20/14 incident.) Progress notes dated 8/27/14 at 3:10 p.m. revealed the resident received the last of the Gentamycin eye drops and there was very little improvement to the eye. The resident's right eye was light red to the upper and lower lid with difficulty keeping the eye open. Staff observed mattering and same level of drainage as when the Gentamycin drops were first ordered. On the same date at 3:46 p.m. staff received an order for [REDACTED]. The facility physician documented on 9/2/14 at 8:51 a.m. he saw the resident and diagnosed the resident with bilateral conjunctivitis and bilateral periorbital edema. The physician directed staff to continue the eye drops and begin Keflex (antibiotic) three times a day for 7 days. On the same date, the facility scheduled an appointment for 9/3/14 at 11 a.m. with an eye specialist at eye clinic at the family's request. On progress notes dated 9/3/14 at 3:25 p.m. the resident returned from an eye specialist with an order for [REDACTED]. The resident should continue the Keflex and tape the eye shut at night to prevent exposure. On progress notes dated 9/10/14 at 11:21 a.m. the resident returned from a follow up eye appointment with the eye specialist. The eye specialist ordered Erythromycin (antibiotic) ointment seven days with 13 refills and the resident should receive the antibiotic ointment indefinitely. The resident should see a neurotology specialist. The order discontinue the Tobradex ointment and Ciloxan. A physician note dated 9/16/14 revealed the resident rolled out of his/her low bed, entrapping the resident's head in the space between the mattress and the side rail. The nursing staff told the resident ' s family member that most likely the resident had been there no more than 10 minutes. The physician documented that the resident sustained [REDACTED]. The neurological examination showed the resident was unable to totally close his/her eyes, the resident could close it about two thirds of the way. The physician reported the bruising and abrasions that were present were documented to her via cell phone pictures were healing well at this time. Progress notes lacked documentation of bruising. A letter dated 9/24/14 from a otology/neurotology specialist stated the resident had right facial nerve paresis. He stated the resident may have had some compression trauma to the facial nerve that led to weakness on that side. On 10/15/14 at 2 p.m., the physician was asked if he thought the side rail incident led to the facial paralysis. He stated he had no opinion on it. On 10/13/14 at 2:05 p.m. Staff R (unit manager) stated the resident had swelling to the right upper eyelid and the sclera to the right eye appeared pink on 7/7/14 at 7 p.m. When reassessed, on 7/8/14 at 5 a.m. the issue resolved and the resident had no other issues with the eye until after the incident on 8/20/14. Staff Interviews: On 10/11/14 at 10:16 p.m. Staff B (nurse aide) stated she found the resident with his/her head down and wedged between the mattress and side rail at the midnight routine round. The resident's alarm did not sound and the resident did not yell for help. She did not know how long the resident remained wedged between the side rail and mattress. She last saw the resident around 10 p.m. She stated when she found the resident, the bed was in low, with the head of the bed slightly rolled up and no padding on the side rail. Staff B confirmed there had been a space between the bed and mattress but there had been no prior issues with the resident getting any body part wedged. Staff B stated the resident had abrasions and bruising to the face and abrasions to the knees. On 10/9/14 at 3:05 p.m., Staff X (registered nurse) stated she heard Staff B holler for help and when she arrived to Resident # 3's room the resident's head was face down between the mattress and side rail with his/her knees on the floor. Staff X stated she did not hear an alarm but she was at the top of the hall so it may have sounded and she just didn't hear it. Staff O (licensed practical nurse) then showed up. The resident had minor abrasions to his/her knees and on the top of the right cheekbone. Staff X stated anytime a resident gets their head caught between the side rail there had to be a significant gap. On 10/9/14 at 11:09 a.m. Staff O identified herself as charge nurse the night the incident occurred. She stated it appeared the resident tried to scoot out of the bed when the resident got his/her feet down and caught his/her head in the side rail. She stated the resident's head was wedged in the side rail. She identified the incident occurred around 3:30 to 4 a.m. On 10/13/14 at 2:45 p.m. the surveyor met with Staff O and Staff B due to the time and alarm discrepancy. Staff B stated the incident occurred at midnight rounds and the alarm did not sound. Staff O stated Staff B told her the alarm sounded and the incident occurred around 3:30 to 4 a.m. At that time, Staff B settled with Staff O and stated she may not remember because 2 months passed since the incident. The surveyor reproached Staff X on 10/13/14 at 2:50 p.m. to ask about the time the incident occurred and she stated she knew it as any time after 1 a.m. On 10/15/14 at 4:42 p.m. Staff CC (registered nurse) stated he worked on the opposite hall on the night of the incident and heard a stat call for a nurse. He arrived at the room and Staff O and a nurse aide were there. He identified the time as later in the shift maybe between 4 a.m. and 6 a.m. INCIDENT PRIOR TO 8/20/14: Progress notes dated 2/6/14 at 1:46 p.m. revealed the family requested that staff pad the resident's rails. The family voiced concern that the resident would place his/her arm though the side rail and break it. On 10/13/14 at 3:20 p.m. Staff R (unit manager) stated they put foam on the metal portion of the side rails after the family voiced concerns. She stated the resident got a new bed on 5/8/14 that did not have metal side rails. The new bed's side rails were more plastic, so the facility did not pad those rails. On 10/6/14 at 2:30 p.m. Staff R stated before the resident fell on [DATE] there was nothing to indicate he/she needed any pad to the side rail. After 8/20/14 they applied a foam rectangle to type to the top of the side rail until the wedge pads came. On 10/13/14 at 2:03 p.m. Staff R identified the resident as in the same bed and mattress as in place when the 8/20/14 incident occurred. At 2:05 p.m. of the same date, the surveyor measured the gap between the mattress and side rail with the resident in the bed. The gap measured 3 inches on both sides of the bed. On 10/14/14 at 11:04 a.m. Staff J (nurse aide) stated she walked in the resident's room one morning prior to the resident using the wedge cushions in the side rails (prior to the 8/20/14 4 a.m. head wedging incident) and found the resident caught up in the side rail. The resident's side was in the gap between the mattress and side rail. Staff J reported it to Staff K (charge nurse) who assisted her in removing the resident from the side rail. Staff K checked the resident and said the resident was OK. Staff J stated it appeared the resident tried to get up and rolled into the gap. The resident laughed about it. She stated the next time she worked with the resident, the side rail wedge pads were in use. On 10/14/14 at 11:50 a.m. the surveyor phoned Staff K at home. Staff K stated she did not recall the incident. She stated she was at home and didn't think about work much when she was at home. Review of August 2014 assignment sheets showed that the only date Staff J and Staff K worked together prior to the 8/20/14 head wedging incident on Resident #3's hall was 8/7/14. Review of assignment sheets after the incident, identified the first day Staff J worked with the resident again was 9/18/14. On 10/9/14 at 2:25 p.m., Staff M stated the resident sometimes squirms and likes to move in the bed. She stated she saw the resident's hand weaved between the side rails in the past but nothing else. On 10/15/14 at 10:23 a.m. Staff BB (nurse aide) stated she had not seen the resident caught in the side rail but she could see how it could happen without the wedge in place. The resident tries to get his/her feet off the bed and the resident's body goes off with the feet. Observation: Observation showed, on 10/2/14 at 9 a.m. the resident ambulated with one staff and walker from the bathroom to the bed. Staff placed the resident in bed with his/her feet elevated on a pillow. The top side rails contained a wedge cushion between the mattress and side rails. Observation showed, on 10/2/14 at 10:50 a.m. the resident in bed with feet over lower edge of bed. 2. A Minimum Data Set ((MDS) dated [DATE] assessed Resident #13 with a brief interview for mental status score of "6" (severe cognitive impairment). The resident required staff assistance o for bed mobility, transfers, ambulation in room and toileting. The resident required limited assistance of one staff with locomotion in room per wheelchair. Progress notes dated 7/17/14 at 8:47 a.m. revealed the resident's family (spouse, daughter and son) arrived at the facility for assisted living evaluation. The entry identified the resident with diarrhea. Interview with registered nurse #1 who visited resident to assess resident for placement: On 10/13/14 at 10:40 a.m. a registered nurse from the assisted living that was present to evaluate the resident for placement, stated the resident needed to use the toilet. Staff H (nurse aide) arrived to the room. Staff H seemed irritated and not friendly. Staff H pushed the resident through the visitors in the room and the resident's foot got caught under the wheelchair. As this occurred, the resident's family told Staff H not to run over the resident's foot. When Staff H and the resident came out of the bathroom, Staff H bumped a family member's leg with the wheelchair. Staff H did not apologize to anyone. The registered nurse stated she did not think Staff H did it on purpose. Interview with registered nurse #2 who visited resident to assess for placement: On 10/13/14 at 9:55 a.m., a registered nurse from an assisted living that was present to evaluate the resident for placement stated Staff H came in and took the resident to the bathroom. Staff H did not appear gruff. She did not recall what occurred exactly but did recall something occurred with the resident's foot during transport. She stated the room was crowded and Staff H did nothing intentional. Progress notes from 7/17/14 did not identify injury to the resident's leg or foot. On 10/9/14 at 12:33 p.m. Staff H stated he took the resident to the bathroom and brought the resident out. He denied that the resident's foot got caught under the chair. He stated reminded the resident to keep his/her feet up and the resident did. Staff H reported in a follow up interview at 10:52 a.m., he confirmed the wheelchair did not have pedals when he transported the resident in it. On 10/13/14 at 4:44 p.m. the Director of Nursing (DON) stated staff should have used pedals while transferring the resident via wheelchair to the bathroom to prevent the foot from getting caught under the wheelchair.

Based on observation, record review, policy and resident and staff interviews, the facility failed to implement services for providing adequate supervision from hazards for three (3) of five (5) residents. The onsite observation and staff interviews identified staff failed to implement adequate supervision as specified in residents ' care plan. The facility identified a census of 105 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had the following Diagnoses: [REDACTED]., anxiety, depression, debility, difficulty walking, lack of coordination, problems with communication, disorder of the bone and cartilage and failure to thrive. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which revealed the resident had severe cognitive impairments. The assessment identified the resident required one staff to physically assist with bed mobility, locomotion, dressing, toilet use, personal hygiene and transfers. The test for balance identified the resident not steady and only able to stabilize himself/herself with staff assistance when walking, turning around and any surface to surface transfers. The resident used a walker and wheelchair for ambulation and had 2 falls without injury since admission/entry or reentry to the facility and/or the prior assessment. According to a Care Plan dated 8/21/13, the resident had a focus area of falls related to risk factors for falls, ambulatory debility, weakness, balance problems, unsteadiness, impaired cognition, falls with a history of fractures and medication use. The interventions included the following: a. Assist of 1 with all transfers. b. Assure sensor alarms were positioned appropriately as needed. c. Sensor alarms to bed, wheel chair and recliner as directed. The care plan also noted the resident had anti-rollbacks added to the resident ' s wheelchair and staff to assist the resident with safe foot wear. The care plan noted the resident should be encouraged to use the call light for assistance and to wait for assistance prior to transfers. The care plan noted staff should monitor the resident for problems with balance during transfers, ambulation, and assist as needed. The care plan noted the resident should ask staff to assist with picking up items from the floor for him/her. According to Fall Risk assessment dated [DATE], the resident had been at risk for falls. According to the Incident Report forms, the resident had fallen as follows: a. On 8/9/13 at 3:30 p.m., the resident had been found sitting on his/her buttocks in front of the reclining chair with no alarm sounding and no injuries noted. The resident stated he/she had been attempting to get his/her walker to go to the bathroom. No new interventions had been placed to help maintain the resident's safety. b. 8/18/13 at 4:15 a.m., the resident had been found sitting on the floor beside the bed with the alarm sounding and no injuries noted. No new interventions had been placed to help maintain the resident's safety. c. 8/22/13 at 2:10 p.m., the resident had been found sitting on his/her buttocks in front of the recliner in his/her room with the alarm sounding and no injuries noted. No new interventions had been placed to help maintain the resident's safety. d. 9/4/13 at 4 p.m., the resident had been found sitting on the floor next to the recliner with the alarm sounding and no injuries reported. No new interventions had been placed to help maintain the resident's safety. e. 9/17/13 at 5:30 p.m., the resident had a witnessed fall to his/her knees, the alarm had been sounding and no injuries reported. No new interventions had been placed to help maintain the resident's safety. f. 9/24/13 at 2:30 p.m. the resident had been found sitting on the floor next to his/her recliner with the alarm sounding and no injuries noted. No new interventions had been placed to help maintain the resident's safety. g. 10/11/13 at 1:05 p.m., the resident had been found sitting on the wheel chair pedals with his/her upper body leaning against the bed with the alarm sounding and no injuries noted. No new interventions had been placed to help maintain the resident's safety. h. 10/11/13 at 2:30 p.m., the resident had been found on the floor with the alarm sounding. The resident complained of pain to his/her right lower extremity with external rotation noted to the right hip. The resident had been sent to the emergency room . The progress notes dated 10/11/13 at 2:30 p.m., documented the resident had been yelling out, " I fell , I fell . " The resident stated he/she stood from the recliner to goto the toilet. The resident complained of right hip pain and unable to straighten his/her right leg on his/her own. The note documented the staff reported toileting the resident at 2:00 p.m., resident had turned on the call light to inform staff of the need to toilet. According to a Radiology Results form dated 10/11/13, the resident had a minimally displaced right hip (intratrochanteric) fracture. The report documented this (fracture) is thought to be fracture. The resident would require a surgical intervention. During an interview 10/30/13 at 8:58 a.m., the Director of Nursing (DON) reported there were no alarms sounding (per documentation). The DON was asked about the falls and she said there were no more interventions. During another interview with the DON on 10/30/13 at 10:15 a.m., she reported the facility does not have sensor alarms. The DON reported the facility does have fall mat alarms (floor mat alarms). 2. According to an MDS assessment dated [DATE], the Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident with a BIMS score of 10 out of 15, which revealed the resident had moderate cognitive impairments. The resident required the assistance of staff with transfers, non-ambulatory and dependent on staff with locomotion. The assessment also indicated the resident as unsteady and only able to stabilize with staff assistance with moving from a seated to standing position, moving on and off the toilet and any surface to surface transfers. The resident had 2 falls since admission/entry/reentry and/or prior assessment with minor injury. According to a Care Plan revised 7/29/13, the resident had a focus area of falls related to risk factors for falls, ambulatory falls, debility, weakness, medication use, balance problems and impaired cognition. The interventions included the following: a. Personal safety alarm when in bed. Sensor alarm in wheel chair. b. Transfer with 1 assist for all transfers. c. Wheel chair for locomotion, resident only able to propel wheel chair short distances on unit. Non ambulatory. According to a Fall Risk Assessment form dated 10/22/13, the resident had been at risk for falls. According to Incident Reports, the resident had fallen as follows: a. 7/16/13 at 1:35 a.m., found on floor beside the bed laying on his/her right side with the bedside table turned over and positioned on the resident. The resident received a laceration to the right side of his/her head, shoulder and knee. The resident had been sent to the emergency room for evaluation and a personal body alarm placed upon return. b. 8/9/13 at 8:30 a.m., the resident had been witnessed attempting to stand up and get behind the wheel chair to ambulate himself/herself, lost balance and fell to his/her buttocks and hit his/her head as the alarm sounded and no other injuries noted. No further interventions had been placed to help maintain the resident's safety. c. 8/28/13 at 8:50 a.m., the staff had been summoned to the resident's room, upon entering the resident had been noted sitting upright on the floor next to the bed with his/her legs under a wheel chair. The resident denied any pain and/or discomfort. The alarm had not been sounding. The staff documented the resident had been in bed prior to the incident and non-compliant with alarm use as he/she removed the device at times. No new interventions had been placed to maintain the resident's safety. d. 9/23/13 at 12:40 p.m., staff had been summoned to the resident's room with the alarm sounding. Upon entering the staff noted the resident's upper body leaning on the wheel chair and the housekeeper holding the resident's legs to keep him/her from falling. The staff lowered the resident to the floor without injury. No new interventions had been placed to help maintain the resident's safety. e. 9/28/13 at 9:15 a.m., the resident attempted to self-transfer to his/her bed as he/she slid and fell without injury. The alarm had been sounding however no new interventions had been placed to help maintain the resident's safety. f. 10/4/13 at 6:25 a.m., the resident had been found sitting on the floor of the bathroom as he/she had attempted to transfer himself/herself to the toilet. An abrasion had been noted on the resident's lower back. No documentation had been present that an alarm had been placed and sounding which the DON confirmed on 10/30/13 at 12:10 p.m. No new interventions had been placed to help maintain the resident's safety. An observation 10/29/13 at 3:10 p.m., revealed the resident positioned in bed with his/her eyes closed and the personal body alarm box attached to the left side rail however not clipped/attached to the resident. During an interview/observation 10/29/13 at 3:15 p.m., the resident's alarm remained unattached. Staff C, CNA confirmed he had taken the resident to the bathroom at 2:45 p.m. and attached/clipped the alarm to the resident however he/she had been known to remove the alarm. During an observation 10/30/13 at approximately 8:40 a.m., Staff D, CNA transferred the resident to bed, positioned for comfort and attached the personal body alarm clip to the resident's pajamas. The resident stated he/she did not like the alarm because it snagged his/her pajamas. The staff member then attached the alarm to the resident's T-shirt. An observation 10/30/13 at 9:10 a.m., revealed the resident positioned in bed, eyes closed with the personal body alarm not clipped/attached to the resident. An observation 10/30/13 at 9:40 a.m., revealed the resident positioned in bed, eyes closed, with the personal body alarm not clipped/attached to the resident. 3. According to an MDS assessment form dated 8/20/13, Resident #5 had [DIAGNOSES REDACTED]., depression, chronic pain, aftercare of a fracture and debility. The assessment indicated the resident had a BIMS score of 12 out of 15 which revealed the resident had moderate cognitive impairments. The resident required assistance of one staff member with transfers and locomotion on and off the unit. The resident ' s test for balance identified he/she was not steady, only able to stabilize himself/herself with staff assistance when turning around. The MDS documented the resident had impairments on both sides of his/her lower extremities. According to an Incident Report 7/7/13 at 12:30 a.m., the resident had fallen, complained of hip pain and sent to the hospital for evaluation and treatment. According to a History and Physical form dated 7/7/13, the resident had been admitted to the hospital with [REDACTED]. According to a Care Plan revised on 7/17/13, the resident had been a high risk for falls related to having been unaware of safety needs, deconditioning, gait/balance problems, incontinence as well as a history of falls with injury and medication use. The interventions included the following: a. The resident used a wheel chair and bed electronic alarm. Ensure the device had been placed at all times. A Fall Risk assessment dated [DATE], indicated the resident as a fall risk. An observation 10/30/13 at 10:55 a.m. and 10 seconds, revealed the resident's call light as on. At 11 a.m. and 30 seconds the resident's alarm sounded as he/she self-transferred from the wheel chair to the bed and proceeded to shut off the alarm box attached to the right handle of the wheel chair. During an interview at the same time, the resident confirmed he/she frequently shut off the alarm. At 11:02 a.m., Staff B, CNA entered the resident's room and the call light had been shut off. During an interview 10/30/13 at 11:05 a.m., Staff A, CNA and Staff B indicated they had been unaware if the resident self-transferred himself/herself and shut off alarms. The facilities Falls Prevention Procedure form (not dated), indicated the purpose had been to minimize the risk for falls. The procedures included the following: a. If the falls assessment showed that the resident had been at risk for falls the Team Leader/Case Manager would instruct the staff caring for the resident to monitor the resident frequently, answer the call light promptly and any other safety interventions put into place to help protect the resident from falls. b. All interventions on the care plan at the time of the fall would be reviewed by the Case manager as to appropriateness of the intervention and new approaches added as indicated. The new intervention and new approaches added as indicated. The new intervention would be shared with the staff caring for the resident and the Case Manager would make an entry in the nurses notes. The facilities Resident Fall Protocol form (not dated), indicated the following: The philosophy of Fountain West Health Center had been the reduction or elimination of falls as an essential step in providing quality care to all residents. The program must have been interdisciplinary and all staff had a sense of ownership in the prevention of falls. The nursing department had been responsible for executing clinical interventions. All staff at Fountain West Health Center had been responsible for observation, monitoring and executing environmental interventions.

Based on record review and staff interviews, the facility failed to follow residents' plan of care during transfers and provide adequate supervision from hazards for four (4) of nine (9) residents (Residents #3, #1, #4 and #2). Resident #3 sustained multiple fractures when staff failed to use the larger EZ lift sling during a transfer; and the facility failed to follow plan of care interventions for Residents #1 and #4. The facility reported a census of 108 residents. Findings Include: 1. Record review of the MDS dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident with both short and long term memory problems. The MDS documented the resident with severely impaired decision making skills. The MDS documented the resident required extensive assistance from staff to totally dependent on one/two staff for all activities of daily living (ADL's). The MDS identified the resident ' s test for balance during transition and walking did not occur; however the surface to surface transfer (transfer between bed and chair or wheelchair) showed the resident not steady, and only able to stabilize with staff assistance. The MDS documented the resident used a wheelchair for mobility and had impairments in both upper and lower extremities. Record review of the Fall Risk assessment dated [DATE] and 1/21/11 documented the resident at risk for falls. Resident #3's Care Plan dated 4/18/11 documented the resident at risk for falls due to his/her immobility as evidence from total assistance with transfers via EZ lift. The care plan identified the resident as non-ambulatory and non-weight bearing and directed staff to use the EZ lift for all transfers and specifically instructed staff to use the large EZ lift sling (burgundy color) and criss cross leg straps to prevent patient from sliding out of sling during mechanical transfers. The goal directed 2 staff were needed with bed mobility for safety during cares. The Incident Report dated 4/14/11 at 9:35 a.m., documented the CNA reported while transferring the resident from bed to the recliner, the resident slid out of the EZ lift (Hoyer) sling in the midst of a transfer. The CNA (Staff B) called the nurse (Staff A) to the resident's room, where the resident had been laying part way on his/her back with his/her left leg extended out; and the right leg bent under the left leg. The incident report documented the facility received orders for X-rays of the resident ' s left hand, right pelvis, hip femur, and lower left at ankle. The X-ray findings dated 4/14/11 revealed three views of Resident # 3's right ankle, and two views of right tibia-fibula. The examination of the ankle identified a nondisplaced distal fibula fracture. The report documented there was also a fracture of the medial malleolus with angulation of the distal fracture fragment. The evaluation of the tibia and fibula showed the distal tibia and fibula fractures. The findings also identified an oblique fracture through the proximal metaphysic which appeared nondisplaced. During interview on 5/11/11 at 11:00 a.m., Staff A stated she responded to a stat call to the resident's room and found the resident laying part way on the his/her back with the left leg extended out and the right leg bent under the left leg. Staff A stated Staff B appeared behind the resident supporting the upper half of the body. Staff A stated Staff B was crying and stated she went to pull the resident back (in the EZ lift sling) the resident slipped out of the sling. Staff A stated Staff B informed her there was a bed pad in the EZ sling and Staff B and Staff G thought that is why the resident slid out of the EZ lift sling. Staff A stated she and several others staff completed assessments and gave the resident care before transferring the resident back into the bed. The resident's family and physician were notified appropriately. During interview on 5/11/11 at 11:20 a.m., Staff B stated she and Staff G went into the resident's room. Staff B stated a bed pad and sling were already under the resident, so she and Staff G went ahead and used those to transfer the resident from the bed into the chair. Staff B stated Staff G operated the EZ lift and she went behind the resident's chair and when she pulled on the sling to get the resident into the chair the resident slid out of the sling onto the floor. Staff B stated she attempted to catch the resident, was unable to do so, so she pushed her body against the resident's body in an attempt to get him/her into the chair. Staff B stated the resident fell on to the floor. Staff B stated Staff G went out of the room to get help. Staff B stated she stayed with the resident and other staff came into the room to provide assistance. Staff B stated she had used a bed pad under the resident before without any problems. Staff B stated she discovered they had also used a medium size sling and probably should have used a large sling due to the resident's size. Staff B stated they placed the bed pad under the resident due to the resident's large amount of urination. Staff B stated they had seen other staff place a bed pad between the resident and the sling. During interview on 5/11/11 at 1:40 p.m., Staff C stated she went into the resident's room around 7:30 a.m. to weigh him/her. Staff C stated she used the bed pad to move the resident from side to side to place and EZ lift (Hoyer) sling under the resident. Staff C stated she kept the bed pad between the resident and the sling so the sling does not get soiled. Staff C stated she went ahead and obtained the resident's weight and covered him/her up leaving the bed pad and the sling under the resident. During interview on 5/12/11 at 11:15 a.m., Staff G stated she and Staff B went into the resident's room and noticed the bed pad and sling already under the resident so they agreed to go ahead and use what was already there to transfer the resident. Staff G stated she guided the EZ lift with the resident in the sling from the bed to the chair. Staff G stated she noticed the resident start to tip a little bit, so she slowly backed the machine out to put the resident in the chair. Staff G stated Staff B guided from the back and got behind the recliner and when they got the resident above the recliner the resident slipped out. Staff G stated Staff B attempted to grab the resident as he/she fell . Staff G stated Staff B suggested putting the bed pad under the resident to address the large amount of urination. Staff G stated she had used a bed pad before with incident. Staff G stated she would not use a bed pad again and make sure the resident had the right size sling with it crossing through the legs. During interview on 5/10/11 at approximately 2:10 p.m., The DON and Staff A stated the sling being used for the resident was not the one which would cross between the resident's legs because it caused bruising to the resident's inner thighs. (According to the care plan the sling was supposed to be used crossed between the resident's thighs.) 2. Record review of the Minimum Data System Assessment tool ((MDS) dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident's short and long term memory as able to be interviewed and not scored. The MDS documented the resident required extensive to total dependence of one to two staff with all activities of daily living (ADL's). Record review of the Fall Risk assessment dated [DATE] documented the resident at risk for falls. The Resident Care Plan dated 9/16/2010 documented under Problem: a. Impaired mobility, non-ambulatory, dependent on staff with locomotion and EZ stand transfers. The care plan documented under Approach/frequency: #13. EZ stand transfers discontinued on 3/18/11. Hoyer lift (EZ lift) transfers 3/18/11. EZ stand transfer with assist of 2 dated 3/22/11. Hoyer lift (EZ lift) transfer dated 4/13/11. Record review of the Incident Report dated 4/01/11 at 6:30 a.m., documented the resident an EZ stand transfer with 2 assist and was transferred with just one CNA. The report documented the CNA (10:00 p.m. to 6:00 a.m.) was transferring resident #1 with the EZ stand, the resident lost his/her balance and fell from the EZ stand unto his/her buttocks. The resident appeared sitting on the buttocks with bilateral legs extended in front and back up against a bed. The report documented the EZ stand straps to the waist and knees not applied during the transfer. The report documented assessments completed and the physician and family notified. During interview on 5/16/11 at 11:44 a.m., Staff J stated she had been getting Resident #1 up for 6 months without problems. Staff J stated she forgot to tighten the belt around the middle of the resident after raising him/her with the EZ stand. Staff J stated the resident lost his/her balance and fell . Staff J stated she did have the strap buckled around the resident's knees. Staff J stated she received additional education regarding both the EZ stand and the EZ lift procedures. 3. Record review of the MDS dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS documented the resident's short and long term memory as able to be interviewed and not scored. The MDS documented the resident required extensive to total dependence of one to two staff with all activities of daily living (ADL's). The Resident Care Plan dated 1/08/09 documented Resident #4 had a potential for falls due to multiple sclerosis, non-ambulatory and balance problems. The care plan directed staff to use the EZ lift and 2 staff assistance for all transfers. Review of personnel records documented Staff H terminated by the facility on 5/03/11 after discovering that Staff H had failed to use the EZ lift for Resident #4. During interview on 5/16/11 at 11:28 a.m., Staff H stated she did not use the EZ lift for the resident's transfer. Staff H stated the resident is very light and she is able to pick the resident up and put him/her in bed. Staff H stated the resident's care plan does say to use the EZ lift, but many staff transfer the resident without the lift. Staff H stated no one saw her do it. Staff H stated Staff I questioned her about it, then Staff H went and informed the DON (Director of Nursing) about it and she got fired. During interview on 5/16/11 at 11:28 a.m., Staff I stated Staff H wheeled the resident into the room and shut the door. Staff I stated two other staff took the EZ lift and went down the hall to use it on two other residents. Staff I stated it was the only EZ lift in that hallway. Staff I stated when Staff H came out of the room he asked Staff H if she had levitating powers Staff I stated Staff H said she picked the resident up and put him/her into the bed by herself. Staff I stated he informed Staff H that was not a good idea and wrote her up. During interview on 5/12/11 at 1:30 p.m., the DON stated there was no incident report from the incident with Staff H because there was no injury. The DON stated Staff H stated she transferred the resident alone because she could do so. The DON stated Staff H was terminated. Record review of the Procedure for EZ lift dated before 5/10/11 failed to document any information regarding using a bedpad between the resident and the sling. Record review of the Procedure for EZ lift dated after 5/10/11 failed to document any information regarding using a bedpad between the resident and the sling. 4. Record review of the MDS dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED].The MDS documented the resident required extensive assistance to total dependence of one to two staff with all activities of daily living (ADL's). Record review of the Fall Risk assessment dated [DATE] documented the resident at risk to fall. The Resident Care Plan dated 2/08/06 documented the resident impaired mobility, non-ambulatory, dependent on staff with locomotion and EZ stand & EZ lift for transfers. The care plan directed staff to use the EZ lift and two staff assist for transfers in and out of bed and EZ stand transfer with one assist once up. Record review of the Incident Report dated 3/24/11 at 4:45 p.m., documented the resident was found lying supine on the floor between the EZ stand and the wheelchair. The report documented that Staff H stated the strap came off the EZ stand during the transfer. The report documented the resident assessed and the physician and family notified. During interview on 5/16/11 at 11:09 a.m., Staff H stated on 3/24/11 she did use the EZ stand to transfer the resident. Staff H stated the care plan documented only one staff could be used with the resident and the EZ stand. Staff H stated when she was putting a depend on the resident the strap slipped off the stand and the resident fell . Staff H stated she did receive re-education on using the EZ stand. During interview on 5/12/11 at 2:05 p.m., Staff A stated when investigating the incident, Staff H stated the strap gave way-came off the EZ stand. Staff A and the surveyor looked at the EZ stand and observed rubber clips which were designed to keep the strap from coming off. Staff A stated the strap was not frayed and did not break-it evidently had not been hooked up correctly. Staff A stated the clip on the EZ stand was not broken.

Based on observation, record review, resident and staff interviews, the facility failed to ensure physicians' orders for medication administrations were followed for 5 of 12 residents reviewed with medication errors. (Resident #1, Resident #4, Resident #5, Resident #11, and Resident #12.) Facility census was one hundred ten (110) residents. Findings include: 1. A Minimum Data Set (MDS) with an assessment reference date of 10/21/10 assessed Resident #1 with a BIMS (Brief Interview for Mental Status score of "8" (moderate cognitive impairment). The resident required extensive assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. The resident required total staff assistance with bathing and wheelchair mobility. The resident was nonambulatory. The resident had [DIAGNOSES REDACTED]. A medication error report dated 11/18/10 identified that the resident received another resident's medications. The resident received the following medications in error on 11/18/10 at 5:45 p.m., in addition to the resident's regular medications: MicroK 20 millequivelants (meq) (electrolyte), [MEDICATION NAME] 25 milligrams (mg.) (antipsychotic), [MEDICATION NAME] 1 gram (antiulcer), Calcium with Vitamin D (vitamin) and [MEDICATION NAME] 50 micrograms (mcg) ([MEDICAL CONDITION]). Staff crushed the medications and placed them in pudding. The resident took 2 bites of the mixture before staff discovered the error. Immediately upon discovering the error, staff notified the physician and the resident's family. The resident's own medications were: [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (heart) and [MEDICATION NAME] nebulizer treatment (breathing). Nurses notes dated 11/18/10 at 5:45 p.m., identified the medication error. On the same date at 6:15 p.m. staff obtained the resident's vital signs. Temperature 98.4 degrees, pulse 102, respirations 30, blood pressure 108/60 and pulse oximetry 92% on room air. Vital signs at 7:15 p.m., temperature 99.8 degrees, pulse 78, respirations 26 and blood pressure 84/42 and pulse oximetry 95% with oxygen at 2 liters. Staff documented the resident as difficult to arouse, moaning to pain only and extremities flaccid. The facility notified the physician and the resident transported to the hospital for examination. On the same date at 11:30 p.m. identified the resident staying at the hospital overnight for observation. The resident returned to the facility on [DATE] at 4 p.m. A hospital history and physical dated 11/18/10 identified the resident received the wrong medication and also received his/her own medications. The report documented the resident ' s blood pressure dropped and the facility transferred the resident to the emergency room . While at the emergency room , the resident appeared groggy and sleepy and received intravenous medication and his/her blood pressure stabilized. (The report identified this was the third time within a year that the resident had a medication error resulting in trips to the hospital.) The final assessment was: medication error resulting in [MEDICAL CONDITION] and lethargy. On 11/22/10 at 5 p.m., Staff B identified herself as the staff that administered the wrong medications to Resident #1. Staff B stated two residents shared the same first name and sat together at the dining room table. She looked at the name band on Resident #1's wheelchair and it contained the name of the other resident. The wheelchair was not marked correctly. After checking the name band, she administered the medications to Resident #1. Resident #1 made a face because Staff B crushed the medications but took the bite. Staff B then checked the name band again and gave the resident another bite. The resident again gave her a "weird look" so Staff B looked at the name band again. At that point, Staff E a C.N.A. (certified nursing assistant) noticed Staff B checking the name band so Staff E also looked at the name band. Staff E informed Staff B that the resident in the wheelchair was not the resident identified by the name band. On 11/23/10 at 9:18 a.m., the Director of Nursing stated staff checks the name bands weekly. Staff had just checked the name bands on 11/16/10 and applied the wrong last name on the name band on Resident #1's wheelchair. Clinical record review identified prior medication errors: A medication error report dated 10/31/09 identified the resident received another resident's medications. A letter describing the incident, written by the Director of Nursing indicated a temporary staffing agency nurse took medications that another nurse prepared and gave them to Resident #1. The resident became hypotensive and the facility transported the resident to the emergency room . A hospital history and physical dated 10/31/09 identified the resident had a drug overdose with blood pressure medications and a pain pill when at the nursing home. The report documented the resident ' s normal diuretic and blood pressure medications would obviously be held and he/she would be monitored for 24 hours. A careful review of the resident's record did not identify a third medication error that resulted in hospitalization . On 11/23/10 at 9:18 a.m., the Director of Nursing confirmed there had not been a third time the resident received the wrong medications that resulted in hospitalization . The resident had three other medication error reports in the file since the first of the year: On 1/25/10 a medication error report identified the resident with orders for blood pressure daily and notify physician of blood pressure greater than 170/90. The resident also had order for a weekly pulse check on Thursdays. The resident's record lacked documentation of either for the month of January 2010. On 4/25/10 a medication error report identified the resident with orders for Akwa Tear ointment to both eyes every night. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/26/10 a medication error report identified the resident with orders received on 1/7/10 for baby shampoo cleanse of both eyes with 1/2 strength shampoo twice daily and as needed. Staff did not transcribe the orders to the MAR indicated [REDACTED]. Observation showed, on 11/23/10 at 9 a.m., Resident #1 seated in a wheelchair at the bedside. A name band on the wheelchair and resident's wrist contained the correct name. The resident answered "yes" when asked if (s)he had just been hospitalized . The resident stated the hospitalization was for "blood pressure". The resident stated (s)he felt better now. 2. Review of medication error forms identified the facility did not follow physician orders [REDACTED]. a. 9/5/10 The facility did not change Resident #11's [MEDICATION NAME] on 9/3/10 as ordered. b. 10/13/10 The facility did not change Resident #12's [MEDICATION NAME] Patch on 10/11/10 as ordered. c. 8/17/10 The facility did not change Resident #5's [MEDICATION NAME] Patch on 8/16/10 as ordered. d.10/27/10 The facility did not change Resident #5's [MEDICATION NAME] Patch on 10/25/10 as ordered. e. 11/16/10 The facility did not change Resident #5's [MEDICATION NAME] Patch as ordered on [DATE]. f. 10/17/10 The facility did not change Resident #4's [MEDICATION NAME] Patch as ordered on [DATE]. The Director of Nursing identified, on 11/23/10 at 1:30 p.m., 21 medication errors in the last 3 months.