Every finding on record at Prairie Gate

Based on observations, facility policy review and staff interview, the facility failed to provide a dignified dining experience when staff sitting at the table engaged in personal conversation while assisting 1 of 5 residents (Resident #33) with eating. The facility reported a census of 36 residents.Findings include: Review of Resident #33's Minimum Data Set (MDS) dated [DATE], revealed the diagnosis list included multiple sclerosis and paralytic syndrome (loss of muscle function or severe muscle weakness caused by disruptions in brain-muscle communication). The MDS identified Resident #33 required set up or clean up assistance with eating.Review of Resident #33's Care Plan revised on 6/16/26 included a Focus area to address I have an ADL (activities of daily living) self-care performance deficit r/t (related to) physical weakness/impaired mobility/self-care abilities.Interventions included, in part: EATING; I require assistance of one for set up, verbal cueing and at times physical assistance with feeding. I use a plate guard.During a dining observation on 8/25/26 starting at 12:51 PM until 1:15 PM, Staff F, Certified Nursing Assistant (CNA) sat at a table to assist Resident #33 with eating lunch. Staff C, CNA also sat at the table to assist other residents as needed. While assisting Resident #33, Staff F and Staff C engaged in a personal conversation. During the conversation Staff Staff F frequently turned their back to Resident #33 residents after assisting with a bite of food. During an interview on 8/26/26 at 4:45 PM, the Director of Nursing stated it is his expectation that staff observe and interact with the residents while assisting them to dine and not have personal conversations with staff only. Review of the facility policy titled Privacy and Dignity Policy approved 4/2025, revealed a Purpose statement which declared: To promote care for all residents in an approach that makes certain that each resident's privacy and dignity is respected by staff. To promote activities which can be carried out by staff, to assist each resident with maintaining or enhancing his/ her self-esteem and self-worth and quality of life.The Procedure section directed, in part:4. Optimal dining experience:b. Sit down next to residents when assisting with meals unless care plan otherwise.c. Conversations to be resident focused.

Based on Electronic Health Record (EHR) review, policy review, family interview and staff interviews the facility failed to report an incident of possible physical abuse to the appropriate entity for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 34 residents.Finding include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented a diagnosis of unspecified dementia without behavioral disturbances. Review of EHR dated 8/28/25 titled, Progress notes documented Resident #1 had a BIMS of 8 indicating moderate cognitive impairment at that time. Review of Resident #1's document titled, Clinical Summary dated 6/19/25 documented Resident #1 had a discharge diagnosis of right hip hematoma related to a ground level fall at home.Review of Resident #1's EHR titled, Progress notes revealed on 7/22/25 Resident #1 was sent to the Emergency Department (ED) via 911 ambulance and returned to the facility on 7/22/25 at 4:12 PM with a diagnosis of UTI.On 10/8/25 at 11:12 AM Staff C, RN Clinical Coordinator explained Resident #1 had passed away. Staff C stated she had no reports that staff were being rough with Resident #1. Staff C acknowledged it took longer to clean Resident #1 up at times because she had loose stools from C-diff. Staff C stated she had explained to Resident #1 that it took longer to clean her up and apply cream to the area because of this. Staff C stated if the resident reported staff being rough it would be reported as a grievance which then the Social Worker would have helped her with that. Staff C stated she had reported to the DON that Resident #1 had concerns when being cleaned up during the time she had a diagnosis of C-diff. Staff C stated she had spoke with Resident #1's daughter and a concern about staff being rough with the resident was never brought up. Staff C stated Staff D, the Previous DON left in July. On 10/8/25 at 11:28 AM Resident #1's daughter stated there was bruising noted on the legs related to a fall. Resident #1's daughter stated Resident #1 returned from the hospital and she spoke with Staff B, Licensed Practical Nurse (LPN) about the bruises that were on Resident #1's right hip. Resident #1's daughter stated Staff B said they were old bruises. Resident #1's daughter stated Resident #1 had complained about some female staff that would come in on overnight shifts and the female staff was pretty rough. Resident #1's daughter stated Resident #1 did not know who that staff was. Resident #1's daughter stated she and Resident #1 told the nurses about the incident. Resident #1's daughter stated she had spoken to Staff B about the bruising and how Resident #1 thought it was from the female staff turning her. Resident #1's daughter stated she had complained to her about it but did not believe that there was any mistreatment by staff at the facility when Resident #1 was at the facility after Staff B spoke to her. On 10/8/25 at 12:18 PM Staff A, Registered Nurse (RN) stated she had worked at the facility for 2 years and one month. Staff A acknowledged Resident #1 had several bruises on her body since admission. Staff A stated Resident #1 nor Resident #1's family never reported staff were rough with her during care. Staff A stated staff had never reported to her that any residents were treated rough including Resident #1. Staff A stated none of the nurses had ever reported to her as the charge nurse that a staff member was being rough with a resident. Staff A stated Staff B had never reported to her that staff on any shift were being rough with a resident including Resident #1. Staff A stated she would inform the Clinical Coordinator about any report of staff being rough with a resident because that would be considered abuse. Staff A stated if there was no Clinical Coordinator then she would report the incident to the Director of Nursing (DON) and if the DON was unavailable she would report it to the Administrator. On 10/8/25 at 1:36 PM Staff B, LPN stated she had worked at the facility for about 6 months. Staff B acknowledged she worked with Resident #1. Staff B stated she worked at the facility when Resident #1 first arrived at the facility. Staff B stated she was present on the first day of admission. Staff B stated Resident #1 had a lot of bruising on her legs from a fall at home. Staff B stated Resident #1 had really bad bruising on her thighs and hips the day she entered the facility. Staff B stated she spoke to Resident #1's family and to Resident #1 frequently. Staff B stated Resident #1 had bruising on her legs and it had not healed yet when she returned from the hospital visit. Staff B stated Resident #1's daughter acted like she did not know about the bruising. Staff B stated it was not from when Resident #1 was at the facility. Staff B stated body audits that were completed every week would reflect the bruising. Staff B stated the interaction with the daughter was passed on in report that day as well. Staff B stated there was a couple times Resident #1 had said one of the staff members was rough when turning her on overnight shift. Staff B stated Resident #1 stated she did not know the staff member's name but that she worked the overnight shift and was rough with her during care. Staff B explained she had determined the staff was Staff E, Certified Nursing Assistant. Staff B stated she completed an assessment on Resident #1 at the time and there were so many bruises on the legs. Staff B stated it was difficult to determine if anything Staff E had done caused any more bruising. Staff B stated she let the charge nurse know. Staff B stated the charge nurse would have been Staff A or Staff F, Registered Nurse (RN). Staff B stated she did not know if Staff E worked with Resident #1 after that. Staff B stated she did not remember if she entered an assessment about the incident. Staff B stated she thought she just reported it to the charge nurse. Staff B stated when she spoke with Resident #1 she stated the overnight staff was rough with her that evening prior. Staff B stated when a resident reported any sort of rough treatment she would just report it to the charge nurse. Staff B stated the Program Coordinator was not working at the facility then. Staff B stated staff reported as being rough with a resident would be considered abuse and did report it as possible abuse to the charge nurse. On 10/9/25 at 8:06 AM Staff F, RN stated she worked at the facility for 2 years. Staff F acknowledged she worked as charge nurse frequently. Staff F stated she will work both halls. Staff F stated if the nurse working hall Wild Lupine had any concerns those concerns would be told to the charge nurse. Staff F stated she was familiar with Resident #1 and worked with her while she was at the facility. Staff F stated no nurse had reported that any staff was rough with residents on any shift. Staff F stated Resident #1 never had voiced any concerns with any staff on any shift being rough with her. Staff F stated Resident #1's family had never spoken to her about any concerns with bruising or staff being rough with care. Staff F stated if it was reported to her that staff were being rough with a resident she would report the incident to the Clinical Coordinator or the DON if there was no Clinical Coordinator. Staff F stated she would also notify the resident's physician and the resident's family member. Staff F stated if the resident claimed staff were rough she would complete a body audit and she would report the incident as suspected abuse. Staff F stated she would speak to the staff and ask if the incident happened and get an interview with the staff that was identified. Staff F stated if the staff was working she would call the DON / Clinical Coordinator and usually that staff would be sent home. Staff F stated the staff would be separated from the resident. Staff F stated this sort of incident was not reported to her about Resident #1 but had been reported about other residents in the past and she had reported that to the administration. Staff F explained that it was a long time ago. Staff F stated Resident #1 had bruises all over her body during admission. On 10/8/25 at 2:32 PM Staff D, Previous DON stated she did not remember Resident #1 complaining of any night shift staff being rough during care. Staff D stated she would have completed a self report for any concern of staff being rough with a resident to the state and investigated the report. Staff D stated she did not remember reporting any concerns to the state in regards to Resident #1. Staff D stated her last day at the facility was in August right after the facility's most recent state survey. Staff D stated she had frequent care conferences with the family and did not remember any complaints from the family or the resident. On 10/9/25 at 11:42 AM the DON stated he would have reported any incidents of suspected abuse to the State Agency. On 10/9/25 at 8:28 AM the Administrator stated if a resident reported a staff being rough during care he would separate the staff from the resident, report it to the state agency, complete an investigation, and then depending on the investigation address the findings. The Administrator stated there was no report of possible abuse or staff being rough to Resident #1 he was aware of. The Administrator acknowledged he was unaware therefore there was not a report to the State Agency.Review of policy modified 6/25 titled, Occurrence Reporting Policy documented the purpose was to obtain a record of the factual information regarding an occurrence. To initiate corrective and preventive measures for unexpected events involving residents. This may be in the form of an occurrence or incident report, referred to in this document as an occurrence report. Any employee discovering, observing or involved in the event will report the event as soon as possible to a supervisor or designee so immediate and necessary action steps can be taken. A nurse/designee would complete the occurrence report. Review of policy modified 1/23 titled, Vulnerable Adult Abuse Prevention Plan documented the plan established the policies, procedures and responsibilities for protecting all adults who are dependent upon this facility for health services and/or a safe environment in which to live. Each resident has the right to be free from abuse including but not limited to verbal, sexual, physical, and mental abuse, injuries of unknown origin, corporal punishment, misappropriation of resident property, mistreatment, neglect or involuntary seclusion. Any form of resident abuse will not be tolerated. With an objective To protect each resident from abuse by care givers (facility employees, volunteers, resident's family or representative, visitors, vendors or other health professionals). Once abuse is suspected or identified, the facility will take all appropriate steps to stop the abuse and protect residents from additional abuse immediately. These steps include but are not limited to reporting the alleged violation within required timeframes and taking appropriate corrective actions.

Based on Electronic Health Record (EHR) review, policy review, family interview and staff interviews, the facility failed to investigate an allegation of abuse to the State Agency for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 34 residents.Finding include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented a diagnosis of unspecified dementia without behavioral disturbances. Review of EHR dated 8/28/25 titled, Progress notes documented Resident #1 had a BIMS of 8 indicating moderate cognitive impairment at that time. Review of Resident #1's document titled, Clinical Summary dated 6/19/25 documented Resident #1 had a discharge diagnosis of right hip hematoma related to a ground level fall at home.Review of Resident #1's EHR titled, Progress notes revealed on 7/22/25 Resident #1 was sent to the ED via 911 ambulance and returned to the facility on 7/22/25 at 4:12 PM with a diagnosis of UTI.On 10/8/25 at 11:12 AM Staff C, RN Clinical Coordinator explained Resident #1 had passed away. Staff C stated she had no reports that staff were being rough with Resident #1. Staff C acknowledged it took longer to clean Resident #1 up at times because she had loose stools from C-diff. Staff C stated she had explained to Resident #1 that it took longer to clean her up and apply cream to the area because of this. Staff C stated if the resident reported staff being rough it would be reported as a grievance which then the Social Worker would have helped her with that. Staff C stated she had reported to the DON that Resident #1 had concerns when being cleaned up during the time she had a diagnosis of C-diff. Staff C stated she had spoke with Resident #1's daughter and a concern about staff being rough with the resident was never brought up. Staff C stated Staff D, the Previous DON left in July. On 10/8/25 at 11:28 AM Resident #1's daughter stated there was bruising noted on the legs related to a fall. Resident #1's daughter stated Resident #1 returned from the hospital and she spoke with Staff B, Licensed Practical Nurse (LPN) about the bruises that were on Resident #1's right hip. Resident #1's daughter stated Staff B said they were old bruises. Resident #1's daughter stated Resident #1 had complained about some female staff that would come in on overnight shifts and the female staff was pretty rough. Resident #1's daughter stated Resident #1 did not know who that staff was. Resident #1's daughter stated she and Resident #1 told the nurses about the incident. Resident #1's daughter stated she had spoken to Staff B about the bruising and how Resident #1 thought it was from the female staff turning her. Resident #1's daughter stated she had complained to her about it but did not believe that there was any mistreatment by staff at the facility when Resident #1 was at the facility after Staff B spoke to her. On 10/8/25 at 12:18 PM Staff A, Registered Nurse (RN) stated she had worked at the facility for 2 years and one month. Staff A acknowledged Resident #1 had several bruises on her body since admission. Staff A stated Resident #1 nor Resident #1's family never reported staff were rough with her during care. Staff A stated staff had never reported to her that any residents were treated rough including Resident #1. Staff A stated none of the nurses had ever reported to her as the charge nurse that a staff member was being rough with a resident. Staff A stated Staff B had never reported to her that staff on any shift were being rough with a resident including Resident #1. Staff A stated she would inform the Clinical Coordinator about any report of staff being rough with a resident because that would be considered abuse. Staff A stated if there was no Clinical Coordinator then she would report the incident to the Director of Nursing (DON) and if the DON was unavailable she would report it to the Administrator. On 10/8/25 at 1:36 PM Staff B, LPN stated she had worked at the facility for about 6 months. Staff B acknowledged she worked with Resident #1. Staff B stated she worked at the facility when Resident #1 first arrived at the facility. Staff B stated she was present on the first day of admission. Staff B stated Resident #1 had a lot of bruising on her legs from a fall at home. Staff B stated Resident #1 had really bad bruising on her thighs and hips the day she entered the facility. Staff B stated she spoke to Resident #1's family and to Resident #1 frequently. Staff B stated Resident #1 had bruising on her legs and it had not healed yet when she returned from the hospital visit. Staff B stated Resident #1's daughter acted like she did not know about the bruising. Staff B stated it was not from when Resident #1 was at the facility. Staff B stated body audits that were completed every week would reflect the bruising. Staff B stated the interaction with the daughter was passed on in report that day as well. Staff B stated there was a couple times Resident #1 had said one of the staff members was rough when turning her on overnight shift. Staff B stated Resident #1 stated she did not know the staff member's name but that she worked the overnight shift and was rough with her during care. Staff B explained she had determined the staff was Staff E, Certified Nursing Assistant. Staff B stated she completed an assessment on Resident #1 at the time and there were so many bruises on the legs. Staff B stated it was difficult to determine if anything Staff E had done caused any more bruising. Staff B stated she let the charge nurse know. Staff B stated the charge nurse would have been Staff A or Staff F, Registered Nurse (RN). Staff B stated she did not know if Staff E worked with Resident #1 after that. Staff B stated she did not remember if she entered an assessment about the incident. Staff B stated she thought she just reported it to the charge nurse. Staff B stated when she spoke with Resident #1 she stated the overnight staff was rough with her that evening prior. Staff B stated when a resident reported any sort of rough treatment she would just report it to the charge nurse. Staff B stated the Program Coordinator was not working at the facility then. Staff B stated staff reported as being rough with a resident would be considered abuse and did report it as possible abuse to the charge nurse. On 10/9/25 at 8:06 AM Staff F, RN stated she worked at the facility for 2 years. Staff F acknowledged she worked as charge nurse frequently. Staff F stated she will work both halls. Staff F stated if the nurse working hall Wild Lupine had any concerns those concerns would be told to the charge nurse. Staff F stated she was familiar with Resident #1 and worked with her while she was at the facility. Staff F stated no nurse had reported that any staff was rough with residents on any shift. Staff F stated Resident #1 never had voiced any concerns with any staff on any shift being rough with her. Staff F stated Resident #1's family had never spoken to her about any concerns with bruising or staff being rough with care. Staff F stated if it was reported to her that staff were being rough with a resident she would report the incident to the Clinical Coordinator or the DON if there was no Clinical Coordinator. Staff F stated she would also notify the resident's physician and the resident's family member. Staff F stated if the resident claimed staff were rough she would complete a body audit and she would report the incident as suspected abuse. Staff F stated she would speak to the staff and ask if the incident happened and get an interview with the staff that was identified. Staff F stated if the staff was working she would call the DON / Clinical Coordinator and usually that staff would be sent home. Staff F stated the staff would be separated from the resident. Staff F stated this sort of incident was not reported to her about Resident #1 but had been reported about other residents in the past and she had reported that to the administration. Staff F explained that it was a long time ago. Staff F stated Resident #1 had bruises all over her body during admission. On 10/8/25 at 2:32 PM Staff D, Previous DON stated she did not remember Resident #1 complaining of any night shift staff being rough during care. Staff D stated she would have completed a self report for any concern of staff being rough with a resident to the state and investigated the report. Staff D stated she did not remember reporting any concerns to the state in regards to Resident #1. Staff D stated her last day at the facility was in August right after the facility's most recent state survey. Staff D stated she had frequent care conferences with the family and did not remember any complaints from the family or the resident. On 10/9/25 at 11:42 AM the DON stated should a resident have any change he would expect that an assessment would have been completed. The DON stated if a resident or resident family member had reported any allegations of abuse should have had an assessment. On 10/9/25 at 8:28 AM the Administrator stated if a resident reported a staff being rough during care he would separate the staff from the resident, report it to the state agency, complete an investigation, and then depending on the investigation address the findings. The Administrator stated there was no report of possible abuse or staff being rough to Resident #1 he was aware of. The Administrator acknowledged he was unaware therefore there was an investigation completed related to the incident. Review of policy modified 6/25 titled, Occurrence Reporting Policy documented the purpose was to obtain a record of the factual information regarding an occurrence. To initiate corrective and preventive measures for unexpected events involving residents. This may be in the form of an occurrence or incident report, referred to in this document as an occurrence report. Any employee discovering, observing or involved in the event will report the event as soon as possible to a supervisor or designee so immediate and necessary action steps can be taken. A nurse/designee would complete the occurrence report. Review of policy modified 1/23 titled, Vulnerable Adult Abuse Prevention Plan documented the plan established the policies, procedures and responsibilities for protecting all adults who are dependent upon this facility for health services and/or a safe environment in which to live. Each resident has the right to be free from abuse including but not limited to verbal, sexual, physical, and mental abuse, injuries of unknown origin, corporal punishment, misappropriation of resident property, mistreatment, neglect or involuntary seclusion. Any form of resident abuse will not be tolerated. With an objective To protect each resident from abuse by care givers (facility employees, volunteers, resident's family or representative, visitors, vendors or other health professionals). Once abuse is suspected or identified, the facility will take all appropriate steps to stop the abuse and protect residents from additional abuse immediately. These steps include but are not limited to investigating within required timeframes and conduct a thorough investigation of the alleged violation taking appropriate corrective actions.

Based on Electronic Health Record (EHR) review, policy review, family interview and staff interviews the facility failed to complete an assessment when a resident reported bruising related to a staff being rough during care for 1 of 1 residents (Resident #1) reviewed. The facility reported a Census of 34 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS also documented a diagnosis of unspecified dementia without behavioral disturbances. Review of EHR dated 8/28/25 titled, Progress notes documented Resident #1 had a BIMS of 8 indicating moderate cognitive impairment at that time. Review of Resident #1's EHR titled, Progress Notes documented no assessment related to resident reports to Staff B, Licensed Practical Nurse (LPN) of Staff E Certified Nursing Assistant (CNA) being rough during care.Review of Resident #1's EHR titled, Assessments documented no assessment related to resident report to Staff B, LPN of Staff E being rough during care.Review of Resident #1's document titled, Clinical Summary dated 6/19/25 documented Resident #1 had a discharge diagnosis of right hip hematoma related to a ground level fall at home.Review of Resident #1's EHR titled, Progress notes revealed on 7/22/25 Resident #1 was sent to the ED via 911 ambulance and returned to the facility on 7/22/25 at 4:12 PM with a diagnosis of UTI.Review of Resident #1's EHR dated 6/19/25 titled, Body Audit completed by Staff F documented a large purplish bruise from fall at home on the left lateral outer thigh. Review of Resident #1's EHR's titled, Body Audit documented no sizes for any skin alterations for audits completed on 6/19, 6/24, 7/8, 7/17, 7/29, 8/5, 8/8, 8/15, 8/28, 9/22 and 9/23.On 10/9/25 at 8:06 AM Staff F, RN stated she worked at the facility for 2 years. Staff F stated Resident #1 had bruises all over her body during admission. Staff F acknowledged she was the nurse that completed the skin assessment upon Resident #1's admission. Staff F stated she could not remember which side of the body the hematoma was on Resident #1 during admission. Staff F acknowledged she had documented a large purplish bruise from fall at home on the left lateral outer thigh. Staff F acknowledged a hospital discharge document titled, Clinical Summary from admission to the facility described the large bruise on the right hip. Staff F stated she could not remember which hip may have gotten left and right confused during the assessment. On 10/8/25 at 11:28 AM Resident #1's daughter stated there was bruising noted on the legs related to a fall. Resident #1's daughter stated Resident #1 returned from the hospital and she spoke with Staff B, LPN about the bruises that were on Resident #1's right hip. Resident #1's daughter stated Staff B said they were old bruises. Resident #1's daughter stated Resident #1 had complained about some female staff that would come in on overnight shifts and the female staff was pretty rough. Resident #1's daughter stated Resident #1 did not know who that staff was. Resident #1's daughter stated she and Resident #1 told the nurses about the incident. Resident #1's daughter stated she had spoken to Staff B about the bruising and how Resident #1 thought it was from the female staff turning her. Resident #1's daughter stated she had complained to her about it but did not believe that there was any mistreatment by staff at the facility when Resident #1 was at the facility after Staff B spoke to her. On 10/8/25 at 1:36 PM Staff B, LPN stated she had worked at the facility for about 6 months. Staff B acknowledged she worked with Resident #1. Staff B stated she worked at the facility when Resident #1 first arrived at the facility. Staff B stated she was present on the first day of admission. Staff B stated Resident #1 had a lot of bruising on her legs from a fall at home. Staff B stated Resident #1 had really bad bruising on her thighs and hips the day she entered the facility. Staff B stated she spoke to Resident #1's family and to Resident #1 frequently. Staff B stated Resident #1 had bruising on her legs and it had not healed yet when she returned from the hospital visit. Staff B stated Resident #1's daughter acted like she did not know about the bruising. Staff B stated it was not from when Resident #1 was at the facility. Staff B stated body audits that were completed every week would reflect the bruising. Staff B stated the interaction with the daughter was passed on in report that day as well. Staff B stated there was a couple times Resident #1 had said one of the staff members was rough when turning her on overnight shift. Staff B stated Resident #1 stated she did not know the staff member's name but that she worked the overnight shift and was rough with her during care. Staff B explained she had determined the staff was Staff E. Staff B stated she completed an assessment on Resident #1 at the time and there were so many bruises on the legs. Staff B stated it was difficult to determine if anything Staff E had done caused any more bruising. Staff B stated she let the charge nurse know. Staff B stated the charge nurse would have been Staff A or Staff F, Registered Nurse (RN). Staff B stated she did not know if Staff E worked with Resident #1 after that. Staff B stated she did not remember if she entered an assessment about the incident. Staff B stated she thought she just reported it to the charge nurse. Staff B stated when she spoke with Resident #1 she stated the overnight staff was rough with her that evening prior. Staff B stated when a resident reported any sort of rough treatment she would just report it to the charge nurse. Staff B stated the Program Coordinator was not working at the facility then. Staff B stated staff reported as being rough with a resident would be considered abuse and did report it as possible abuse to the charge nurse. On 10/8/25 at 2:32 PM Staff D, Previous DON stated she did not remember Resident #1 complaining of any night shift staff being rough during care. Staff D stated she would have completed a self report for any concern of staff being rough with a resident to the state and investigated the report. Staff D stated with any report of staff being rough during care an assessment should have been completed and documented. On 10/9/25 at 11:42 AM the DON stated should a resident have any change he would expect that an assessment would have been completed. The DON stated if a resident or resident family member had reported any allegations of abuse should have had an assessment. On 10/9/25 at 8:28 AM the Administrator stated a body audit would have only been completed when the resident was out of the facility for longer than 24 hours but an assessment should have been completed when Resident #1 reported the staff were being rough with her. The Administrator acknowledged he was unable to find that any assessment was completed related to the report of staff being rough with Resident #1 by any nurse. Review of policy modified 6/25 titled, Occurrence Reporting Policy documented the purpose was to obtain a record of the factual information regarding an occurrence. To initiate corrective and preventive measures for unexpected events involving residents. This may be in the form of an occurrence or incident report, referred to in this document as an occurrence report. Any employee discovering, observing or involved in the event will report the event as soon as possible to a supervisor or designee so immediate and necessary action steps can be taken. A nurse/designee would complete the occurrence report.

Based on clinical record review, document review and staff interview the facility failed to protect residents from accidents and injuries for 1 of 3 residents (Resident #135) reviewed. The facility reported a census of 33 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #135 dated 6/10/25 documented an admission date of 3/27/25 and a Brief Interview for Mental Status (BIMS) score of 04 indicating severe cognitive impairment. The MDS documented diagnoses of vascular dementia, depression, rheumatoid arthritis, and cancer. The MDS revealed Resident #135 required partial/moderate assistance of a helper to complete transfers and used a wheelchair for mobility. A review of the facility self report documented on 6/25/25 at 1:50 pm Staff A, Certified Nursing Assistant (CNA) assisted Resident #135 after a meal with the wheelchair transfer. Resident #135 did not have her feet on the foot pedals and fell out of the wheelchair during the transfer, sustaining a contusion to the left forehead. A review of the electronic communication document titled Patient Fall between the facility and the Hospice Physician on 6/26/25 documented the following: a witnessed fall, facility aide was transporting patient from the dining room to her recliner in community room when she fell out and hit left eyebrow area and right arm on floor. 1.5 cm x 2.5 cm abrasion with blue bruising noted around abrasion. The physician confirmed an injury had occurred. A review of the document titled Resident Occurrence Report dated 6/26/25 revealed analysis and summary of causal factors as follows: Resident is declining, mental status declined that she suddenly/accidentally fell herself in the wheelchair with short-term intervention to place to bed for comfort measures and long-term intervention to tilt in space wheelchair for proper positioning. A review of the document titled Care Plan revealed Resident #135 had limited physical mobility related to weakness/impaired mobility/self-care abilities, and intervention in place to use a tilt in space wheelchair for mobility, date Initiated 02/14/2022. A review of the document titled Escorting Resident With Wheelchair dated June 25, 2025 documented all-staff training was provided following the incident with Resident #135. On 07/08/25 at 9:15 am the Administrator stated the video camera footage showed Staff A, pulled Resident #135 wheelchair away from the dinner table and started pushing her forward while the resident's feet were under the foot pedals. The Administrator confirmed Staff A did not take time to place Resident #135 feet onto the foot pedals. As soon as they left the dining room and came around the corner, the resident fell out of the wheelchair. On 07/08/25 at 10:07 am in an interview with the Director of Nursing (DON), she confirmed Resident #135 did not have her feet on foot pedals during the transfer and her expectation was that the staff transfer residents who are in wheelchairs with feet placed on foot pedals.

Based on observation, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 3 reviewed (Resident #24). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #24 documented a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS also documented utilization of an indwelling catheter. An observation of catheter cares completed on Resident #24 on 7/8/25 at 9:48 AM by Staff B, Certified Nursing Assistant (CNA) revealed Staff B completed hand hygiene, applied gloves, applied gown, cleansed catheter tubing with alcohol swab about 4 - 6 inches down tubing, and removed gloves. She did not complete hand hygiene. She applied new gloves, placed barrier on the ground, obtained graduate, removed the tip of the catheter, emptied urine into the graduate (450 mL), cleansed the tip of the catheter with alcohol wipe, replaced the tip of the catheter, replaced the catheter bag in the privacy bag, removed gloves, and did not complete hand hygiene. She applied gloves, picked up the graduate, emptied the graduate into the toilet, turned on the faucet with gloves on in the bathroom to fill graduate with water, emptied the graduate into the toilet, removed gloves, removed gown, and completed hand hygiene. On 7/8/25 at 10:04 AM the DON stated she did not expect the catheter tip to be cleansed prior to emptying but after urine was emptied. The DON stated the facility's expectation was hand hygiene would be completed between glove changes and when moving from one contaminated area of the body to the catheter. Review of policy dated 2020 titled, Infection Control Standard Precautions documented it was the policy of the facility that hand hygiene procedures would be adhered to in order to prevent the transmission of pathogens. Hand hygiene should be performed before and after contact with the resident, after contact with visibly contaminated surfaces, before donning personal protective equipment (PPE), and after removing PPE.

Based on record review, staff, resident and family interviews, and facility policy review the facility failed to treat the resident with respect and dignity for 1 of 3 residents (Resident #4) with dignity and respect during personal cares. The facility reported a census of 35 residents. Findings include: According to Resident #4's Admission Minimum Data Set (MDS) assessment tool with a reference date of 3/27/2025, she had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she had no impairments to her upper and lower extremities, and she utilized a walker and wheelchair for mobility. The MDS indicated she required supervision or touching assistance to go from a sitting to lying position, lying to sitting position, from a chair/bed to chair, and toileting transfer. The MDS listed the following diagnoses for Resident #4: polyosteoarthritis and thyroid disease. The Care Plan Focus Area with an initiation date of 3/21/2025 documented she had an Activities of Daily Living (ADLs) self-care deficit due to advanced age, weakness, impaired mobility, self-care abilities, osteoarthritis and physical debility. The Care Plan documented she required the assistance of one staff with a gait belt, and walker for ambulation and transfers. Staff are to assist as needed (PRN)/requested for bed mobility. The following Progress Note was documented for Resident #4: on 5/15/2025 at 2:22 PM her physician was notified of right shoulder pain. Resident had an appointment at the clinic earlier and was aware of the right shoulder pain. The physician requested staff to continue to monitor her pain. Record review revealed Staff C Registered Nurse (RN) completed a body audit for Resident #4 on 5/15/2025. Staff C documented the following in the additional comments on skin integrity section: skin is clean, dry and intact. Claimed pain on right upper arm on hyperextension movement; rated a 2-3 on the pain scale. On 5/22/2025 at 1:10 PM Resident #4's daughter and emergency contact #1 stated her mom said one of the people on staff at night came in to her room a couple times during the night to see if she wanted to go to the bathroom. That night the staff member woke her up, told her to roll over. Her mom said she couldn't unless she has something to grab on to. She was flat on her back, in bed. The staff kept saying roll over, you're wet as Resident #4 said I can't. The staff member jerked her arm to roll her over. She indicated her mom had fallen a week or so before and her arm was just starting to feel better. After that staff helped her, that arm hurt. Her mom stated the staff member had a gruff attitude and she did not show compassion for those that couldn't help themselves. Her mom wondered about others that couldn't speak up and how could they report these things. That one particular night she was pretty upset about it. Her mom could not recall her name but described her as a tall slender black girl that wore a turbine. Resident #4 reported no further concerns since that day, that gal has not been back in. On 5/22/2025 at 2:12 PM observed Resident #4 sitting in the recliner in her room, reading a book. When asked if anyone was ever rough when they were assisting her with care, she stated about 2-3 weeks ago some tall, black lady on the overnight shift was. She could not think of her name. She came in three times that night. At about 2:30 AM the staff member came in her room after she had her call light on, pulled her covers off and asked what she wanted. The resident stated she needed to go to the bathroom. Resident #4 pointed to two signs in her room that read call don't fall. She knew the staff member could read and see them, that's why she asked for help. The staff member said she was wet then positioned her bed flat, crossed her own arms and said turn on your side. The resident told her she is lying flat and couldn't turn on her side, especially when she does not have something to grab on to. The staff member said, I said turn over. The resident motioned her arms in the air in a patting manner then pulled her arms toward her. When asked what that meant, she stated she pulled on her right arm and pulled her over on her side. The staff member then told her to stay on her side because she needed to be changed. The resident stated the staff member gave her a sitz bath front and back. After she was done, she threw her covers on her and left. After this her right shoulder/arm started to hurt. She had grabbed that arm to turn her. She reported this because it bothered her and she worried about the residents that don't know what's going on or what is wrong or right. She told the facility she did not want that girl in her room any more. She couldn't stand to think about what happened because it really bothered her. She was told the facility took care of it and she denied further issues. On 5/22/2025 at 12:39 PM Staff A Clinical Coordinator stated Resident #4's daughter reported to her that her mother had said the Certified Nursing Assistant (CNA) that worked overnight was rough with her. Staff came in checking to see if she was wet. The staff member said she was wet and needed to be changed. The staff member told the staff to roll over and the resident said she couldn't, so the staff member helped her to roll over. The resident said the staff member was rough and pulled on her arm. When asked what arm she pulled on, Staff A said she could not remember but remembered it was an arm she had previously injured during a fall a couple of weeks ago. When asked what staff member the resident spoke of, Staff A stated all she knew was it was one of the black ladies. When they did their investigation, they narrowed it down to two CNAs: one being Staff B. Once the Director of Nursing (DON) and Social Worker interviewed residents they were able to narrow it down to Staff B based on the responses from the residents. When Staff A spoke with the resident she stated she was done with the staff member. She was rough with her and pulled on her arm. On 5/22/2025 at 1:01 PM Resident Services Director stated when she spoke to Resident #4 she sated her shoulder was sore when she was trying to move it around; her right shoulder. She was kind of napping so she left her rest. On 5/22/2025 at 1:15 PM Staff C Registered Nurse (RN) stated she went in and completed an assessment on Resident #4 after the alleged incident was reported. She checked her mobility and when she checked her right arm and shoulder, she complained of pain. She only complained when her arm was hyperextended. She believed the resident rated it a 3 out of 10. The physician was notified and wanted them to continue to monitor. She did not need an as needed (PRN) for pain management. When she assessed her later that day her pain had subsided. On 5/22/2025 at 1:48 PM the Administrator stated Staff B Agency CNA could have been nicer when assisting Resident #4. Since the staff member was an Agency CNA they notified her agency and asked that she not return. He suggested the agency do more training with Staff B with ADL assistance. On 5/22/2025 at 3:29 PM Staff B stated she went in to Resident #4's room, changed her diaper, turned her and that was it. The resident resisted and pulled back on her. When turning someone you can see and feel when they are resisting and she did that as she tried to pull her dress up and her diaper down. Staff B stated the resident was fighting her and did not want to turn. Nothing can be done because it's her word against the resident's. People like that have a plan and do things on purpose. It's a catch 22, anyone can do that and now she's stuck. She denied pulling on her arm or shoulder. She acknowledged the bed was flat and she had no side rails to hold on to when rolling. She kept saying, I don't know if this was planned or what but it's her job to clean their butts. Anyone can get you in trouble. On 5/22/2025 at 3:48 PM Staff D CNA stated she was working on the other side of the floor but was assisting with call lights. She came out of a different room, and heard a call light going off, so she decided to see what was going on. She had no idea where Staff B was, she was working that night as well. When she walked in to Resident #4's, first thing the resident did was give out a huge sigh of relief that she was in here. Resident #4 then stated finally someone that knows what she is doing, she was in tears. Resident #4 told her she was flat on her back all night, couldn't find her remote or call light, her back hurt, and her bed was wet. Staff D assisted Resident #4 to the bathroom then to her in her chair while she changed her bedding. Resident then stated she did not want to be caught in bed. Resident #4 stated Staff B got rough with her she positioned her, was not listening to bring head and legs up in bed, roughing her shoulders around and tossing her around in bed. Staff D felt bad, but made sure she was comfortable and left. On 5/23/2025 at 8:34 AM Staff E CNA, that took care of Resident #4 the morning after alleged incident, went in to the resident's room and the resident was pretty upset. When she asked the resident what was wrong, the resident asked Staff E to sit her up, because she had been laying down. She stated she felt trapped, could not get up or move. The resident's bed was flat, she had to help set her up. Resident #4 stated I don't know if you know who that overnight aide was but she was too rough. When she came in, she rolled her over way too rough, did not give her time to turn, and handled her with too much force. She was not happy, said she was sore not sure from laying down or being turned too hard. Resident #4 stated that staff member was not very friendly, just turned her over. Staff E still turned it in because no one should be treated like that. Resident #4 described the staff as a tall black lady, the facility has not scheduled her lately. Staff E added Resident #4 is not a complainer, never heard her complain about staff or treatment before. Goes with the flow kind of person. She did not want to get anyone in trouble but the resident used the words rough and in pain, so she had to report it. The facility provided a document titled Resident Rights Policy with a modified date of November 2022. The purpose of the policy is to make residents aware of Resident Rights, to ensure the correlation between person-centered care and resident rights, and to be in full compliance with all rules, regulations, and standards regarding Resident's Rights.

Based on observation, record review, staff interview and facility policy review the facility failed to properly check an alarmed door after a resident (Resident #1) exited the care center. The facility reported a census of 35 residents. Findings include: According to Resident #1's annual Minimum Data Set (MDS) assessment tool with a reference date of 10/2/2024 documented he had a Brief Interview of Mental Status (BIMS) score of 5. A BIMS score of 5 indicated severe cognitive impairment. Resident #1 did not exhibit wandering behavior during the review period, he utilized a walker and wheelchair for mobility. The MDS indicated he required partial/moderate assistance for chair/bed to chair transfer and toilet transfers. The Care Plan Focus Area with an initiated date of 8/31/2024 documented he was at risk for elopement. Staff were directed with the following: -Assist Resident #1 to his destination of choice when seen wheeling in the hallway (not to dining room). Resident does enjoy wheeling himself to the dining room. -Distract/redirect resident from wandering by offering diversional and/or structured activities, food, conversation, television, book. Prefers to socialize or observe activities in the day room. -Resident requires a door security system on unit and double doors closed on unit at all times when wandering. -Observe for verbalizations of wanting to leave the building. -Provide resident with activities of interest. -Updated on 12/17/24: every 15 minute checks. Record review revealed the following Progress Note on 12/17/2024 at 8:00 PM: At 7:31 PM Resident #1 eloped off the unit through the double doors to the Independent Living apartments trying to find a screw for his room. Resident #1 was assisted to his room, assessed with no injuries found. He was assisted to bed and 15-minute checks were implemented. The Facility Report #136837 revealed the facility investigation was initiated on 12/17/24. The report documented on 12/17/24 at 7:31 PM Resident #1 noted outside care center double doors leading into the independent bistro dining room. Resident stated he was looking for his room to find a screw. Resident returned to his room with no injuries noted by Staff C. Family notified and resident assisted to bed per his request and 15 minute safety checks initiated and care plan updated. The investigation found Staff F turned off the door alarm between 7:15 and 7:30 PM when he heard it sounding . He looked down the hall and saw a male resident in the hall heading toward the Bistro. Staff F mistakenly thought it was another resident that will get signed out by independent living. The investigation revealed steps taken including: -The resident transferred on 12/18/24 to the secure memory unit with family and physician approval. -New elopement assessment completed on all residents. -Door code changed. -Twice daily door checks implemented on the door alarm. -Staff education implemented. On 5/23/2025 at 12:59 PM it was observed to be roughly 62 feet from the double doors off of the dining room to the bistro. On 5/22/2025 at 1:55 PM the Administrator stated Staff F Cook/Chef should not have assumed that he thought it was a resident that was in Independent Living. He should have verified who it was. On 5/23/2025 at 10:33 AM Staff F stated since Resident #1 went out the double doors, he has been educated on letting nursing staff know the alarm sounded and if possible assist the person back to the care center side. That day he heard the alarm sounding, saw someone on the other side of the door but did not think too much of it. He only saw the back of the resident's head but was not 100% on who it was. Staff F should have checked on the resident and been more proactive. On 5/23/2025 at 12:49 PM in an email correspondence, the Administrator stated the protocol for staff to follow in the event a door alarm is activated is to notify the charge nurse if they are unable to state what set off the alarm. The facility provided a policy titled Wandering and Elopement Policy with a modified dated of December 2022. This facility promotes the least restrictive environment for all residents while recognizing the potential of residents wandering from the facility. The facility may utilize monitoring and alarm systems; sign in and out logs on all units/ households and maintain pictures of all residents. The facility will maintain a response plan for implementation in the event of a missing resident.

Based on observations, resident interviews, staff interviews, facility investigation review, personnel file review and clinical record review the facility failed to ensure care was provided in a dignified manner for 3 of 14 residents (Resident #21, #11, and #6) reviewed for dignity. The facility also failed to ensure residents can exercise their rights by refusing cares for 1 of 3 residents (Resident #17) reviewed for resident rights. The facility reported a census of 32 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #21 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit). She required substantial assistance with dressing and was totally dependent with sit to stand transfers, chair to bed transfer and toilet transfers. Her diagnosis included cancer, anemia, heart failure and hemiplegia. The Care Plan, updated on 6/11/24, showed that Resident #21 required 2 staff assist with the sit to stand mechanical lift for transfers. She had self-care performance deficits related to weakness/impaired balance, hemiplegia affecting the right side and vertebra/back pain. She was unable to ambulate and required one assist to turn in bed. According to a facility incident investigation, on 8/1/24, a Family Member (FM) for Resident #21 called the facility and reported that Staff A, Certified Nurse Aide (CNA) had picked up Resident #21 and plopped her into her recliner on the previous evening shift. The FM indicated that she had previous concerns with Staff A manhandling the resident. Resident #21 was interviewed and stated that Staff A did not use a gait belt or a second person to assist with the transfer. When interviewed by the Administrator, Staff A reported that the resident was struggling to stand so he had her put her arms around his neck and used a gait belt to transfer. On 8/12/24 at 11:24 AM, Resident #21 said that Staff A was rough with her. She said that he picked her up by giving a bear hung up under her arms and it hurt her then he threw me down in the chair. She said that it hurt her back and typically, they would use two people and a gait belt to transfer her. She said that other residents had complained that he was rough also. On 8/12/24 at 1:50 PM, the FM said she had witnessed Staff A transferring Resident #21 in a rough manner on more than one occasion. She said that Staff A would lift the resident, swing her around and just let her drop into the chair. She said that he did not have the temperament or the compassion to care for the elderly, and she had requested that he not provide cares to Resident #21. On 8/1/24 Resident #21 called the FM and said that Staff A had picked her up and let her fall into the chair, her back hurt, and she was crying. FM said that there were many times that Staff A would not use a gait belt, and he would just hold onto the resident on the back of the shirt. A review of the Personal Files revealed the following Supervisors/Managers Coaching Notes in the file for Staff A: -3/1/23 not consistently following team sheets when aiding or assisting with residents. He's been reminded multiple times that following the care plan is facility policy and the safest practice when caring for residents. - 7/7/23 Verbal Warning: it was reported that Staff A had been rushing through resident cares and not showing compassion to residents. While providing resident cares, Staff A had been rude, blunt, short tempered and did not show manners towards the residents. - 9/13/23 Written Warning: it was reported that on 9/2/23 and 9/13/23, Staff A did not follow the care plan or use appropriate equipment when transferring residents. - 9/20/23 Suspension: it was reported that on 9/18/23, Staff A rushed through resident care and did not show compassion to the residents. He was too rough and did not follow the team sheets. Numerous residents requested that he not work with them. The staff member was put on a 3-day suspension. Failure to meet expectations would result in termination. - 8/9/24 Notice of Termination: Reported that he transferred a resident correctly and rushed through cares. the team sheets stated that she should be transferred with one assist with one for safety when transferring. On 8/13/24 at 8:46 AM, Staff D, CNA said that Staff A would get a little rough, and in a hurry when transferring with the sit to stand. He said that he did tell one of the nurses one time about the concerns. On 8/13/24 at 8:56 AM Staff C, CNA said that a lot of the residents said they didn't want him to care for them, because he went too fast and he didn't listen to the residents to find out how they prefer to be transferred or when they ask him to slow down. On 8/13/24 at 9:50 AM, Staff B, Registered Nurse (RN) said she had some concerns with Staff A and how he transferred residents. She said he would get in a hurry and he wouldn't listen to the residents when they asked him to slow down and take it easy. On 8/14/24 on 6:27 AM Staff E, CNA said that several residents would ask Staff A to slow down when providing care. Many of resident didn't want him to provide care and they become more anxious if/when he was present. On 8/14/24 at 9:52 AM, the Care Coordinator acknowledged that Staff A had been disciplined previously for not following safe transfer techniques and rushing the residents. She said that Resident #21 was one assist with one stand by staff and Staff A was not following the care plan when he transferred her alone, without a gait belt, and by lifting her up under her arms. 2. According to the MDS dated [DATE], Resident #11 had a BIMS score of 13 (moderate cognitive deficit). She required partial assistance with dressing and footwear, and was totally dependent with sit to stand transfers with the mechanical lift. The Care Plan revised on 6/25/24, showed that Resident #11 had self-care performance deficits, impaired balance/gait of osteoporosis compression fracture. She had limited physical mobility was not able to ambulate. She had communication problems related to a hearing deficit and the potential for psychosocial well-being problems. Staff were directed to allow time to answer questions and verbalize her feelings, perceptions and fears. On 8/12/24 2:18 PM when asked about Staff A, Resident #11 said that he was very nervous, and always moving around and in a hurry. One night, the lights went out at the facility so she went to the room next door to check on her neighbor. Staff A saw her in the other resident's room, grabbed her by the shirt and yelled at her that she was not to be in another resident's room. He then pushed Resident #11 in her wheel chair back into her own room. She said that she did not like to see him coming into her room because I just don't know what he's going to do. 3. According to the MDS dated [DATE], Resident #6 had a BIMS score of 12 (moderate cognitive deficit). She was totally dependent on staff for toileting hygiene, dressing, sit to stand and transfers. The Care Plan last revised on 7/30/24, showed that Resident #6 had self-care performance deficits, weakness and impaired mobility. She was not able to ambulate, and required the help of 2 staff for transfers with the use of the sit to stand mechanical lift. She was at risk for pain related to muscle spasms, multiple sclerosis, tardive dyskinesia and seizures. On 8/12/24 at 10:55 AM Resident #6 said that she did not want Staff A to care for her because he got in a big hurry. She said that he would grab onto her to move her and she would always tell him to slow down. She said that one time, he got into a hurry when she was on the toilet and tried to transfer her and she fell . According to the Facility policy titled: Vulnerable Adult Abuse Prevention Plan modified January 2023 each resident had the right to be free from abuse including but not limited to verbal, sexual, physical and mental abuse, injuries of unknown origin, corporal punishment, misappropriation of property, mistreatment, neglect or involuntary seclusion. Any form of resident abuse would not be tolerated. The philosophy included service provided would be of the highest quality and designed to promote independence, dignity and holistic well-being. According to the facility policy titled: Gait Belts for Transfer and Ambulation dated December 2014, gait belts would be used for all transfers of weight bearing resident who require assistance with transfers and/or ambulation if indicated on the care plan. 47673 4. The MDS dated [DATE] for Resident #17 documented a BIMS of 12 indicating moderate cognitive impairment. Review of MDS also indicated Resident #17 required substantial / maximal assistance with showering and for self bathing. On 8/12/24 at 11:39 AM Resident #17 stated on the pm shift of 8/11/24 staff that told her that she had to shower. Resident #17 stated that she told the staff that she had showered the day before. Resident #17 stated the facility staff was talking down to her and not allowing her to say she did not want the shower. Resident #17 stated the facility staff told her that she had to shower. Resident #17 stated she once again told the facility staff that she showered the day before. Resident #17 stated the facility staff would not let her refuse. Resident #17 stated she did not know the facility staff's name. On 8/13/24 at 11:56 AM Resident #17 stated she did not feel like she was treated with dignity. Resident #17 stated she felt like she could not say no to the shower. Resident #17 stated she did not feel like the staff should be allowed on the facility grounds. Resident #17 stated she told her several times that she did not want to get into the shower but the staff was very forceful with her words. Resident #17 stated she did not feel was treated in a dignified manner because of the way she was spoken to by the facility staff. Resident #17 stated she just got into the shower because she felt like she did not have an option. Resident #17 stated she was not worried that she would be physically abused. Resident #17 stated the incident made her feel very upset and she felt like a child being told what to do. Review of document titled, 2024 Prairie Gate Shower Schedule: documented no signatures on Sunday 8/11/24 and signatures for Staff H and Staff J on 8/10/24. On 8/13/24 at 1:08 PM Staff J, Certified Nursing Assistant (CNA) stated she worked Saturday 8/11/24 on the am shift. Staff J stated she gave Resident #17 a shower on 8/11/24 during the day. Staff J stated Resident #17 told her she had a shower the night before. Staff J stated she spoke with Staff I the nurse working on 8/11/24. Staff J stated Staff I said the bath for Resident #17 was not documented. Staff J stated Staff I helped to transfer Resident #17 to the shower chair. Staff J stated she signed the shower sheet. Staff J stated she was not given a log in for the electronic health records (EHR). Staff J stated Staff I stated there were not enough people on the night shift prior. Staff J stated Resident #17 never said she did not want to take a shower. Staff J stated she signed the shower sheet and Staff H signed next to her when she came in on the pm shift that night. Staff J stated Staff H came in on 8/11/24 at 2pm and stated that she gave the shower the night prior. Staff J stated she was just in Resident 17 ' s room prior to lunch 8/13/24 and helped Resident #17 with applying hearing aids. Staff J stated Resident #17 did not seem mad or upset with her at that time. On 8/14/24 at 11:02 AM Staff I, Registered Nurse (RN) stated she worked 8/11/24 am shift. Staff I stated Staff J was the CNA that cared for Resident #17 and showered her that day. Staff I stated Staff J called her to Resident #17 room for transfer assistance. Staff I stated Resident #17 said she was showered the night prior. Staff I stated she entered Resident #17 room to ask if she would come down to breakfast and Resident #17 told her that she was not happy because of the shower situation. Staff I stated Resident #17 stated she wished the staff were all on the same page around there. On 8/14/24 at 11:53 AM Staff H stated she was familiar with Resident #17. Stated she worked 8/10/24 and 8/11/24 from 2:00 PM - 10:00 PM. Staff H stated she had given Resident #17 a bath on Saturday. Staff H stated she asked Resident #17 on 8/10/24 if she wanted to take a shower before dinner. Staff H stated Resident #17 stated she would be fine with taking one before dinner. Staff H stated she documented in the EHR that she did give the shower but forgot to mark it on the shower sheet. Staff H stated she ended up signing it the next evening when she had come back to work after Resident #17 had gotten another shower. Staff stated she found out that because Staff J told her that she completed the showers that were not given the night before. Staff H stated Resident #17 was very upset after taking both of the baths. Staff H stated Resident #17 told her Staff J was very mean when getting her into the shower when not listening to her and by telling her to just get into the shower. Staff H stated Resident #17 stated she did not feel abused. Staff H stated Resident #17 never said she was physically harmed by Staff J. Staff H stated Resident #17 talked about how upset she was about the way she had to take a second shower non-stop on 8/11/24 pm shift. On 8/14/24 at 1:16 PM the DON stated the staff were trained to re approach the resident if shower was refused. The DON stated the am nurse could have contacted the 2nd shift CNA to question about showers. The DON stated Staff I the nurse working am shift 8/11/24 was a brand new RN and did not look in the EHR. The DON stated if the resident refuses twice then staff are expected to notify the nurse and have the nurse attempt to approach the resident about bathing.

Based on electronic health records (EHR), document review, resident interviews, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed (Resident #6, #8, #9, and #12). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #9 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of EHR documented Resident #9 resided in room [ROOM NUMBER]. On 8/12/24 at 11:05 AM Resident #9 stated the facility was short of staff on the evening shift. Resident #9 stated sometimes there was only one person for the whole hall. Stated once in a while she had to wait longer than 15 minutes to have her call light answered. Review of document titled, Device Activity Report for room [ROOM NUMBER] documented on 8/14/24 call light was turned on at 8:56 AM and shut off at at 9:31 AM total of 34 minutes, 8/13/24 call light was turned on at 10:53 AM and shut off at 11:10 AM total of 17 minutes, 8/13/24 call light was turned on at 7:37 AM and shut off at 7:55 AM total of 17 minutes, and 8/8/24 call light was turned on at 7:54 AM and shut off at 8:13 AM total of 19 minutes. 2. The MDS dated [DATE] for Resident #12 documented a BIMS of 11 indicating moderate cognitive impairment. Review of EHR documented Resident #12 resided in room [ROOM NUMBER]. Review of document titled, Device Activity Report for room [ROOM NUMBER] documented on 8/11/24 call light was turned on at 7:20 AM and shut off at at 7:44 AM total of 24 minutes, 8/8/24 call light was turned on at 6:26 PM and shut off at 6:43 PM total of 17 minutes, and 8/8/24 call light was turned on at 6:46 AM and shut off at 7:08 AM total of 21 minutes. On 8/14/24 at 2:57 PM Resident #12 stated a couple days prior the call light was on and it rang and rang and rang so she took herself to the bathroom. Resident #12 stated she never had an accident related to call light length. Resident #12 stated she had to use the toilet a couple of times, had to wait longer than 15 minutes to prevent incontinence and took herself to the toilet. On 8/14/24 at 3:52 PM the DON stated the facility's expectation was less than 15 minutes and ideally less than 10 minutes for call light response. The DON acknowledged there were call lights that were longer than 15 minutes recently. The DON stated the staff have been educated to go by the nursing station to see which resident's room light has been on the longest and attend to that light first. 41785 3. According to the MDS dated [DATE], Resident #6 had a BIMS score of 12 (moderate cognitive deficit). She was totally dependent on staff for toileting hygiene, dressing, sit to stand and transfers. The Care Plan for Resident #6, last revised on 7/30/24, showed that she had self-care performance deficits, weakness and impaired mobility. She was not able to ambulate and required the help of 2 staff for transfers with the use of the sit to stand mechanical lift. She was at risk for pain related to muscle spasms, Multiple Sclerosis, Tardive Dyskinesia and seizures. On 8/14/24 3:21 PM a family member for Resident #6 said that she and other family members visited the facility on a regular basis, and they had noticed that the call light response took a long time. She said that there were several times that Resident #6 would call a family member from her cell phone and ask them to call the facility because her call light was not within reach and she couldn't find it. The resident had a small purse that she kept around her neck contained her cell phone. According to a 7-day, Device Activity Report, the call light responses included the following: On 8/14/24 at 9:15 AM response was 24 minutes On 8/12/24 at 8:58 AM response time was 26 minutes On 8/12/24 at 7:17 AM response time was 42 minutes On 8/11/24 at 8:25 AM response time was 47 minutes On 8/10/24 at 7:06 AM response time was 80 minutes On 8/8/24 at 9:39 AM response time was 60 minutes 4. According to the MDS dated [DATE], Resident #8 had a BIMS score of 15 (intact cognitive ability). She was totally dependent on staff for sit to stand, chair to bed transfer, toilet transfer. Her diagnosis included amyotrophic lateral sclerosis, muscle weakness, abnormalities of gait and mobility. The care plan revised on 6/28/24, showed that Resident #8 had self-care performance deficits, weakness, impaired range of motion to bilateral upper and lower extremities, impaired gait and balance. She required 2 staff assistance with the sit to stand on the mechanical lift. She was at risk for falls, and staff were to place the call light within reach and answer promptly. On 8/14/24 at 3:16 PM, Resident #8 said that it was not unusual for the call light response to take over an hour. She said that one night, it took 2 hours and 15 minutes for them to answer. The staff usually explained to her that they were busy answering other call lights. According to a 7-day, Device Activity Report, the call light responses included the following: On 8/13/24 at 9:43 PM response was 63 minutes On 8/12/24 at 7:24 AM response was 57 minutes On 8/11/24 at 8:51 AM response was 36 minutes On 8/9/24 at 7:52 AM response was 25 minutes On 8/9/24 at 8:07 AM response was 40 minutes On 8/8/24 7:04 AM response was 58 minutes On 8/8/24 4:42 AM response was 57 minutes On 8/7/24 at 4:27 AM response was 33 minutes. A facility policy modified on November of 2022, and titled: Call Lights, indicated that the purpose of the policy was to respond promptly to residents call for assistance. Staff were directed to answer all call lights promptly whether or not they were assigned to the resident. Answer the call lights in a prompt, calm, courteous manner, turn off the call light as soon as possible.

Based on observation, staff interview and policy review the facility failed to post daily nursing census in a prominent area, accessible to visitors and residents. The facility reported a census of 32 residents. Findings include: In an observation on 8/13/24 at 2:46 PM it was discovered that the daily nursing census was posted in the nurse's station. There was no daily posting of the number of nursing and certified nurse aide hours. On 8/14/24 at 10:20 AM, Staff F Scheduling staff, said that she printed off the daily schedule with hours and posted it by the front door on the first floor. Given that the nursing home residents were all housed on the second floor, she said that she was not aware that it needed to be posted where the residents could see it. A facility policy modified on October 2022 titled, Nurse Hours Posting Policy, showed that nursing staff data would be posted in a designated public area by the staffing personnel. The data would be posted in a prominent place readily accessible to residents and visitors.

Based on observation, interview and policy review the facility failed to ensure that food was stored according to safe practices. An initial tour of the kitchen revealed that there were many undated, open containers in the refrigerator and dry storage. The facility reported a census of 32 residents. Findings include: On 8/12/24 at 10:02 AM, the Dietary Manager (DM) provided an initial tour of the kitchen and the following items were found open and undated in the walk-in refrigerator: a. A tray of individual cups of fruit. b. A container of soup c. A bag of raw broccoli d. A bag of cilantro open. A container of raw chicken was sitting on the top shelf above other fresh foods. The dry storage area contained open and undated; 2 bags of potato chips, a bag of dehydrated cherries, and a container of cherries in the juice. The DM acknowledged that staff were expected to date packages so soon as they were opened. A facility policy titled; Safe Food Storage updated on 5/2019, stated that in order to ensure the safety for the food supply throughout, staff were to label, date and properly cover all food items upon opening of package. If food products were stored together in a refrigerator, they should be placed upon the shelf in the following order from top down: Prepared ready to eat Fish and Seafood items Whole cuts of raw beef Whole cuts of raw pork Ground or processed meats Raw poultry

Based on observation, clinical record review, resident interview, and staff interview, the facility failed to maintain a safe, and comfortable environment by not changing the bed linen on 1 of 4 residents beds (Resident #9). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 8/12/24 at 3:36 PM Resident #9 stated she has not had her bedding changed in 2 weeks. Resident #9 stated the morning staff usually change the bedding. Review of the Medication Administration Record dated August 2024 revealed Resident #9 had a room number of 252. On 8/13/24 at 3:00 PM an observation revealed the same bedding on Resident #9's bed as on 8/12/24 observation. On 8/14/24 at 3:11 PM Staff G, Certified Nursing Assistant (CNA) stated she had worked at the facility since November of 2023. Staff G stated bed linen was changed per the schedule and rooms 250 through 252 are changed on Monday. Staff G stated she did not change bedding on Monday. Staff G stated usually the morning shift changes the linen and sometimes it was hard to get around to changing the linen. Staff G stated she cared for the residents in rooms 250 through 252. Staff G stated she told the next shift she had not changed the bed linen and asked the next shift to change the sheets if they had time. Staff G stated she spoke to Staff H, CNA about the need to change the bedding. On 8/14/24 at 3:56 PM the DON stated the CNA's are expected to strip the bed on the am shift. The DON stated the facility's expectation was that the bed linen for the residents were changed weekly. The DON stated there is a schedule for the bed linens to be changed on the wall in the nursing office. Review of documented titled, Bed Stripping Schedule found posted on the wall at the nurses station documented rooms [ROOM NUMBER] were to be completed on Mondays. On 8/14/24 at 4:19 PM Staff H CNA stated she did not change any bedding on 8/12/24 pm shift and am shift staff did not express to her that the bedding on any of the residents needed to be changed. Staff H stated she worked the hall with Resident #9 on 8/12/24 and cared for Resident #9 on 8/12/24.

Based on clinical record review, policy review, resident interview and staff interviews the facility failed to complete an accurate assessment that reflected the resident's status during the observation period of the MDS for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 32 residents. Finding include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 5/30/24 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 8/12/24 at 2:36 PM Resident #1 stated she did not take insulin. Review of Resident #1's MDS revealed days of insulin injection as 1. Review of Resident #1's Medicaiton Administration Record (MAR) since admission for the months of May, June, July, and August 2024 revealed no physician orders for insulin. On 8/14/24 at 1:13 PM the DON stated the MDS should have been coded as an injection and not insulin. The DON stated the MDS was incorrectly coded. Review of the policy titled, Resident Assessment Instrument (RAI) Process, modified October 2022: MDS 3.0, Care Area Assessments, Care Planning and Submission documented Minimum Data Set (MDS): is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare and/or Medicaid. An accurate assessment requires collecting data and information from multiple sources. These sources must include the resident and direct care staff on all shifts, and should also include the resident ' s clinical records, physician, and family, guardian or significant other as appropriate or acceptable. Documentation in the clinical record must support the items coded on the MDS.

Based on clinical record review, personnel file review, resident interview, staff interviews and policy review the facility failed to ensure that staff used safe transferring techniques for 1 of 3 residents reviewed. Resident #21 required the assistance of 2 with transfers and Staff A, Certified Nurse Aide (CNA), transferred her alone and without a gait belt. The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #21 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit). She required substantial assistance with dressing and was totally dependent with sit to stand transfers, chair to bed transfer and toilet transfers. Her diagnosis included cancer, anemia, heart failure and hemiplegia. The Care Plan, update on 6/11/24, showed that Resident #21 required 2 staff assist with the sit to stand mechanical lift for transfers. She had self-care performance deficits related to weakness/impaired balance, hemiplegia affecting the right side and vertebra/back pain. She was unable to ambulate and required one assist to turn in bed. According to a facility incident investigation, on 8/1/24, a Family Member (FM) for Resident #21 called the facility and reported that Staff A, Certified Nurse Aide (CNA) had picked up Resident #21 and plopped her into her recliner on the previous evening shift. The FM indicated that she had previous concerns with Staff A manhandling the resident. Resident #21 was interviewed and stated that Staff A did not use a gait belt or a second person to assist with the transfer. When interviewed by the Administrator, Staff A reported that the resident was struggling to stand so he had her put her arms around his neck and used a gait belt to transfer. On 8/12/24 at 11:24 AM, Resident #21 said that Staff A was rough with her. She said that he picked her up by giving a bear hung up under her arms and it hurt her then he threw me down in the chair. She said that it hurt her back and typically, they would use two people and a gait belt to transfer her. She said that other residents had complained that he was rough also. On 8/12/24 at 1:50 PM, the FM said she had witnessed Staff A transferring Resident #21 in a rough manner on more than one occasion. She said that Staff A would lift the resident, swing her around and just let her drop into the chair. She said that he did not have the temperament or the compassion to care for the elderly, and she had requested that he not provide cares to Resident #21. On 8/1/24 Resident #21 called the FM and said that Staff A had picked her up and let her fall into the chair, her back hurt, and she was crying. FM said that there were many times that Staff A would not use a gait belt, and he would just hold onto the resident on the back of the shirt. A review of the personal files revealed the following Supervisors/Managers Coaching Notes in the file for Staff A: 1) 3/1/23 not consistently following team sheets when aiding or assisting with of residents. He's been reminded multiple times that following the care plan is facility policy and the safest practice when caring for residents. 2) 7/7/23 Verbal Warning: it was reported that Staff A had been rushing through resident cares and not showing compassion to residents. While providing resident cares, Staff A had been rude, blunt, short tempered and did not show manners towards the residents. 3) 9/13/23 Written Warning: it was reported that on 9/2/23 and 9/13/23, Staff A did not follow the care plan or use appropriate equipment when transferring residents. 4) 9/20/23 Suspension: it was reported that on 9/18/23, Staff A rushed through resident care and did not show compassion to the residents. He was too rough and did not follow the team sheets. Numerous residents requested that he not work with them. The staff member was put on a 3-day suspension. Failure to meet expectations would result in termination. 5) 8/9/24 Notice of Termination: Reported that he transferred a resident correctly and rushed through cares. the team sheets stated that she should be transferred with one assist with one for safety when transferring. On 8/13/24 at 8:46 AM, Staff D, CNA said that Staff A would get a little rough, and in a hurry when transferring with the sit to stand. He said that he did tell one of the nurses one time about the concerns. On 8/13/24 at 8:56 AM Staff C, CNA said that a lot of the residents said they didn't want him to care for them, because he went too fast and he didn't listen to the residents to find out how they prefer to be transferred or when they ask him to slow down. On 8/13/24 at 9:50 AM, Staff B, Registered Nurse (RN) said she had some concerns with Staff A and how he transferred residents. She said he would get in a hurry and he wouldn't listen to the residents when they asked him to slow down and take it easy. On 8/14/24 on 6:27 AM Staff E, CNA said that several residents would ask Staff A to slow down when providing care. Many of resident didn't want him to provide care and they become more anxious if/when he was present. On 8/14/24 at 9:52 AM, the Care Coordinator acknowledged that Staff A had been disciplined previously for not following safe transfer techniques and rushing the residents. She said that Resident #21 was one assist with one stand by staff and Staff A was not following the care plan when he transferred her alone, without a gait belt, and by lifting her up under her arms. According to the facility policy titled: Gait Belts for Transfer and Ambulation dated December 2014, gait belts would be used for all transfers of weight bearing resident who require assistance with transfers and/or ambulation if indicated on the care plan.

Based on clinical record review, observations, resident interviews and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #29) requiring the use of oxygen. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #29 documented a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. Review of MDS also indicated Resident #29 required the use of oxygen. On 8/12/24 at 10:56 AM an observation of oxygen tubing without date. Observation of nebulizer mask on counter on paper towel also undated. On 8/12/24 at 10:56 AM Resident #29 stated she had not seen the tubing changed during her stay at the facility. On 8/13/24 at 2:58 PM Staff K, Registered Nurse (RN) stated oxygen supplies are usually changed out once a week on the night shift. Staff K stated she was not sure what day that respiratory supplies were changed out on during the week. On 8/13/24 at 3:00 PM Staff L, RN stated he did not know who or when the oxygen tubing and nebulizer equipment was changed out. Staff L stated he thought it was in the resident's care plan. Staff L stated he would talk to the DON and ask her. Staff L stated after talking to the DON there is a weekly duties sheet that has the pm shift changing oxygen supplies out every Saturday as well as a monthly check sheet that also makes sure tubing and respiratory supplies are changed out. On 8/13/24 at 3:25 PM Staff M stated nurses change the oxygen tubing. Staff M stated the tubing is changed on the am shift. Staff M stated also if tubing was soiled or broken. Staff M stated there is no scheduled time to change the oxygen tubing or nebulizer masks. Staff M stated he only changed the tubing if the tubing was soiled. Staff M stated he had not changed the tubing on Resident #29 since has worked at the facility. On 8/13/24 at 3:34 PM Staff N, RN stated he only works the PM / overnight shift. Staff N stated oxygen tubing is changed per the doctors orders. Staff N stated would also change oxygen tubing out when the tubing is soiled or broken. Staff N stated there was no routine or scheduled time to change the oxygen tubing. Staff N stated he did not change Resident #29's tubing on 8/10/24. Staff N stated he does not date the tubing when he does change the tubing. On 8/14/24 at 11:02 AM Staff I stated all oxygen tubing and resp equipment completed on overnight shift. Staff I stated oxygen tubing change was located in the TAR not on a specified date. Staff I stated the facility expected the oxygen tubing was dated with tape and the date would be applied to the tubing when changed. Staff I stated she did not know of any checklist that oxygen should be changed. On 8/14/24 at 1:03 PM the DON stated the facility's expectation was the oxygen tubing would be changed weekly. The DON stated oxygen tubing change was on a nursing task calendar. The DON stated oxygen tubing should be dated. The DON stated going forward the task will be found on the treatment administration record.

Based on clinical record review, Pharmacy Drug Book review, clinical staff interview, provider interview, staff interviews, and facility policy review the facility failed to follow physician's orders resulting in a significant medication error for 1 of 3 residents (Resident #1) reviewed. On 3/7/24 the Cardiologist ordered Bumetanide 2 mg BID x 3 days then 2 mg once a day. The facility failed to initiate the once a day order. The resident was without her Bumetanide from 3/10/24-3/15/24. On 3/15/24 at 8:00 PM through 5/23/24 the resident received Bumetanide 2 mg BID when it was ordered for her to receive 2 mg once a day. On 3/27/24 the facility initiated an order for Bumex 1 mg at noon, with the 2 mg order in place. The resident received 5 mg of Bumetanide a day for roughly 58 days when 3 mg was ordered. There was an immediate need for the facility to take steps to ensure residents were protected from significant medication errors. The facility reported a census of 32 residents. On 5/30/24 at 4:48 PM, the State Survey Agency informed the facility of the significant medication error creating an Immediate Jeopardy situation resulting in the resident being sent to the hospital with an admitting diagnosis of an acute kidney injury (AKI) on 5/23/24. The facility staff removed the immediacy on 5/31/24 at 10:12 AM when staff implemented the following Corrective Actions: a. the facility educated all nurses by 5/30/24 on processing, initiating, reconciling, and clarification of orders; b. starting 5/30/24 the clinical coordinator/designee will audit orders received to ensure staff initiate and clarify orders when new orders are received; and c. results of these audits will be reported to the QAPI committee for review and modifications as needed. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented educated of their policy and procedures. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 5/9/24 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The assessment tool documented she received a diuretic. The MDS listed the following diagnoses: acute and chronic respiratory failure with hypoxia and hypercapnia, heart failure, hypertension, respiratory failure, atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic heart failure, obstructive sleep apnea, morbid obesity, adjustment disorder with mixed anxiety and depressed mood. The Care Plan focus area with an initiation date of 2/21/2024 documented Resident #1 had potential fluid deficit due to diuretic use, medication side effects/chronic disease processes. The Care Plan directed staff to administer medications as ordered and observe for side effect and effectiveness, complete lab work per orders and monitor Resident #1's weight per facility policy. The following Progress Notes documented: a. On 3/7/24 at 4:25 PM Resident #1 and her sister went to her Cardiology appointment today. New orders to start Bumetanide 2 mg two times a day (BID) for 3 days, daily weights with instruction to call the physician with a 2-pound weight gain in 24 hours or 5-pound weight gain in one week, monitor blood pressure daily and send results in one week to cardiology. Note documented by Staff C Clinical Coordinator. b. On 3/15/24 at 12:57 PM new orders received per facsimile from resident's Cardiologist. New orders for Bumetanide 2 mg by mouth BID. Continue with daily weights and blood pressure checks, send at the end of the week. Note documented by Staff D Registered Nurse (RN). c. On 3/27/24 at 1:12 PM Cardiologist gave verbal order to start Bumetanide 1 mg at noon daily. Continue to monitor blood pressure and weight daily. d. On 5/22/24 at 3:25 PM residents blood pressure running low today, has voiced pain in stomach, heartburn and was nauseated this morning. She did not eat much lunch, isn't taking fluids in well, and stated overall does not feel well. She was given as needed (PRN) Tums and Zofran (anti-nausea) and it did help. She stayed in her room for lunch, did come out for breakfast. Staff encouraged to use manual blood pressure cuff on her and not automatic. Also noted a 15.4 weight loss in 11 days, has been a steady loss, reported these findings to RN, note was placed in (A Registered Nurse Practitioner (APRN) folder who will be coming tomorrow. Resident declined wanting to go to the hospital at this time when asked, encouraged to let staff know if any changes occur. e. On 5/23/24 at 12:47 PM Staff C received an order from resident's cardiologist to refer resident to hospital for further evaluation and management due to some deviated lab results. f. On 5/23/24 at 2:39 PM resident sent to the hospital at 1:20 PM. A document titled After Visit Summary dated 3/7/24 at 10:30 AM at a Health Clinic Heart Failure, documented the following changes to the resident's medication list as of 3/7/24 at 10:31 AM: a. Bumetanide (diuretic) 2 milligrams (mg), take 1 tablet (2 mg total) by mouth once daily. Take two times a day (BID) for the first three days, then go to once daily. This document lacked facility staff signature as being noted. A document titled Physician's Visit Report dated 3/7/24 documented the following medication change: a. Bumetanide 2 mg BID for three days, then once daily. This document signed as noted by Staff B Registered Nurse (RN) and Staff C. A Cardiology Note with an encounter date of 3/14/24 from a Health Clinic Heart Institute, documented a consult note was made on 3/15/24 with the following order on page one: increase Bumetanide to 2 mg BID. On page two it documented approved medication requests as of 3/15/24 at 10:56 AM: change Bumetanide take one tablet (2 mg total) by mouth two times a day. Take two times a day for first three days, then go to once daily. This document signed as being noted by Staff B and Staff D. A verbal order with an order date of 3/27/24 at 11:31 AM documented the following order summary: Bumetanide 1 mg, give 1 tablet by mouth one time a day. The order confirmed by Staff A Licensed Practical Nurse (LPN). Review of March 2024 Medication Administrator Record (MAR) revealed the following orders: a. Bumetanide oral tablet 2 mg, give 1 tablet by mouth BID related to chronic systolic (congestive) heart failure for three days, with an order date of 3/7/24 and discontinued date of 3/10/24. b. Bumetanide tablet 2 mg give 1 tablet by mouth BID for fluid retention with a start date of 3/15/24 and discontinued date of 5/28/24. c. Bumetanide oral tablet 1 mg, give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure. Please give at noon, with a start date of 3/27/24 and discontinued date of 5/28/24. The facility failed to initiate the order for Bumetanide 2 mg once a day after the 2 mg BID order ended on 3/10/24. Resident #1 had no active Bumetanide order from 3/10/24 until 3/15/24. Resident #1 was ordered to receive 2 mg of Bumetanide daily from 3/11/24 through 3/26/24 but had received 4 mg daily. Resident #1 was ordered to receive 3 mg of Bumetanide daily starting 3/27/24 but had received 5 mg daily. Review of April 2024 MAR revealed the following orders: a. Bumetanide tablet 2 mg give 1 tablet by mouth BID for fluid retention with a start date of 3/15/24 and discontinued date of 5/28/24. b. Bumetanide oral tablet 1 mg, give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure. Please give at noon, with a start date of 3/27/24 and discontinued date of 5/28/24. Resident #1 continued to receive 5 mg daily when 3 mg daily was ordered. Review of May 2024 MAR revealed the following orders: a. Bumetanide tablet 2 mg give 1 tablet by mouth BID for fluid retention with a start date of 3/15/24 and discontinued date of 5/28/24. b. Bumetanide oral tablet 1 mg, give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure. Please give at noon, with a start date of 3/27/24 and discontinued date of 5/28/24. Resident #1 continued to receive 5 mg daily when 3 mg daily was ordered. On 5/30/24 at 1:03 PM Resident #1's Cardiologist's nurse verified her Bumetanide orders as the following: a. On 3/7/24 Bumetanide 2 mg BID x 3 days then 2 mg daily b. On 3/27/24 Bumetanide 2 mg in the morning and 1/2 tablet (1 mg) in the afternoon c. On 4/9/24 Resident #1 was seen in the clinic with no medication changes d. On 5/6/24 Resident #1 was seen in the clinic and to continue with 2 mg in the morning and 1/2 tablet (1 mg) in the afternoon. Review of labs results for Resident #1 revealed the following: a. 2/5/24: potassium 4.3 (normal is 3.5-5.5), blood urea nitrogen (BUN)(measures the amount of urea nitrogen in your blood) 13 (normal is 6-22), creatinine (check function of kidneys) 0.31 (normal 0.50-1.20), glomerular filtration rate (GFR) (measures how well kidneys filter blood) 111 b. 3/4/24: potassium 4.3 BUN 14, creatinine 0.38, GFR 106 c. 3/15/24: potassium 5 BUN 15 creatinine 0.34, GFR 109 d. 4/5/24: potassium 3.4, BUN 19, creatinine 0.40, GFR 104 e. 5/13/24: potassium 5.2, BUN 22, creatinine 0.61, GFR 94 f. 5/22/24: potassium 6.5, BUN 67, creatinine 1.43, GFR 39 Review of the facility's 2024 [NAME] Pocket Drug Guide for Nurses with a copyright date of 2024 revealed on page 56 Bumetanide was a loop diuretic. Staff are to monitor electrolytes, hydration, hepatic function with long term treatment; water and electrolyte depletion is possible. Indication and dosage: treatment of edema associated with heart failure, kidney, hepatic diseases. Adult dosage is 0.5-2 mg every day by mouth. Dosage to be adjusted based on abnormal kidney function especially in older adults. Adverse effects listed as: anorexia, asterixis, drowsiness, headache, hypokalemia, nocturia, nausea, vomiting, diarrhea, orthostatic hypotension, and polyuria. A document titled Discharge Summary with an admitted [DATE] and discharge date of [DATE] listed a primary discharge diagnosis of acute kidney injury (AKI). Her past medical history for essential hypertension, hyperlipidemia, atrial fibrillation, chronic heart failure who presented to the emergency room (ER) secondary to abnormal labs. Resident stated that she had some nausea and heartburn the last couple of days. She indicated she was having mild diarrhea with 2-3 bowel movements a day for about a week and some of them were loose. Recent labs completed showed BUN of 67, creatinine of 1.4, and potassium of 6.5. Her supplement potassium was held and given kayexalate (treatment of high potassium levels). Repeat potassium level was drawn and was 5.6. Resident stated she has lost about 15 pounds in 11 days. She is on Bumetanide per cardiology. On 5/30/24 at 2:47 PM the Director of Nursing (DON) stated Resident #1's order for Bumetanide 2 mg BID x 3 days then once a day order was left that way and not entered correctly. They noted this order was written on 3/15/24 and it should have been clarified. They educated the nurses to look at all pages of documents when a resident returns from an appointment, not just the first page and to clarify the orders if needed. On 6/4/24 at 9:59 AM the Nurse Practitioner (NP) at Resident #1's Cardiologist office verified she was seen in their clinic in March and had orders for Bumetanide 2 mg BID x 3 days then once a day. After that Resident #1's Bumetanide order was 2 mg in the morning and 1 mg in the afternoon. She was unsure why they continued to give the resident 2 mg BID when it should have been daily along with the 1 mg in the afternoon. The NP indicated the facility should have called the clinic for clarification once they reviewed the orders that were sent back with the resident following her appointment. If Resident #1 was in fact receiving 5 mg instead of 3 mg of Bumetanide this could have cause her acute kidney injury. Bumetanide works with in the kidney because it is a loop diuretic and helps to excrete excess urine and fluid. Too much medication would force the kidney to cause excessive excretion which could have caused the kidney injury. She was unsure why the facility did not question the original order back in March. On 5/30/24 at 3:14 PM Staff C stated the doctor's orders were unclear on the first page and the medication list did not match what was written on the second page. When she discovered this on 5/23/24 she called the clinic to clarify the orders but the clinic nurse was unclear of what the physician had ordered. They completed education with their nurses to pay attention to all pages of documents returned with residents from appointments. If the orders do not match they need to reach out to get clarification. When asked what happened to the daily dose of 2 mg order she signed off as being noted on 3/7/24 she acknowledged she may have missed the second part of the order, not sure if she was pulled away and did not put in the second half of the order. On 6/5/24 at 9:11 AM Staff B stated two nurses sign the after-visit summaries and physician visit report sheets to ensure the orders are carried out. The day shift charge nurse usually carries out the new orders, the night charge nurse will counter sign that it was carried out. At night the charge nurse will make sure the order was put in the computer correctly. The clinical coordinator will also check the orders to make sure they are carried out correctly. When asked what happened when the Cardiologist ordered Bumetanide 2 mg BID x 3 days then once a day and the daily order was not implemented. Staff B stated it was checked by the day shift charge nurse, he presumed Staff C had confirmed with the physician what was ordered. There was an order on the first page of the visit sheet and the same order was on the second page, he thought it was a double entry order but he should have been clarified and he thought it was. It's the day shift charge nurse's duty to clarify orders since the night shift nurses don't have access to these physician's for clarification. The daily BID dose was put in and that's what he checked and signed off as being put in the computer. On 6/5/24 at 10:22 AM Staff D stated when a resident returns from an appointment with new orders the nurse is to look at the paperwork, see what orders have changed, and update the orders in the computer. The night shift charge nurse will double check to make sure nothing was missed with the new orders and hopefully nothing is missed. When asked about the 3/15/24 order for Bumetanide 2 mg BID x 3 days then daily she stated one page said one thing and another page said something different. She should have seen this and clarified what the doctor wanted. A policy titled Order Processing Policy with a modified date of May 2024, documented the purpose of the policy is to obtain orders for care and treatment of the resident as necessary. The policy listed the following procedure for staff to follow: 1. Obtain an order from the prescriber. a. For orders written by a provider in the facility, telephone and verbal orders, the preferred document is Provider Order Form. b. Orders written during a consult or by a provider outside the facility will be processed on the original document. 6. Orders that include more than one dose or frequency will be transcribed in a manner that with each administration of the medication it can be documented the dose and/or the frequency the medication that was administered. 7. Each order should then be noted by the nurse to include the date and time the order was processed. A second review of all orders are required. One of the reviews may be completed by a trained Health Unit Coordinator. For sites with limited staffing on a specific shift, a process is to be implemented to ensure the orders received are second checked by a qualified staff within the next scheduled shift. A policy titled Medication Administration Policy with an approved date of January 2009, documented the purpose of this policy is to ensure safe, effective and timely drug therapy, to provide for an accurate and concise documentation system. A. Medication Administration 1. RN's, LPN's, CMA's will administer medications as ordered by the attending physician/nurse practitioner. 2. The 8 rights of drug administration will be followed when administering all medication:\ a. Right resident b. Right drug c. Right dose d. Right dosage form (i.e. liquid, solid, crushed, etc.) e. Right route f. Right time g. Right reason h. Right documentation B. Medication Administration Record 1. Accurate transcription of medication orders is the responsibility of licensed nursing staff. 2. Medications are transcribed from the physician order sheet to the MAR in the electronic medical record MAR (EMAR). 3. MAR will include the name of the medication, dosage, route, frequency, and any other information including specific monitoring required prior to administration of medication. 4. Discontinued dates are entered as indicated into the electronic medical record and will be reflected at the discharged time in EMAR.

Based on employee file review, staff interviews, position description and employee handbook review the facility failed to ensure 1 of 3 employed nurses had either a multistate license or a single state license for the State of Iowa. The facility reported a census of 32 residents. Findings include: Review of Staff A Licensed Practical Nurse (LPN) employee file revealed a hire date of 4/14/21 and termination date of 5/24/24. Staff A's employee file revealed two QuickConfirm License Verification Reports (provides online license verification to work in another state): a. A report dated 6/11/2021 documented Staff A had an unencumbered (full and unrestricted license to practice) multistate license, with an expiration date of 10/31/2021. Staff A was licensed to practice in Iowa. b. A report dated 6/4/2024 documented Staff A had an unencumbered single state license with an expiration date of 10/31/2025. Staff A was licensed to only practice in Nebraska. On 6/4/24 at 1:17 PM the Human Resources Manager II stated she took over the Human Resources Manager II position May 1, 2023. She acknowledged she is responsible for completing license verifications for new staff. When she was informed of Staff A's licensed verified as a single state license in Nebraska as of 6/2/24, she indicated she would need to follow up with their Regional Human Resource Director about that. She acknowledged she ran a report today because she noticed Staff A had not had a report ran since 2021. During a follow-up interview at 3:15 PM she indicated Staff A went from a multistate license to a single state license without notifying the facility. The Human Resources Manager II indicated she pulled all licensed staff member's reports for verification and they were all fine. On 6/5/24 at 11:05 AM the Administrator stated when Staff A renewed her licensed in 2023, they did not catch that it went from a multistate to single state license. He had the Human Resource Manager verify everyone with a license to ensure they are current and correct, they all were. The facility has a program that runs a report when triggered to check verification. When it triggered for Staff A, it must have been missed. The LPN Position Description and Performance Summary listed the following minimum qualifications: LPN with current licensure with the State Board of Nursing in state(s) in which he/she practices. The Employee Handbook with an effective date of 1/1/2024 indicated, as an employee staff are required to complete and update certain employment records and related forms. The following action may result in immediate termination: failure to maintain licensure as required for hired position.

Based on clinical record review, staff interviews, medical clinic personnel interviews and facility policy review the facility failed to clarify a discrepancy in orders timely and failed to transcribe physician orders as directed for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 32 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 5/9/24, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The assessment tool documented she received a diuretic. The MDS listed the following diagnoses: acute and chronic respiratory failure with hypoxia and hypercapnia, heart failure, hypertension, respiratory failure, atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic heart failure, obstructive sleep apnea, morbid obesity, adjustment disorder with mixed anxiety and depressed mood. The Care Plan focus area with an initiation date of 2/21/24 documented Resident #1 had potential fluid deficit due to diuretic use, medication side effects/chronic disease processes. The Care Plan directed staff to administer medications as ordered and observe for side effect and effectiveness, complete lab work per orders and monitor Resident #1's weight per facility policy. A document titled After Visit Summary dated 3/7/24 at 10:30 AM from the Health Clinic Heart Failure, documented the following changes to the resident's medication list as of 3/7/24 at 10:31 AM: a. Bumetanide (diuretic) 2 milligrams (mg), take 1 tablet (2 mg total) by mouth once daily. Take two times a day (BID) for the first three days, then go to once daily. This document lacked facility staff signatures as being noted. A document titled Physician's Visit Report dated 3/7/24 documented the following medication change: a. Bumetanide 2 mg BID for three days, then once daily. This document signed as noted by Staff B Registered Nurse (RN) and Staff C Clinical Coordinator. A Cardiology Note with an encounter date of 3/14/24 from a Health Clinic Heart Institute, documented a consult note made on 3/15/24 with the following order on page one: increase Bumetanide to 2 mg BID. On page two it documented approved medication requests as of 3/15/24 at 10:56 AM: change Bumetanide take one tablet (2 mg total) by mouth two times a day. Take two times a day for first three days, then go to once daily. This document signed as being noted by Staff B and Staff D RN. A Verbal Order with an order date of 3/27/24 at 11:31 AM documented the following order summary: Bumetanide 1 mg, give 1 tablet by mouth one time a day. The order confirmed by Staff A Licensed Practical Nurse (LPN). Review of March 2024 Medication Administrator Record (MAR) revealed the following orders: a. Bumetanide oral tablet 2 mg, give 1 tablet by mouth BID related to chronic systolic (congestive) heart failure for three days, with an order date of 3/7/24 and discontinued date of 3/10/24. b. Bumetanide tablet 2 mg give 1 tablet by mouth BID for fluid retention with a start date of 3/15/24 and discontinued date of 5/28/24. c. Bumetanide oral tablet 1 mg, give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure. Please give at noon, with a start date of 3/27/24 and discontinued date of 5/28/24. The facility failed to initiate the order for Bumetanide 2 mg once a day after the 2 mg BID order ended on 3/10/24. Resident #1 had no active Bumetanide order from 3/10/24 until 3/15/24. Resident #1 was ordered to receive 2 mg of Bumetanide daily from 3/11/24 through 3/26/24 but had received 4 mg daily. Resident #1 was ordered to receive 3 mg of Bumetanide daily starting 3/27/24 but had received 5 mg daily. Review of April 2024 MAR revealed the following orders: a. Bumetanide tablet 2 mg give 1 tablet by mouth BID for fluid retention with a start date of 3/15/24 and discontinued date of 5/28/24. b. Bumetanide oral tablet 1 mg, give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure. Please give at noon, with a start date of 3/27/24 and discontinued date of 5/28/24. Resident #1 continued to receive 5 mg daily when 3 mg daily was ordered. Review of May 2024 MAR revealed the following orders: a. Bumetanide tablet 2 mg give 1 tablet by mouth BID for fluid retention with a start date of 3/15/24 and discontinued date of 5/28/24. b. Bumetanide oral tablet 1 mg, give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure. Please give at noon, with a start date of 3/27/24 and discontinued date of 5/28/24. Resident #1 continued to receive 5 mg daily when 3 mg daily was ordered. On 5/30/24 at 1:03 PM Resident #1's Cardiologist's nurse verified her Bumetanide orders as the following: a. On 3/7/24 Bumetanide 2 mg BID x 3 days then 2 mg daily b. On 3/27/24 Bumetanide 2 mg in the morning and 1/2 tablet (1 mg) in the afternoon c. On 4/9/24 Resident #1 was seen in the clinic with no medication changes d. On 5/6/24 Resident #1 was seen in the clinic and to continue with 2 mg in the morning and 1/2 tablet (1 mg) in the afternoon. On 5/30/24 at 2:47 PM the Director of Nursing (DON) stated Resident #1's order for Bumetanide 2 mg BID x 3 days then once a day order was left that way and not entered correctly. They noted this order was written on 3/15/24 and it should have been clarified. They educated the nurses to look at all pages of documents when a resident returns from an appointment, not just the first page and to clarify the orders if needed. On 6/4/24 at 9:59 AM the Nurse Practitioner (NP) at Resident #1's Cardiologist office verified she was seen in their clinic in March and had orders for Bumetanide 2 mg BID x 3 days then once a day. After that Resident #1's Bumetanide order was 2 mg in the morning and 1 mg in the afternoon. She was unsure why they continued to give the resident 2 mg BID when it should have been daily along with the 1 mg in the afternoon. The NP indicated the facility should have called the clinic for clarification once they reviewed the orders that were sent back with the resident following her appointment. On 5/30/24 at 3:14 PM Staff C stated the doctor's orders were unclear on the first page and the medication list did not match what was written on the second page. When she discovered this on 5/23/24 she called the clinic to clarify the orders but the clinic nurse was unclear of what the physician had ordered. They completed education with their nurses to pay attention to all pages of documents returned with residents from appointments. If the orders do not match they need to reach out to get clarification. When asked what happened to the daily dose of 2 mg order she signed off as being noted on 3/7/24 she acknowledged she may have missed the second part of the order, not sure if she was pulled away and did not put in the second half of the order. On 6/5/24 at 9:11 AM Staff B stated two nurses sign the after-visit summaries and physician visit report sheets to ensure the orders are carried out. The day shift charge nurse usually carries out the new orders, the night charge nurse will counter sign that it was carried out. At night the charge nurse will make sure the order was put in the computer correctly. The clinical coordinator will also check the orders to make sure they are carried out correctly. When asked what happened when the Cardiologist ordered Bumetanide 2 mg BID x 3 days then once a day and the daily order was not implemented. Staff B stated it was checked by the day shift charge nurse, he presumed Staff C had confirmed with the physician what was ordered. There was an order on the first page of the visit sheet and the same order was on the second page, he thought it was a double entry order but he should have been clarified and he thought it was. It's the day shift charge nurse's duty to clarify orders since the night shift nurses don't have access to these physician's for clarification. The daily BID dose was put in and that's what he checked and signed off as being put in the computer. On 6/5/24 at 10:22 AM Staff D stated when a resident returns from an appointment with new orders the nurse is to look at the paperwork, see what orders have changed, update the orders in the computer. The night shift charge nurse will double check to make sure nothing was missed with the new orders and hopefully nothing is missed. When asked about the 3/15/24 order for Bumetanide 2 mg BID x 3 days then daily she stated one page said one thing and another page said something different. She should have seen this and clarified what the doctor wanted. A policy titled Order Processing Policy with a modified date of May 2024, documented the purpose of the policy is to obtain orders for care and treatment of the resident as necessary. The policy listed the following procedure for staff to follow: 1. Obtain an order from the prescriber. a. For orders written by a provider in the facility, telephone and verbal orders, the preferred document is Provider Order Form. b. Orders written during a consult or by a provider outside the facility will be processed on the original document. 6. Orders that include more than one dose or frequency will be transcribed in a manner that with each administration of the medication it can be documented the dose and/or the frequency the medication that was administered. 7. Each order should then be noted by the nurse to include the date and time the order was processed. A second review of all orders are required. One of the reviews may be completed by a trained Health Unit Coordinator. For sites with limited staffing on a specific shift, a process is to be implemented to ensure the orders received are second checked by a qualified staff within the next scheduled shift. A policy titled Medication Administration Policy with an approved date of January 2009, documented the purpose of this policy is to ensure safe, effective and timely drug therapy, to provide for an accurate and concise documentation system. A. Medication Administration 1. RN's, LPN's, CMA's will administer medications as ordered by the attending physician/nurse practitioner. B. Medication Administration Record 1. Accurate transcription of medication orders is the responsibility of licensed nursing staff. 2. Medications are transcribed from the physician order sheet to the MAR in the electronic medical record MAR (EMAR). 3. MAR will include the name of the medication, dosage, route, frequency, and any other information including specific monitoring required prior to administration of medication. 4. Discontinued dates are entered as indicated into the electronic medical record and will be reflected at the discharged time in EMAR.

Based on observation, staff interviews, provider interview, clinical record review and facility policy review the facility failed to implement interventions to prevent worsening of a pressure sore for 1 of 3 residents reviewed. On 2/21/24 Resident #1 presented with a pressure sore on his heel. Staff failed to obtain and implement physician treatment orders until 2/27/24. The facility reported a census of 29 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. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He used a manual wheel chair and walker for mobility and required substantial assistance with hygiene and upper body dressing. The MDS documented he was at risk for developing pressure ulcers but did not have any pressure ulcers. The Care Plan revised on 2/13/24, documented Resident #1 had activities of daily living self-care performance deficits. He was admitted to the facility on [DATE] after a fall at home that resulted in a fracture in the back. He had limited physical mobility, and used assistive device for repositioning in bed. The Care Plan focus with an initiation date of 2/13/24 documented the resident is at risk for further skin integrity impairment. An addition to the care plan made on 2/26/24 that the resident would be using heel boots when in bed or to elevate the heels on pillows when in bed. Staff directed to complete treatments as ordered and to monitor of effectiveness of the interventions. The Progress Notes for the resident documented the following: On 2/22/24 at 10:55 AM wound assessment with a deep tissue injury (DTI) pressure wound that is new. On 2/22/24 at 11:54 AM resident has a stage two pressure ulcer on buttocks. Chamosyn applied to area. DTI to left heel. Betadine applied to area. On 2/23/24 at 10:12 AM the resident has a stage 2 pressure ulcer on his righ buttocks. Resident also has a STI on his right heel. (note lacked if treatment completed to heel) On 2/24/24 at 1:19 PM pressure ulcer noted to remain intact to right heel, dark purple in color and soft to touch. Right buttock continues to have pressure ulcer with calmoseptine applied. (note lacked if treatment completed to heel) On 2/24/24 at 2:53 PM right heel is purple in color and soft to touch. Chamosyn to buttock. Heel protector and float heels. (note lacked if treatment completed to heel) On 2/25/24 at 11:08 AM pressure ulcer remains to right heel, dark purple in color and soft to touch. (note lacked if treatment completed to heel) On 2/26/24 at 10:28 AM right heel continues to be purplish in color, soft and non tender. Resident educated on repositioning to promote wound healing. (note lacked if treatment completed to heel) The Progress Notes lack daily documentaiton of the heel wound. On 2/27/24 at 11:55 AM, observed Resident #1 in his wheelchair in his room, and a family member visiting with him. The family member said that the resident had a spot on the bottom of his right heel that was bothering him. The resident was wearing socks, and his heels were resting against the foot plate of the wheel chair. As the family member removed his stocking, the resident said that his heel hurt. He had a calloused area with reddened edges and it was warm to the touch. The resident said ouch a couple of times when the family member touched it. After his sock was put back on, the resident rested his foot back against the foot platform of the wheel chair. On 2/27/24 at 12:21 PM, Staff A, Licensed Practical Nurse (LPN) prepared the treatment for an ulcer on the resident's bottom, and said that she wasn't aware of a spot on the heel of Resident #1. She looked at the bottom of his foot, noted the reddened area and size and said that they could maybe put the heel protection boot on him during the day and a cushion for the wheel chair platform. On 2/27/24 at 2:50 PM, Staff C, Registered Nurse (RN) said that she had been approached by PT on 2/21/24 that the resident was having pain on his heel so she assessed it and asked the Director of Nursing (DON) to look at it also. She said they usually let the DON know about a new skin issue and then they would notify the Nurse Practitioner (NP) for a treatment order. She said that the NP would come out to the facility on ce a week and she was due to be there the following day. On 2/27/24 at 3:15 PM, the DON said that she was aware of the heel ulcer on Resident #1 on 2/22/24 and had directed the nurse to get an order for treatment. She reviewed the file and found that the order had not been entered so she entered it herself on 2/27/24. On 2/27/24 at 4:18 PM the Physician returned a call and stated he could not recall the resident or the heel. After he reviewed the resident record he stated the Nurse Practitioner had written an order on 2/22/24 for betadine to be applied to the heel daily. A review of the electronic record on 2/27/24 revealed that the chart lacked a treatment order for the heel ulcer and lacked daily wound monitoring. The Treatment Administration Record (TAR) for February 2024 documented an order to complete a body audit assessment weekly on bath days. The TAR revealed signatures of completion on 2/7/24, 2/14/24 and 2/21/24. According to the Skin and Wound Evaluation sheet dated 2/22/24 at 10:55 AM, Resident #1 had a new deep tissue injury on his right heel. The ulcer was in-house acquired and discovered on 2/21/24. The area measured 5 centimeter (cm) total area x 2.2 cm width x 2.8 cm length. The surrounding tissue was calloused, and povidone iodine used to cleanse. The chart lacked documentation that the practitioner, family, dietician or therapy had been notified. The TAR included an order dated 2/27/24 at 7:00 PM for betadine to the deep tissue injury on the right heel twice daily until resolved. On 2/28/24 at 7:57 AM, Staff E, from Physical Therapy (PT) said that she was working with Resident #1 and putting on his slippers when he said that his heel was hurting. She took a look and found the right heel to be dark purple, with a fluid filled area. She said it looked like a deep tissue injury. On 2/28/24 at 9:46 AM, Staff F, Certified Occupational Therapy Aide (COTA) took a couple of cushions into the resident's room and stated that they lowered the seat on the wheel chair so his feet could better reach the floor and decrease the pressure while seated in his wheelchair. She said that the team had a discussion to remove the leg rests from the wheel chair. If the leg rests were to be used for transport the heel loop on the right side to prevent resident from resting heel on it. According to the policy titled: Skin Integrity Management Policy, last approved, September of 2006: The nurse would examine the condition of the wheelchair cushion, any other support surfaces on the wheelchair, and or the bed surface for adequate comfort and pressure reduction. Request treatment order for the Nurse Practitioner/Medical Doctor. Procedure: upon discovery of a non-surgical wound 1. Initiate Pressure Ulcer/Injury Managment Checklist 2. Request treatment order from NP/MD, using standing orders where appropriate. 3. Initiate Daily Wound Monitoring in the TAR

Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to assess a resident's wounds for 1 of 4 residents reviewed for wounds (Resident #4). The facility failed to perform follow up skin assessments and interventions on Resident #4's right lower extremity wound after first identifying the skin concern on 10/11/22, which subsequently resulted in deterioration of the wound. The resident's physician ordered antibiotics for the resident on 10/25/22. The facility reported a census of 16 residents. Findings include: The minimum data set (MDS) assessment dated [DATE] revealed Resident #4 had diagnoses of Alzheimer's disease, hemiplegia (paralysis on one side of the body), and an unstageable pressure ulcer to her right ankle. The MDS documented the resident had a brief interview for mental status (BIMS) score of 3, indicating severely impaired cognition. The MDS documented the resident had total dependence on two staff for transfers. The MDS documented the resident had an unstageable deep tissue injury but no infection or open lesions. The care plan initiated on 7/6/20 and revised on 10/26/22, revealed the resident had a risk for impaired skin integrity related to cognitive impairment, impaired mobility, and history of a pressure injury. The care plan also listed the resident had a skin tear and an infection to her right lower leg (revised on 10/26/22), and at risk for further infection. The staff directives included: administer antibiotics as prescribed (added 10/26/22), encourage fluid intake, watch for signs of increased infection such as increased redness, pain, swelling, or drainage, and pad the foot pedals for pressure prevention (initiated 11/18/21). Resident Occurrence Report dated 10/11/22 8:15 AM revealed the resident had a skin tear that required medical attention and first aid. A screw on the wheelchair foot pedal caused the injury. Occupational Therapy (OT) contacted on 10/11/22 at 12:27 PM to cover the screws of the wheelchair. The record lacked a skin assessment for 10/11/22 regarding the skin tear to the right lateral calf. A physician's order, dated 10/11/22, revealed the resident had a skin tear to her right upper ankle. The area was cleansed with soap and water, and territories applied. A skin and wound evaluation, completed 10/25/22, for a skin tear to the right lateral calf acquired on 10/11/22. The area measured 2.1 x 1.3 centimeters, and had evidence of infection including increased pain, redness, inflammation, and warmth. The physician evaluated Resident #4 and ordered an antibiotic on 10/25/22. A physician's order, dated 10/25/22, revealed culturelle capsule (Lactobacillus) one tablet by mouth 2 times a day (BID) for 14 days (a bacterial supplement to replace gut bacteria killed by the antibiotic), and doxycycline 100 milligrams (mg, an antibiotic) tablet BID for 10 days for right leg cellulitis. A physician's order, dated 10/27/22, revealed the facility staff should apply betadine to the resident's right lower leg twice a day until healed. The progress notes revealed the following: a. On 10/11/22 at 8:26 AM, resident had a skin tear and hematoma to the right outer upper ankle. Area cleansed with soap and water, and steristrips applied. An intervention included to apply foam higher up on the wheelchair legs to prevent scraping. Family and physician notified. At 12:27 PM, Occupational Therapy (OT) contacted to place something over the screw on the resident's wheelchair foot pedals. b. On 10/12/22 at 3:53 PM, a skin tear noted to right outer ankle approximated with steri-strips. Skin is otherwise clean, dry, and intact without signs or symptoms of infection or breakdown. c. On 10/16/2022 at 9:39 AM, pressure ulcers measurements performed to the right ankle deep tissue injury and right pinky finger. See skin and wound assessments for measurements. The progress note lacked information about the skin tear to the right outer ankle. d. On 10/25/2022 at 12:04 PM, a Physician's Order Note revealed the physician evaluated the resident's right leg and wrote orders for doxycycline 100 mg PO BID for 10 days for cellulitis and culturelle 1 tablet by mouth BID for 14 days. Observations on 10/25/22 at 2:10 PM with Staff G, Registered Nurse (RN), revealed the resident had a quarter sized skin tear 2 inches above her right ankle. Staff G reported the resident sustained the skin tear a couple of weeks ago when the CNAs (certified nursing assistants) transferred the resident with a hoyer into her wheelchair, and a screw by the wheelchair leg pedals caught and tore the resident's skin. In an interview 10/24/22 at 2:53 PM, a family member reported the resident had a sore on her ankle. In an interview 10/25/22 at 2:30 PM, the Clinical Care Coordinator reported no skin assessment other than a progress note regarding the skin tear on Resident # 4. The Clinical Care Coordinator reported since the resident had now developed a concern on how the wound looked, they now planned to initiate a skin assessment form on the electronic health record. A skin integrity management policy, modified 10/2022, revealed the purpose to properly identify, assess, and monitor residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers/injuries, to implement preventative measures, and to provide appropriate treatment modalities for pressure ulcers/injuries according industry standards of care. A care plan developed or modified to reflect alterations in interventions and implementation of new interventions specific to the resident. The care plan interventions shall be communicated to the appropriate staff via the nursing assistant assignment sheet or My Best Day and/or through report. The procedure included to inspect the skin with cares for signs and symptoms of breakdown, and a body audit performed by designated employee on shower day or other designated day at least weekly, and findings documented per facility policy. Upon discovery of a non-surgical wound: 1. Initiate Pressure Ulcer/Injury Management Checklist 2. Request treatment order from provider 3. Initiate Daily Wound Monitoring in the electronic treatment administration record. 4. Initiate new Wound Assessment using the Skin and Wound App to complete the measurements of the wound 5. Complete wound assessment in the electronic health record which included the onset of skin condition, type of wound, location, date, wound measurements, surrounding skin description, drainage, odor, and/or pain. The wound documentation completed at least weekly, or more frequently depending on the wound characteristics. 6. Implement appropriate interventions and update care plan and nursing assistant assignment sheets or My Best Day 7. Communicate changes with appropriate staff members