Every finding on record at Ramsey Village

Based on clinical record review, staff interview, pharmacy record review and policy review, the facility failed to follow professional standards regarding following physician's orders by failing to remove previously applied fentanyl patches after 72 hours of use and before applying new patches, putting residents at risk of an overdose for 1 of 3 residents (Resident #1) reviewed for medication administration. The facility reported a census of 69 residents. Findings include:Review of Minimum Data Set (MDS) dated [DATE] revealed, Resident #1's Brief Interview for Mental Status (BIMS) of 14, indicating cognitively intact. Resident #1's diagnoses include coronary artery disease, respiratory failure with hypoxia, history of polio resulting in chronic pain, muscle wasting and atrophy, anxiety, depression, and PTSD with dependence of two for assistance with a mechanical lift for ambulation and use of wheelchair for mobility. Resident #1's MDS included antipsychotics, antidepressants, diuretic, opioid and anticonvulsant high risk medications. Review of Care Plan dated 10/8/2025 documented Resident #1's use of opioid pain medication therapy with interventions to administer pain medications as ordered by physician, monitoring and documenting side effects and effectiveness. Review of Resident #1's Physician Order Summary indicated an order for Fentanyl patch 72 hour, 75 mcg, apply one patch to skin one time every 3 days (72 hours) for pain and removal per schedule. Review of Pharmacy provided Emergency Kit-Transactions By Patient report revealed on 3/23/26 at 9:01 PM one Fentanyl 25 mcg patch and at 10:05 PM two Fentanyl 25 mcg patches, to equal total 75 mcg, were removed from the Emergency medication kit for Resident #1. Review of Resident #1's March 2026 Medication Administration Record (MAR) revealed on 3/23/26 previously applied Fentanyl patch was removed and 75 mcg patch administered. With indication noted to see nursing progress notes related to Fentanyl patch administration. Review of Resident #1's Nursing Progress note dated 3/23/26 at 9:04 PM noted three 25 mcg patches received from pharmacy and applied to Resident #1's shoulders. A Pharmacy provided Packing Slip Proof of Delivery document dated 3/24/26 revealed two 75 mcg Fentanyl patches delivered and received at the facility for Resident #1. Review of Resident #1's March 2026 MAR documented on 3/26/26 previously applied Fentanyl patches were removed and 75 mcg Fentanyl patch was applied to Resident #1. Review of Controlled Drug Record log labelled 75 mcg fentanyl patch, quantity of two patches delivered on 3/24/26 with start date of 3/26/25 documented on 3/26/26 at 8:00 PM, one of two patches was administered to Resident #1, with one patch remaining. A Nursing Progress note dated 3/29/26 at 9:15 PM documented Resident #1 with altered mental status, not at baseline with response to her name. Resident #1's representative contacted, representative reported noticing the change with Resident #1 when visiting earlier in the day. Order received from provider, Resident #1 transferred to the local Emergency Department to be evaluated. Review of Emergency Department Provider note dated 3/29/26 revealed, Resident #1's chief complaint was altered mental status, nursing home staff had not seen her since she was checked on at shift change (2:00 PM) and she was not acting herself and not making sense. Two fentanyl patches were found on both of her shoulders dated three days ago and unsure of dosages. Emergency Medical Services (EMS) gave Narcan (medication used to treat patients exposed to high-potency opioid) dose en route to hospital, which helped a little. An additional dose of Narcan was given in ED with little improvement. Resident #1 admission to the Intensive Care Unit (ICU) for further workup and management. Further review of Resident #1 hospital admission documents indicated, Resident #1 was discharged , returning to the facility on 4/1/26.A Pharmacy provided Packing Slip Proof of Delivery document dated 4/10/26 revealed five 75 mcg Fentanyl patches delivered and received at the facility for Resident #1. Review of April 2026 MAR documented previously applied Fentanyl patches were removed and 75 mcg Fentanyl patch was applied to Resident #1 on 4/10/2026, 4/13/2026, 4/16/2026, and 4/19/2026. Review of Controlled Drug Record log labelled 75 mcg fentanyl patch, quantity of five patches delivered on 4/10/26 with start date of 4/10/25 documented on 4/10/26 at 11:00 PM, 4/13/26 at 9:00 PM, 4/16/26 at 8:00 PM and 4/19/26 at 9:00 PM patches were administered to Resident #1, with one of five patches remaining. A Nursing Progress note dated 4/20/26 at 7:05 PM revealed, Resident #1 noted to be unresponsive to verbal stimulation, Resident #1 sent to the local Emergency Department. Review of Hospital Progress note dated 4/22/26 at 10:05 AM stated, Resident #1 presented with altered mental status potentially in the setting of unintentional opioid overdose, as two fentanyl patches were removed en route to hospital. Naloxone (Narcan) was administered on 4/20/26.During an interview on 4/23/26 at 12:20 PM Director of Nursing (DON) reviewed and acknowledged the extra patches documented to be on Resident when transporting to the hospital via EMS. DON stated after 72 hours the patches don't have much effect, that's why they're removed and changed every 72 hours, it is sloppy nursing and an opportunity to re-educate the nurses on removing and applying patches. Review of facility provided Administering Topical Medications Policy, stated the following for trans-dermal patches:a. Clean and dry a selected area that is approved for application of the patch. Rotate sites with each new application, if possible. b. Remove old patch. c. Remove wrapper from the patch. Do not touch the adhesive surface. d. Apply to the skin, pressing firmly for approximately ten seconds.e. Remove gloves. Wash and dry hands thoroughly.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure mechanical lifts were used correctly during transfers for 3 of 5 residents (#1, #4, #5). The facility failed to lock wheelchairs during resident transfers for 2 of 5 residents (#2, #4), and failed to ensure foot pedals were attached while transporting a resident in a wheelchair for 1 of 5 residents (#3). The facility reported a census of 69 residents.Findings include:. 1. The Minimum Data Set (MDS) for Resident #1 dated 9/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of end-stage renal disease, Alzheimer's Disease, non-Alzheimer's dementia, lack of coordination, and abnormalities of gait and mobility. It indicated she was independent with eating, required setup assistance with oral hygiene, maximal assistance with toileting hygiene, bathing, upper body dressing, and all mobility except lying to sitting on the side of the bed, and was dependent with lower body dressing, footwear, personal hygiene, and lying to sitting on the side of the bed. It also indicated she was frequently incontinent of bowel and bladder, and she used a walker and wheelchair for mobility.The Care Plan dated 4/02/24 indicated the resident had bowel and bladder incontinence and directed staff to check the resident per schedule, assist with toileting as needed, and to provide peri care after each incontinent episode. A revision dated 9/17/24 indicated the resident required 1-person assistance with a walker for transfers.On 10/22/25 at 12:13 PM, Staff A, Certified Nurse Aide (CNA) and Staff B, CNA took Resident #1 to the shower room to check and change her. The staff locked the sit-to-stand mechanical lift to raise the resident from the wheelchair, however did not lock the mechanical lift when the resident was raised from the toilet. On 1/22/25 at 12:44 PM, Staff B stated the mechanical lift's wheels are unlocked to lift a resident and she only locks the wheelchair if the resident is transferring to or from it. She added sometimes the mechanical lift's wheels are locked and sometimes they aren't.At 1:13 PM, Staff A stated the sit-to-stand mechanical lift's wheels should be locked when transferring a resident. She stated the wheels should not have been unlocked and suggested Staff B might have forgotten to lock them.The manufacturer's document titled Operation Manual revised 10/06/16 directed staff to unlock the sit-to-stand wheels after the resident was raised.2. The MDS for Resident #2 dated 8/18/25 revealed a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of coronary artery disease, diabetes mellitus, Alzheimer's Disease, non-Alzheimer's dementia, macular degeneration, and periprosthetic fracture (fracture around a prosthetic knee). It indicated she required supervision with eating, moderate assistance with oral hygiene, maximal assistance with upper body dressing, personal hygiene, and rolling left-to-right in bed, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It also indicated she was always incontinent of bowel and bladder and used a wheelchair for mobility.The Care Plan dated 8/05/25 indicated the resident had bowel and bladder incontinence and directed staff to check the resident per schedule, assist with toileting as needed, and to provide peri care after each incontinent episode A revision dated 9/05/25 directed staff to complete all transfers with transfer disc and assist of 2 and gait belt.On 10/22/25 at 12:44 PM, Staff B, CNA and Staff C, CNA took Resident #2 into the shower room to check and change her. Staff C placed a gait belt around the resident and Staff B and Staff C assisted Resident #2 to a standing position from her wheelchair. The rear wheelchair tires were noted to be unlocked during the transfer and Staff C pushed it away to pivot Resident #2 to sit on the toilet.At 1:00 PM, Staff C stated sit-to-stand wheels and wheelchairs should be locked during resident transfers. She stated she thought she locked the wheelchair but added there is no reason to leave a wheelchair unlocked during a resident transfer. She also added it made moving the wheelchair easier as Resident #2 had a hard time holding the toilet assist bar.At 1:08 PM, the Unit Manager (UM) stated the resident's left wheelchair lock needed to be tightened because it was loose and allowed the wheel to turn when in the locked position.3. The MDS for Resident #3 dated 7/15/25 revealed a BIMS score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, cerebrovascular accident (stroke), renal (kidney) disease, abnormalities of gait and mobility, and cognitive communication deficit. It indicated she was independent with eating and required maximal assistance with all other ADLs. She was independent with rolling left-to-right, required supervision with sit-to-lying and bathing, moderate assistance with lying-to-sitting, and maximal assistance with all other mobility. It also indicated she was frequently incontinent of bowel and bladder and used a wheelchair for mobility.The Care Plan dated 1/15/25 indicated the resident's wheelchair leg of pedal should be padded.On 10/22/25 at 1:43 PM, Staff D, Hospice CNA transported Resident #3 down the unit hall to her room in a wheelchair without foot pedals attached. Staff D stated she had given the resident a shower and the resident doesn't require foot pedals because she propels herself. She stated the resident should probably have foot pedals if she is being pushed by staff. She said if the resident dangled her feet in the way, she probably would've put the pedals on her w/c.On 10/23/25 at 3:22 PM, the Administrator indicated the facility did not have a policy regarding wheelchair safety.4. The MDS for Resident #4 dated 8/14/25 did not include a Brief Interview for Mental Status (BIMS) score because the resident was rarely or never understood. It included diagnoses of Alzheimer's Disease, non-Alzheimer's dementia, the need for assistance with personal care, lack of coordination, and cognitive communication deficit. It indicated he was independent with eating, required moderate assistance with oral hygiene, maximal assistance with toileting hygiene, personal hygiene, lower body dressing, and all forms of mobility, and was dependent with bathing, upper body dressing, and footwear. It also indicated he was always incontinent of bowel and bladder and used a wheelchair for mobility.The Care Plan dated 8/19/25 indicated the resident required 1-person assistance for transfers.On 10/22/25 at 3:16 PM, Staff F, CNA took the total body mechanical lift into Resident #4's room. Staff F and Staff G, CNA placed Resident #4 on a sling in his bed. After connecting the sling to the mechanical lift, Staff F closed the legs of the lift, positioned the lift over Resident #4 with the legs under the bed, and raised him off the bed. Staff F moved the lift out from under the resident's bed with the legs closed, positioned the resident over his wheelchair from the side, and lowered the resident onto his wheelchair. Staff G was standing behind the resident's wheelchair and guided the resident onto his seat. The wheelchair was noted to be unlocked throughout the transfer.At 3:38 PM, Staff G stated the total body mechanical lift's legs should be opened when lifting a resident, closed when moving the resident to the destination, and kept in whichever position was obtainable at the destination. She also stated the lift's wheels should be unlocked but wheelchairs should be locked when transferring a resident. She further stated there was no reason the resident's wheelchair was unlocked during transfer.At 3:40 PM, Staff F stated the total body mechanical lift's legs should be opened when lifting or lowering a resident only if the stationary object can't accommodate the lift's legs being closed. He also stated wheelchairs should be locked when transferring a resident to or from it unless there is a person stabilizing the wheelchair.5. The MDS for Resident #5 dated 8/20/25 revealed a BIMS score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of cerebrovascular accident (stroke), diabetes mellitus, and hypothyroidism. It indicated he required setup assistance with eating, moderate assistance with rolling left-to-right, was independent with eating, dependent with toileting, and required maximal assistance with all other ADLs. He also required moderate assistance with rolling left and right, maximal assistance with sit-to-lying and lying-to-sitting, and was dependent with all other mobility. It also indicated he was always incontinent of bowel and frequently incontinent of bladder and used a wheelchair for mobility.The Care Plan revised 1/10/25 indicated Resident #5 required assistance of 2 with a mechanical lift for transfers.On 10/22/25 at 2:56 PM, Staff A, CNA and Staff E, CNA took the mechanical lift into Resident #5's room to transfer him from his recliner to his bed for incontinence care. Staff E positioned the total body mechanical lift in front of the resident. Staff A and Staff E connected the sling to the lift. Staff E locked the wheels of the mechanical lift and raised Resident #5 off the recliner. She repositioned the lift under the bed with the legs closed, left the wheels unlocked, and lowered the resident onto his bed.At 3:12 PM, Staff E stated the total body lift wheels should be locked when lifting and lower a resident and unlocked to move them in the lift. She stated she forgot to lock the wheels when lowering him onto his bed.The manufacturer's document titled User Manual revised 5/11 indicated the total body mechanical lift's legs must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. It also indicated the manufacturer does NOT recommend locking the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. It further indicated to ensure the legs of the lift (with patient) are in the open position and the wheelchair wheels are locked before lowering the patient into the wheelchair for transport.On 10/23/25 at 2:46 PM, the Director of Nursing (DON) stated the wheelchair wheels should be locked during all transfers and he would have to refer to the sit-to-stand mechanical lift's owner's manual. He also stated staff should not propel residents in wheelchairs without foot pedals. He further stated staff should've opened the mechanical lift's legs once under the resident's bed if space allowed and staff should've followed the manufacturer's recommendations which state to unlock the mechanical lift's wheels when raising or lowering a resident.

Based on observation, record review, staff interview, and policy review, the facility failed to provide repositioning and incontinence care for 1 of 3 residents (#6). The facility reported a census of 69 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of renal (kidney) disease, Alzheimer's Disease, non-Alzheimer's dementia, disorder of kidney and ureter, and need for assistance with personal care. The MDS documented that the resident required supervision with eating, maximal assistance with oral and personal hygiene, bathing, upper body dressing, and rolling left and right in bed, and was dependent with all other Activities of Daily Living (ADLs) and mobility. The MDS also indicated he was always incontinent of bowel and bladder.The Care Plan dated 12/15/22 and revised 8/28/24 documented the following; the resident had bladder incontinence and used disposable briefs. 2-4 times per shift and prn and directed staff to clean peri-area with each incontinence episode. It also indicated the resident had bowel incontinence and directed staff to check the resident per schedule and assist with toileting as needed, provide a bedpan/bedside commode, and provide pericare after each incontinent episode. A revision dated 10/01/25 indicated the resident was dependent with toilet use and required 2-person assistance and a mechanical lift for all transfers. Check resident per schedule and assist with toileting as needed.During a continuous observation on 10/23/25 that began at 8:46 AM, Staff I, Certified Medication Aide (CMA) brought Resident #6 in his wheelchair to the TV lobby area after breakfast. The resident stayed in the location where he was placed and in the same position in his wheelchair until 11:00 AM at which time Staff J, Certified Nursing Aide (CNA) transported him back to the dining room to eat lunch.Between 11:12 AM and 11:27 AM, Staffs A, B, H, J, and K, CNAs, and Staffs L, M, and N, Licensed Practical Nurse (LPN) stated they had not assisted Resident #6 for repositioning or toileting after breakfast.The Electronic Health Record (EHR) indicated the resident received bladder elimination and personal hygiene assistance on 10/23/25 at 8:52 AM and toileting transfer and toileting hygiene at 8:53 AM.At 11:30 AM, Staff O, CNA, stated she provided Resident #6's incontinence care and repositioning at 9:40 AM. She also stated Staff J and Staff K assisted her. She further stated she documents resident hygiene care after she completes it and the times documented were from before breakfast.At 2:46 PM, the Director of Nursing (DON) stated staff should've taken the resident to his room after his breakfast and performed incontinence care and repositioning.A policy titled Repositioning revised May 2013 indicated residents who are in a chair should be on an every one hour (q1 hour) repositioning schedule.

Based on observations, record review, staff interview, and policy review the facility failed to disinfect a mechanical lift after use between 2 of 2 residents, failed to perform hand hygiene during perineal care for 1 of 3 residents reviewed (#4), and failed to remove Personal Protective Equipment (PPE) before leaving a resident's room who was on Enhanced Barrier Precautions (EBP). The facility reported a census of 69 residents. Findings include:1. On 10/22/25 at 2:56 PM, Staff A, Certified Nurse Aide (CNA) and Staff E, CNA used a mechanical lift in a resident's room to transfer him from his wheelchair to his bed. After they completed the transfer, Staff E pushed the mechanical lift into the hallway and returned to the resident's room. The mechanical lift was not sanitized.At 3:16 PM, Staff F, Certified Medication Aide (CMA), took the mechanical lift into Resident #4's room to transfer him from his bed to his wheelchair and did not sanitize it. Staff F positioned the lift near Resident #4's bed and Staff F and Staff G stated Resident #4's perineal care needed to be completed before they transferred him to his wheelchair. Staff F and Staff G, CNA, performed hand hygiene and both donned gloves. Staff F handed Staff G a trashcan and Staff G grabbed it with her left, gloved hand and placed it on the floor beside the foot of the resident's bed. As Staff F left the room to get more gloves, Staff G used the same left, gloved hand to remove some perineal wipes from the packaging and performed Resident #4's perineal care that included retracting his foreskin and wiping the head of his penis. She did not perform hand hygiene or change gloves.The Minimum Data Set (MDS) for Resident #4 dated 8/14/25 did not include a Brief Interview for Mental Status (BIMS) score because the resident was rarely or never understood. It included diagnoses of Alzheimer's Disease, non-Alzheimer's dementia, the need for assistance with personal care, lack of coordination, and cognitive communication deficit. It indicated he was independent with eating, required moderate assistance with oral hygiene, maximal assistance with toileting hygiene, personal hygiene, lower body dressing, and all forms of mobility, and was dependent with bathing, upper body dressing, and footwear. It also indicated he was always incontinent of bowel and bladder.The Care Plan dated 1/31/25 indicated the resident had bowel and bladder incontinence and directed staff to check the resident per schedule, assist with toileting as needed, and to provide peri care after each incontinent episode. A revision dated 8/19/25 indicated he required assistance with transfers.At 3:35 PM, Staff F and Staff G completed Resident #4's perineal care and used the mechanical lift to transfer him from his bed to his wheelchair without sanitizing the lift.At 3:40 PM, Staff F stated shared resident equipment is sanitized before and after each use but added he assumed the previous users sanitized it when they were finished using it.At 4:13 PM, Staff G stated she should've performed hand hygiene between moving the trashcan and performing Resident #4's perineal care.A policy titled Handwashing/Hand Hygiene revised [DATE] directed staff that hand hygiene is indicated immediately before touching a resident; before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching a resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal.A policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised [DATE] directed staff that Durable Medical Equipment (DME - medical equipment that can withstand repeated use) must be cleaned and disinfected before reuse by another resident.On 10/23/25 at 2:46 PM, the Director of Nursing (DON) stated staff should've removed the gloves, performed hand hygiene, and donned new gloves before performing perineal care and staff should sanitize shared equipment before and after each use.2. On 10/23/25 at 7:34 AM, Staff H, CNA, donned PPE and entered a semi-private resident room with both residents on EBP. At 7:36 AM, Staff H exited the room with the PPE gown on and walked to another unit to get a mechanical lift. At 7:40 AM, Staff H stated both residents were on EBP due to each one had an invasive device. He stated he didn't know he wasn't supposed to exit the room wearing PPE if he hadn't touched anything but added he should've known better.A policy titled Personal Protective Equipment - Using Gowns revised [DATE] directed staff that gowns must be discarded in the appropriate container located in the room.On 10/23/25 at 2:46 PM, the DON stated staff should've removed the PPE before exiting the residents' room.

Based on observations, clinical record review, staff interviews, guidance from the Centers for Disease Control (CDC) and facility policy review the facility failed to implement enhanced barrier precautions for one of one resident reviwed (Resident #4), and failed to perform appropriate hand hygiene during personal cares for three of three residents observed for toileting hygiene (Res #3, Res #4 and Res #61). The facility additionally failed to properly sanitize a full body mechanical lift between the usage of the lift between two residents. The facility reported a census of 62 residents. Findings include: 1. The admission Minimum Data Set (MDS) of Resident #4 dated 6/14/25 recorded the resident to require substantial/maximal assistance for toileting hygiene. The Care Plan of Resident #4 documented the resident had an indwelling urinary catheter, dated 6/10/25. Observation of transfer, toileting, and catheter care began on 8/27/25 at 10:13 am with Staff E and Staff I, Certified Nurse Aides (CNA) present. Resident #4 was sitting in her wheelchair. Staff E, CNA, placed gloves on her hands and removed the resident's cushioned boots (for skin protection). She removed the foot support from the wheelchair and then stepped out of the room momentarily and returned still wearing gloves. Staff I, CNA entered the room with a stand up mechanical lift and donned gloves. Staff E placed the sling for the mechanical lift behind Res #4 and gave the resident simple one step instructions as to how they would transfer her. Both staff continued to wear the same gloves as they positioned Res #4 into the lift, assisted her to a standing position, guided her to the toilet, lowered her pants and brief, and lowered her safely onto the toilet. Staff E obtained a graduated cylinder and placed it on the sink next to the toilet. She then disconnected the safety sling from the standing mechanical lift and placed the graduated cylinder directly on the floor. She opened the drain from the resident catheter urine bag and emptied the urine into the graduated cylinder. Staff I stated she was going to obtain an alcohol swab to cleanse the drain tip. She left the room and returned quickly with an alcohol swab which she handed to Staff E, not wearing gloves at that time. Staff I placed new gloves on her hands, with no hand hygiene witnessed. Staff E remained in the same gloves she had on since the beginning of the observation. She cleansed the tip of the drain, placed the drain in place and replaced the urine bag into a dignity bag. She picked the graduated cylinder up off the floor and stated she would hold it until the resident was off the toilet. Staff I then opened a cart with supplies in it, and obtained wet wipes from the cart. Staff E then placed the graduated cylinder, still with urine in it, back on the floor. She removed her gloves, disposed of them, and placed new gloves on her hands, with no hand hygiene observed. Staff I, still wearing gloves, obtained the standing mechanical lift and brought it back to the room. Both staff assisted the resident securely back into the sling to stand. Staff E ran the remote control of the mechanical lift with her gloved hand and Staff I held the catheter bag in place as the resident was raised to a standing position. Staff E then cleansed the buttocks of resident #4, still wearing the same gloves used to raise the standing left. Staff E then removed her gloves and placed new gloves on with no hand hygiene witnessed. Both staff members assisted the resident to replace her clothing and then guided her back to her wheelchair and placed her urinary bag clipped under her wheelchair. Staff E then returned to the restroom, picked up the graduated cylinder off the floor and emptied the urine into the toilet. She then obtained paper towels and dried the graduated cylinder without rinsing it and placed it back on the floor. Both staff at the end of the observation removed their gloves and used hand sanitizer. On 8/27/25 at 10:25 am, Staff E, CNA was asked about a fully stocked isolation cart outside of Resident #4's room. She stated it contained isolation gowns but neither Resident #4 nor her roommate were in isolation. When asked if she had received education regarding Enhanced Barrier precautions and stated she was not aware what that meant. She stated she could ask a nurse what that was. She added the isolation cart had been outside of that room for quite a while but nobody used it. On 8/27/25 at 11:00 am, the Director of Nursing stated staff has been educated about enhanced barrier precautions and they discuss it in morning huddle. 2. The Annual MDS of Resident #61, dated 8/10/25 documented him to be fully dependent for toileting hygiene and bed mobility. The MDS coded the resident to be always incontinent of bowel and bladder. The Care Plan of Resident #61 documented a problem area of Activities of Daily Living (ADL) self care performance and directed staff to check and change the resident for incontinence every two hours. Observation began on 8/28/25 at 3:00 am. The resident was in bed, with his call light on the bedside table several feet away from him out of reach. At 3:22 am, Staff R, Certified Nurse Aide (CNA) entered the room, stated she was just checking on the resident and quickly exited the room again. At 4:30 am, Staff R entered the room again, and stated she needed to perform incontinence cares for the resident. She entered the bathroom, obtained supplies and placed gloves on her hands with no hand hygiene observed. She went to the bedside and opened the incontinence brief of Resident #61 which appeared to be heavily saturated with urine. Staff R stated her normal routine on the night shift is to perform incontinence cares for the resident every two hours. She cleaned his penis and groin with wet wipes, cleaning front to back. She then turned the resident to his left side, tucked his soiled brief and two disposable under pads underneath him. The resident was incontinent of bowel. Staff R then cleansed his buttocks, removed the soiled supplies and placed the items in a trash can on the floor next to her. She then obtained a clean brief and a clean disposable under pad. She then removed and disposed of her gloves and obtained barrier cream from a night table across the room. She placed new gloves on her hands with no hand hygiene witnessed and placed barrier cream on the resident's groin. She then fastened the incontinence brief and placed a support pillow between the resident's knees. She removed her gloves, adjusted his sheets and blankets and put away the wipes and barrier cream and lowered the bed. Staff S, Licensed Practical Nurse (LPN) then entered the room to assist Staff R to reposition the resident. Staff R then stated when they repositioned him, he had urinated again so they were going to change him again. Staff R then changed her gloves and obtained new supplies. She opened the resident's brief, and again cleansed his penis and groin. She tucked the brief underneath him as she turned him to his side. Staff S, LPN then cleansed his buttocks and removed the soiled brief and disposed of it. Staff S then removed her gloves, entered the bathroom to wash her hands and placed new gloves on her hands. Staff S then went to the doorway where a linen cart was parked and obtained a clean hospital gown. She then placed a new disposable under pad and a new brief underneath the resident and applied a prescription powder on his buttocks. Both staff removed the wet hospital gown from the resident and Staff R then put the soiled gown on the floor next to the trash can. Staff S placed the clean gown on the resident. Staff R removed the trash bag from the trash can, picked the gown up off the floor, and exited the room still wearing her gloves. Upon returning to the room at 4:56 am, Staff R placed a new liner in the trash can and put away extra supplies. She placed the support pillow again between the resident's legs and positioned the resident in a comfortable position. She then removed the call light from the bedside table and clipped it to his sheets. She stated the call light is normally always in reach. She replaced the fall mat on the floor next to the bed and left the bed in a low position. An article from the CDC dated 6/28/24 titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes documented the following: Point 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of Multidrug-Resistant Organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Point 3. Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities (unless otherwise indicated as part of Standard Precautions). Residents are not restricted to their rooms and do not require placement in a private room. Enhanced Barrier Precautions also allow residents to participate in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. The facility policy Handwashing/Hand Hygiene, revision date October 2023, documented the following: Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task c. after contact with blood body fluids, or contaminated surfaces; d. after touching a resident e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. 3. The admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #3 needed substantial/maximal assist for toileting hygiene, upper and lower body dressing and was dependent with sit to stand and chair to bed transfers. The Care Plan initiated 6/17/25 indicated that Resident #3 had a self-care performance deficit with dressing and personal hygiene requiring assist of one. During an observation on 08/27/2025 at 10:27 AM Staff I, CNA and Staff J, CNA performed morning cares including transfer for Resident #3. Resident #3 was incontinent of bladder so peri cares were provided. Staff I, CNA and Staff J, CNA then transferred Resident #3 via pivot disk. Both Staff I, CNA and Staff J, CNA failed to perform hand hygiene between glove changes during peri care when going from dirty area to clean area. In an interview on 08/27/2025 at 1:23 PM The DON stated that hand hygiene should be performed in many instances. Stated hand hygiene should be performed with glove changes when providing peri-care. 4. On 8/25/25 at 1:04 PM, Staff C, Certified Nurse Aide (CNA) and Staff D, CNA exited Resident #11's room with a mechanical lift and transported it into Resident #33's room without sanitizing it. At 1:14 PM, Staff C and Staff D stated there was not a reason why the mechanical lift wasn't sanitized between use. A policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised 7/2014 indicated reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). On 8/28/25 at 8:25 AM, the Director of Nursing (DON) stated staff should have sanitized the mechanical lift before using it on the next resident.

Based on electronic health record review, staff interview, and policy review, the facility failed to notify the physician of blood sugars <60 for 1 of 1 residents reviewed for insulin use (Resident #22). The facility reported a census of 62. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 5/24/25, revealed Resident #22 with a Brief Interview for Mental Status score of 2, indicated severe cognitive impairment. Diagnoses on the MDS include diabetes, stroke, seizure disorder, and non-Alzheimer's dementia. Medications listed include an anticonvulsant and hypoglycemic (to lower blood sugar). The Medication Administration Report (MAR) on Resident #22 for August 2025 listed the use of a long acting insulin, Lantus 32 units, administered one time a day in the morning, and the use of a short acting insulin, Humalog, administered at meals three times a day in amounts based on blood sugar readings. Blood sugars are checked three times a day to correlate with meal service.The MAR for August and July 2025 documented the following low blood sugars for Resident #22: 59mg/dL on 7/3/25 at 5:00 p.m.55mg/dL on 7/6/25 at 5:00 p.m.60mg/dL on 7/19/25 at 5:00 p.m.56mg/dL on 8/2/25 at 5:00 p.m. 60mg/dL on 8/3/25 at 5:00 p.m.No documented interventions to correct the low blood sugars identified in the electronic or paper health record. This includes repeat blood sugar checks to ensure levels improved prior to the next scheduled check. No documented communication to the physician or their designee notifying of the low blood sugars identified in the electronic or paper health record. During an interview on 8/27/25 at 3:25 PM, Staff U, Registered Nurse, explained Resident #22 was unable to report their blood sugar is low and typically does not show physical signs of low blood sugars. These are usually noted during scheduled checks. During an interview on 8/28/25 at 930 AM, Staff T, Unit Manager, explained their preference is for staff to recheck blood sugars for levels <65. These should then be documented in the electronic health record. Staff T acknowledged the lack of documented staff interventions regarding Resident #22's low blood sugars. Staff T noted there are no parameters written in current orders on when to notify the physician for low blood sugars. After reviewing Resident 22's blood sugars, Staff T believed the physician should be notified. During an interview on 8/28/25 at 12:00 PM, Staff T confirmed Resident #22's inability to tell staff if they feel funny and may be experiencing low a blood sugar. Staff T clarified further the physician should be notified if a blood sugar is <60mg/dL, as per facility protocol. The facility document Geriatric Protocols for [NAME] Village, signed by the Medical Director on 1/9/25, outlined the following:Report blood sugars <60 or >400 to the appropriate providerFingerstick blood sugar can be done as needed for signs/symptoms of hypo/hyperglycemia (low or high blood sugars)Nurses: When a protocol is used:a. Document in the Progress Notes what protocol initiated and whyb. Put the order into the resident's eMAR; Select verbal as the communication method when entering the orderc. Print, note, and double note the orderd. Include necessary information for physician notification on the order if needed; Use nursing judgement to determine if a fax or follow-up of the concern is needed

Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to fully develop a comprehensive care plan for 3 of 17 residents reviewed (Resident #4, #28, & #50). The faciltiy reported a census of 62 residents. Findings include: 1. The admission Minimum Data Set (MDS) of Resident #4 dated 6/14/25 recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless; having trouble concentrating on things, and moving or speaking slowly or being fidgety or restless during the previous 2-week look back period. The MDS recorded diagnoses that included Alzheimer's Disease, Anxiety and Depression. The MDS documented the resident received antipsychotic, antianxiety, and antidepressant medications during the prior 7 days of the lookback period. Section V of the MDS, The Care Area Assessment Summary (CAA) documented communication, behavioral symptoms, and pressure ulcer/skin integrity would be included on the resident Care Plan. The MDS question V0200B2 was signed 6/16/25. The RAI Manual stated the RN coordinator is required to sign and date the CAA Summary after all triggered CAA's have been reviewed to certify the completion of the comprehensive assessment. Facilities have 7 days after completing the RAI assessment to develop or revise the resident's care plan. Facilities should use the date at V0200B2 to determine the date at V0200C2 by which the care plan must be completed (V0200B2 + 7 days). The Order Summary of Resident #4 documented Lorazepam, an antianxiety medication, had started on 8/22/25. The Order Summary additionally documented the use of Seroquel, an antipsychotic medication in use since 6/11/25. Review of Resident #4's care plan conducted on 8/26/25 revealed the Focus Areas of Potential for Skin Breakdown and Pressure Ulcers were both added to the Care Plan on 8/11/25. The Care Plan failed to reveal communication or behavioral symptoms to be addressed on the Care Plan. The Care Plan additionally failed to reveal documentation of the use of anti anxiety or antipsychotic medications. The care plan listed Psychotropic medications, with no target behavior symptoms noted to be addressed. The Care Plan additionally noted the use of an antidepressant, also failing to address the target behaviors being addressed for the use of the medication. On 8/28/25 at 10:46 am, the MDS Coordinator stated the Care Plan should be developed within 14 days of completing the MDS. She stated she had not been made aware Resident #4 had been started on an antianxiety medication, but said the normal process is for the floor nurses to inform her of medication changes to update the Care Plan. On 8/28/2025 at 12:21 pm, the Administrator stated triggered CAAs should be listed on the care plan. 2. The Quarterly MDS assessment for Resident #28 dated 8/10/25 revealed a Brief Interview for Mental Status (BIMS) score was not established because the resident was rarely or never understood. It included diagnoses of cerebral infarction (tissue damage caused by lack of blood flow to the brain), non-Alzheimer's dementia, anxiety, depression, sarcopenia (age-related loss of muscle mass, strength, and function), and quadriplegia. It indicated the resident required setup assistance with eating, maximum assistance with oral and personal hygiene, upper body dressing, and rolling left-to-right in bed, and was dependent with all other Activities of Daily Living (ADLs) and other mobility. It further revealed the resident took antianxiety and antidepressant medications in the 7-day look-back period. The Care Plan included antianxiety and antidepressant medication use but did not include resident specific target behaviors for staff to monitor or nonpharmacological interventions for staff to attempt. The Progress Notes dated 5/13/25 and 8/19/25 indicated the resident did not have behaviors or mood symptoms but failed to identify the resident's target behaviors. 3. The MDS assessment for Resident #50 dated 5/31/25 revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of heart failure, non-Alzheimer's dementia, and chronic obstructive pulmonary disease (COPD). It indicated the resident required setup assistance with eating, maximum assistance with oral hygiene and upper body dressing, and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility. It further revealed the resident took antianxiety and antipsychotic medications in the 7-day look-back period. The Care Plan did not include resident specific target behaviors for staff to monitor for antipsychotic medication use or nonpharmacological interventions for staff to attempt. The Progress Notes dated 1/07/25 indicated the resident scratched and swatted at staff but did not indicate for which diagnosis this behavior was associated. A Progress Note dated 6/11/25 indicated the resident refused cares and became verbal but did not indicate for which diagnosis this behavior was associated. On 8/26/25 at 1:28 PM, Staff B, Licensed Practical Nurse (LPN) stated residents' behaviors should be listed on their Treatment Administration Record (TAR) or Medication Administration Record (MAR). He stated neither resident had orders for their behaviors. He further stated since neither resident had an order on their TAR or MAR, staff should enter a progress note regarding behaviors. He confirmed he was not able to locate the resident specific target behaviors on either resident's Care Plan. On 8/28/25 at 8:34 AM, the Director of Nursing (DON) stated staff should have included the residents' target behaviors in their respective Care Plans. The facility policy Care Planning - Interdisciplinary Team, revision date March 2022, directed the following: - Resident Care Plans are developed according to the timeframes and criteria established by 483.21. - Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team.

Based on electronic health record review, staff interview, and policy review, the facility failed to update the Care Plan for 1 of 17 residents reviewed (Resident #9) for the discontinued use of a diuretic. The facility reported a census of 62. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 6/8/25 revealed Resident #9 with a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. Diagnoses on the MDS include Alzheimer's dementia, hypertension, and seizure disorder/epilepsy. The MDS noted the use of an anticonvulsant and no other high-risk drug. The Care Plan, with a target date of 9/14/25, listed the use of diuretic therapy for edema. This was initiated on 9/20/24. The Progress Noted dated 9/19/24 at 9:43 a.m. documented the use of Lasix, a diuretic, for three days due to edema (swelling) and tenderness to Resident #9's lower legs. The medication order history noted an order for Lasix from 9/19/24 to 9/22/24. The Order Summary Report, obtained on 8/28/25, did not list a current order for a diuretic. During an interview on 8/28/25 at 9:30 AM, Staff T, Unit Manager, explained they initiate and update resident Care Plans for the chronic confusion or dementia illness (CCDI) unit. This is completed upon admission, quarterly, and as needed with input from floor nurses. Staff T noted Resident #9 is not currently on a diuretic and acknowledged this was not removed from the Care Plan in a timely manner. The facility policy Care Planning-Interdisciplinary Team, revision date March 2022, stated the following:Resident Care Plans are developed according to the timeframe and criteria established by S483.21Comprehensive, person-center Care Plans are based on resident assessments and developed by an interdisciplinary team

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure safe and accurate delivery of oxygen therapy for one of three residents reviewed for respiratory care (Resident #71). The facility reported a census of 62 residents.Findings include:The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #71 had diagnoses of anemia, congestive heart failure, chronic respiratory failure with hypoxia and obstructive sleep apnea. The MDS documented that the resident had oxygen therapy. The MDS documented a Brief Interview for Mental Status score of 14 out of 15 for the resident, which is a score for cognitive status skills intact.The Care Plan documented a problem with initiated date 8/19/25 as follows; Resident #71 had altered respiratory status and difficulty breathing requiring oxygen. The Care Plan lacked documentation on oxygen flow rate or delivery method. It also indicated that Resident #71 could use Continuous Positive Airway Pressure (CPAP) on preset settings at night and as needed during the day if she requested it.The Physician's Orders indicated Resident #71 had oxygen that could be titrated to maintain oxygen saturations above 90% on nasal cannula (nc) initiated on 8/22/25. The Physician's Orders lacked an order for CPAP use. The orders were updated on 8/26/25 to indicate oxygen at 1 liter nc that may be titrated to keep oxygen saturation greater than 90%.The Progress Notes indicated that resident #71 was wearing CPAP during the night shift 5 times (8/20/25 at 2:26 a.m., and 8/24/25 at 12:58 a.m.) without indicating the oxygen flow rate to the CPAP machine. The Progress Notes (8/23/25 at 4:31 a.m., 8/20/25 at 2:26 a.m., and 8/24/25 at 12:58 a.m.) lacked documentation of Resident #71 wearing oxygen while sleeping during the day or that Resident #71 puts the CPAP on by herself. The Progress Notes also lacked assessment of respiratory status or pulse oximetry when wearing oxygen with the CPAP.The Vital Signs tab revealed that oxygen saturations were never less than 90% on room air. It further revealed that the oxygen saturation was only taken 4 times while the CPAP was on Resident #71 and once when oxygen was on at an unknown flow rate via nc.In an observation on 08/26/2025 at 1:26 PM Resident #71 was resting in bed with eyes closed wearing CPAP mask with 1 liter oxygen running to the CPAP machine.During an interview on 08/26/2025 at 1:30 PM Staff K, LPN stated that Resident #71 used the CPAP when she is sleeping and she puts it on by herself. It is usually at night but sometimes she puts it on during the day if she is sleeping.During an interview on 08/26/2025 at 1:38 PM Staff K, LPN stated that Resident #71 arrived with oxygen and thought it was at 2 liters but wasn't sure. He also stated that they check her pulse oximetry 2x daily. Staff K, LPN then stated that Resident #71's oxygen had not been adjusted as she was stable so it must have been 1 liter and not 2 liters. Staff K, LPN could not answer where the documentation indicating Resident #71 wears oxygen with her CPAP when she sleeps and not when short of breath.During an interview on 08/26/2025 at 2:30 PM The DON stated that if a resident had a CPAP, they must maintain it for themselves. He would not expect and order for CPAP as the staff does not assist. When asked if they would accept a CPAP with oxygen to it he stated he would have to assess it to see if they could meet the needs. The DON reported oxygen would need an order. When informed of Resident #71 having oxygen to her CPAP he was unaware. The DON stated he would not expect any documentation of oxygen in the chart if Resident #71 was putting on the oxygen herself. He added that she does what she wants to do.The Care Plan lacked documentation that the resident was assessed for self-administration of oxygen or CPAP, or was able to do so.In an interview on 08/27/2025 8:27 AM Resident #71 stated that she had oxygen at 1 liter to her CPAP every time it is on and she puts it on whenever she sleeps. She denied putting on oxygen because she is short of breath or because of low saturations. Resident #71 added that she checks her own pulse oximetry and had a finger machine in a chain around her neck. She takes care of the CPAP herself but stated that no one told her she had to she just does it herself. Stated she turns the machine off and on but does not adjust the machine. Stated not sure who set up the oxygen.In an interview on 08/27/2025 at 1:23 PM The DON stated that a CPAP should actually have an order. Stated that the Assistant DON did get an order yesterday after this surveyor asked about it. Stated Resident #71 was not short of breath as her saturations have all been above 90% and at 94% on room air when she admitted . He then stated that if resident is putting oxygen on with the CPAP despite not being short of breath, she is choosing to do so. The DON added that nursing should be documenting somewhere that she is using the oxygen. When questioned if the oxygen order should actually be at 1 liter when using the CPAP, he stated, I don't disagree. The DON denied having a policy on CPAP or oxygen use.

Based on observations, family interviews and staff interviews, the facility staff failed to provide sufficient staff to safely feed residents who required feeding assistance during three of three meals observed. The facility staff also failed to complete incontinence care for 1 of 2 residents reviewed for incontinence care (#2) in a timely manner. The facility reported a census of 62 residents.Findings include:1.On 8/25/25 at 1:30 pm, a family member of Resident #61 stated she comes to feed her family member daily every day for lunch and again for supper. She stated she feels if she is not there to feed him, he would not get feeding assistance. She added that when she arrives, there are other residents at the next table who require feeding assistance and often no staff is present, or if they are present, they are often on their phones rather than assisting the residents.On 8/26/25 at 5:25 pm, observation began for the evening meal. Resident #61 was at one table, with his family member assisting him to eat. Residents #8, #17, #23 & #64 were sitting at Table #2, all had meals in front of them. Staff L, Certified Nurse Aide (CNA) was sitting at table 2, assisting Resident #8 to eat her meal. The other three residents had food in front of them but nobody to assist them. Six minutes into the observation, Staff L stood and walked around the table and assisted Resident #17 to take some of his meal. At 5:32 pm, Staff M, CNA arrived to assist but only stayed for a moment and left again. She returned at 5:38 pm and sat to feed Resident #17. Staff L rotated to assist the other three residents. Staff N, CNA was observed entering and exiting the dining room periodically during the observation but never assisted any of the residents who required feeding assistance. On 8/26/25 at 5:55 pm, Staff L, CNA was asked if it was a common occurrence for her to be the only staff member to assist four different residents. She stated it varies. She added it is on the schedule for each hallway which staff member is supposed to assist in the dining room, and she had not been scheduled for the dining room. She had been scheduled to pass room trays but when room trays arrived, another staff member was all ready passing them, so she came to the dining room to assist. When the meal was over, it was observed that resident #64 had eaten 10-15% of her meal. During chart review the following day, Resident #64's meal record was recorded at having eaten 75-100% of her evening meal on 8/26/25. The documentation was recorded to have been done at 5:00 pm, prior to meal service. This was documented by Staff O, CNA, who was not observed to be in the dining room during the meal service. During clinical review of all staff members of the facility who were current in CPR training, which includes training for if a resident is choking, no staff members present in the dining room were noted to have the current training. On 8/27/25, at 9:23 am, the Director of Nursing reported if there was an emergency in the dining room, his expectation would be for the staff member to run and get a nurse to assist. He stated typically there are at least two CNAs scheduled to assist in the dining room. He said whichever staff member assists to feed a resident, it is their responsibility to chart how much the resident eats. On 8/27/25 at 10:02 am, Staff O, CNA stated the other staff member who was working on the hall with her that day gave her the information as to how much the residents ate. She stated she had completed all of the other charting except meal intake, and the other staff member told her how much they ate and she documented it. Lunch observation on 8/27/25 began at 11:35 am. Residents #8, #17, #23 & #64 were sitting at Table #2, all had meals in front of them with no staff present at the table with them. Resident #8, who had a diet order of puree diet with honey thickened liquids reached for her food with her fingers and began eating independently. Resident #8 was noted to be coughing lightly. After several minutes, Staff E arrived and sat to assist to feed Resident #17. Staff E then assisted Resident #8 to clean her hands and assist her to eat her meal. Breakfast observation began on 8/28/25 at 8:37 am. Resident #8 was observed with food in front of her, feeding herself, with no staff present at the table. Various facility staff were observed at the opposite end of the dining room. Resident #8 was again observed to be lightly coughing during when feeding herself. The Care Plan of Resident #8 directed staff she needed supervision and cueing for her meals, intervention dated 10/11/24. On 8/28/25 at 8:39 am, Resident #17 was heard stating loudly I would like to eat my breakfast as his food sat in front of him but no staff were present to assist him. At 8:42 am, Staff P, CNA arrived and began assisting both Resident #8 and Resident #17.Staff Q, CNA was at the next table assisting Resident #61. Staff Q was additionally walking throughout the dining room offering set up assistance to multiple other staff members and periodically returning to assist Resident #61. At 8:44 am, the MDS Coordinator arrived and sat to assist Resident #8. Resident #8 was noted to continue coughing lightly with intake. At 8:50 am, Resident #8's cough intensified, and the MDS Coordinator removed her from the dining room. At 9:04 am, Resident #8 was observed in the common area near the nursing station, with the MDS Coordinator assessing her, listening to her lung sounds and obtaining a pulse oximetry. She stated she had notified the hospice nurse of the morning episode and they would be arriving shortly. She stated she thought Resident #8 had probably aspirated some during breakfast. On 8/28/25 at 8:55 am, Staff P, CNA stated when the food was served to the eating assist residents, she was present at the table with them. She explained she got up and left the table to go to the other end of the dining room to assist others with set up assistance. She stated that Resident #8 is to be supervised when eating but it's ok to be in the general area and not directly at the table. On 8/28/25 at 12:20 pm, the Administrator stated she expects staff to be present in for feeding assist residents at the time their plates are served and should be assisting them throughout their meal. On 8/28/25 at 12:22 pm, the DON verified the two staff members discussed the prior day had no training on file for choking or performing the Heimlich maneuver. He again stated if there were an emergency with a resident, staff would need to get a nurse to assist. 2. On 8/25/25 at 11:47 AM, Resident #2 informed Staff C, Certified Nurse Aide (CNA) that he had a bowel movement and had not been changed. Staff C asked Resident #2 if it was ok to change him at that time. Resident #2 stated he would notify her to change him when he finished eating.At 11:48 AM, Resident #2 activated his call light and Staff C entered his room, turned off the call light, and exited his room within two (2) minutes.At 12:27 PM, Resident #2 stated he had not been cleaned of his bowel movement yet.At 12:54 PM, Staff C and Staff D, CNA entered another resident's room to assist her to the restroom per her husband's request.At 12:58 PM, Resident #2 stated he still had not been cleaned from his bowel movement.At 1:04 PM, Staff C and Staff D exited a resident's room with a mechanical lift and transported it to another resident's room.At 1:05 PM, Resident #2 activated his call light.At 1:12 PM, Staff C and Staff D entered Resident #2's room to clean him.The Minimum Data Set (MDS) assessment for Resident #2 dated 7/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, cerebral infarction (tissue damage caused by lack of blood flow to the brain), non-traumatic intracerebral hemorrhage (brain bleed), and constipation. It indicated he required setup assistance for eating, moderate assistance with upper body dressing, maximum assistance with oral and personal hygiene, and bathing, and was dependent with toileting, lower body dressing, and footwear.The Care Plan dated 1/09/25 directed staff to check the resident per schedule and assist with toileting as needed and to provide pericare after each incontinent episode. It also revealed he required two-person assistance for turning, repositioning, and toilet use.At 1:28 PM, the Director of Nursing confirmed the resident's call light was activated at 11:58 AM and again at 1:05 PM.On 8/27/25 at 11:11 AM, Staff E, CNA stated she did not recall Staff C asking her for assistance. She was on the hall the first half of the lunch shift.At 2:46 PM, Staff C stated she did not recall if she asked anyone for assistance with Resident #2 prior to Staff D helping her.On 8/28/25 at 8:32 AM, the Director of Nursing (DON) stated staff should have consulted for assistance when asked by the resident.A policy titled Activities of Daily Living (ADL), Supporting revised March 2018 indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. Hygiene (bathing, dressing, grooming, and oral care);b. Mobility (transfer and ambulation, including walking);c. Elimination (toileting);d. Dining (meals and snacks); ande. Communication (speech, language, and any functional communication systems)

Based on clinical record review, observation, staff interview and manufacturer's instructions, the facility failed to prime an insulin flexpen prior to administering the insulin dose to ensure the proper amount of insulin administered for one of one residents observed who received insulin during medication pass (Resident #72). The facility reported a census of 62 residents.Findings include:The electronic health record (EHR) Medical Diagnosis list revealed Resident #72 had a diagnosis of Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene. The Order Summary for Resident #72 dated 8/27/25 included a physician's order for insulin Aspart 10 units subcutaneously (SQ) two times daily for diabetes started on 8/25/25. It also included a physician's order for additional insulin Aspart on a sliding scale based on Resident #72's blood sugar results three times daily for diabetes started on 8/25/25.The Medication Administration Record (MAR) dated 8/1/25 - 8/31/25 revealed an order for insulin 10 units and an additional sliding scale dose based on Resident #72's blood sugar results SQ. The MAR revealed Staff B, Licensed Practical Nurse (LPN), documented Aspart insulin 10 units SQ with an additional 2 units for blood sugar of 234 milligrams per deciliter administered on 8/26/25/25.In an observation on 08/26/2025 at 11:22 AM Staff B, LPN reported that Resident #72's blood sugar was 234. Staff B, LPN attached a needle on the end of the Aspart insulin FlexPen and dialed the pen to 12. Staff B, LPN failed to prime the insulin pen prior to administering the dose.During an interview on 08/26/2025 at 11:30 AM Staff B, LPN stated he does not prime the insulin pens as someone told him with the current needles he did not have to. Staff B, LPN showed this surveyor the bottom of a new needle and stated the needle goes down further. Did not know who had told him this.During an interview on 08/27/2025 at 1:23 PM the Director of Nursing (DON) stated that insulin pens should be primed with 2 units and pushed to inject to get rid of any air that might alter the dose. Then dial to desired dose and give to the resident. The DON denied that the needles they use do not need to be primed. He also added that they have no policy for insulin pens and they follow the manufacturers guidelines.The manufacturer's guidelines for the Aspart insulin FlexPen indicate the proper use starting on page 81 and ending on page 84. The following are the listed steps for proper usage:a. Pull off the pen cap.b. Remove the paper tab from a new disposable needle. Screw the needle straight and tightly onto your FlexPen.c. Pull off the big outer needle cap and keep it for later.d. Pull off the inner needle cap and dispose of it. Never try to put the inner needle cap back on the needle. You may stick yourself with the needle.e. Turn the dose selector to select 2 units.f. Hold your FlexPen with the needle pointing upwards and tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge.g. Keeping the needle upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If a drop of insulin still does not appear, the pen is defective, and you must use a new one.h. Turn the dose selector to select the number of units you need to inject. The dose can be corrected either up or down by turning the dose selector in either direction until the correct dose lines up with the pointer. When turning the dose selector, be careful not to push the pushbutton as insulin will come out. You cannot select a dose larger than the number of units left in the cartridge.i. Inject the dose by pressing the push-button all the way in until 0 lines up with the pointer. Be careful only to push the push-button when injecting. Turning the dose selector will not inject insulin.j. Keep the push-button fully depressed and let the needle remain under the skin for at least 6 seconds. This will make sure you get the full dose. Withdraw the needle from the skin, then release the pressure on the push-button. Always make sure that the dose selector returns to 0 after the injection. If the dose selector stops before it returns to 0, the full dose has not been delivered, which may result in too high blood sugar level.k. Lead the needle into the big outer needle cap without touching it. When the needle is covered, carefully push the big outer needle cap completely on and then unscrew the needle. Dispose of it carefully and put the pen cap back on. The link for the manufacturer's guideline can be found at: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ema.[NAME].eu/en/documents/product-information/novorapid-epar-product-information_en.pdf

Based on record review, staff interview, and policy review, the facility failed to identify target behaviors for psychotropic medications (medications that affect a person's mental state, emotions, and behavior) for 2 of 5 resident (#28, #50). The facility reported a census of 62. Findings include: 1. 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #28 dated 8/10/25 revealed a Brief Interview for Mental Status (BIMS) score was not established because the resident was rarely or never understood. The MDS documented diagnoses of cerebral infarction (tissue damage caused by lack of blood flow to the brain), non-Alzheimer's dementia, anxiety, depression, sarcopenia (age-related loss of muscle mass, strength, and function), and quadriplegia. It indicated the resident required setup assistance with eating, maximum assistance with oral and personal hygiene, upper body dressing, and rolling left-to-right in bed, and was dependent with all other Activities of Daily Living (ADLs) and other mobility. It further revealed the resident took antianxiety and antidepressant medications in the 7-day look-back period. The Care Plan with a target date of 11/24/25 documented antianxiety and antidepressant medication use but did not include resident specific target behaviors for staff to monitor for or nonpharmacological interventions for staff to attempt. The Progress Notes dated 5/13/25 and 8/19/25 indicated the resident did not have behaviors or mood symptoms but failed to identify the resident's target behaviors.2. 2. The Annual Minimum Data Set (MDS) assessment for Resident #50 dated 5/31/25 revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated severely impaired cognition. The MDS documented diagnoses of heart failure, non-Alzheimer's dementia, and chronic obstructive pulmonary disease (COPD). The MDS indicated the resident required setup assistance with eating, maximum assistance with oral hygiene and upper body dressing, and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility. It further revealed the resident took antianxiety and antipsychotic medications in the 7-day look-back period.The Care Plan did not include resident specific target behaviors for staff to monitor for antipsychotic medication use or nonpharmacological interventions for staff to attempt. The Progress Notes dated 1/07/25 at 8:05 a.m. documented the resident scratched and swatted at staff but did not indicate for which diagnosis this behavior was associated.Nurses Note on 4/14/25 at 9:00 a.m. documented as follows; This nurse attempted to give resident her medication and resident pulled away. This nurse reminded resident that it was important to take her medication and she threw the cup of water she washolding in this nurses face and chest. It was at that moment no further attempts were made, but did not indicate for which diagnosis this behavior was associated.A Social Service Note dated 6/11/25 at 12:49 documented as follows the resident does have behaviors at times, she may refuse cares and get verbal.A Pharmacist's Recommendation to Prescriber dated 4/14/25 recommended a Gradual Dose Reduction (GDR) for Resident #50's antipsychotic medication. The physician declined the GDR recommendation due to psychotic disorder with delusions due to known physiological condition but did not include resident specific target behaviors.On 8/26/25 at 1:28 PM, Staff B, Licensed Practical Nurse (LPN) stated residents' behaviors should be listed on their Treatment Administration Record (TAR) or Medication Administration Record (MAR). He stated neither resident had orders for their behaviors. He further stated since neither resident had an order on their TAR or MAR, staff should enter a progress note regarding behaviors. He confirmed he was not able to locate the resident specific target behaviors on either resident's Care Plan.On 8/26/25 at 1:45 PM, Staff D, Certified Nurse Aide (CNA) stated Resident #50's behaviors included scratching, biting, and kicking and she documents observed behaviors in the Electronic Health Record (EHR). She also stated she has never been provided a list of resident specific behaviors for Resident #28 or #50. She indicated the resident specific target behaviors were not identified in documentation but stated all residents who receive psychotropic medications have the same behavior symptoms list in their EHR.On 8/26/25 at 2:30 PM, Staff F, Certified Medication Aide (CMA) stated she had not been told which resident specific target behaviors were on the behavior symptoms list.On 8/27/25 at 7:53 AM, Staff G, LPN, stated she was new and didn't know the residents very well. She stated Resident #50 sometimes refused her meds was what she had been told. She was not able to locate the residents' specific target behaviors.At 9:36 AM, Staff H, Assistant Director of Nursing (ADON) stated she didn't know the residents well because she'd only been there for 3 weeks.Both residents' EHR included MARs which revealed both residents received their psychotropic medications but lacked resident specific target behaviors. It also revealed Resident #50's EHR did not include a behavior symptoms list.Neither residents' Physician Orders included resident specific target behaviors for psychotropic medication use.On 8/28/25 at 8:27 AM, the Director of Nursing (DON) stated staff should have clarified the target behaviors with prescribing providers.A policy titled Psychotropic Medication Use revised 2022 indicated consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to appropriately provide assessments and interventions for necessary care and services for 1 of 4 residents reviewed (Resident #1). Clinical record review revealed the Assistant Director of Nursing notified the nursing staff of a wound on Resident #1's left foot after admission. The nurse failed to conduct an assessment and failed to notify the provider to acquire an intervention for 48 days after admission. The facility reported a census of 61 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that Resident #1 admitted to on 9/23/25 from Home/Community (e.g., assisted living). This MDS documented that Resident #1's diagnoses included diabetes, Alzheimer's disease, functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without damage to the spinal cord), bipolar disorder, and polyneuropathy (nerve damage that affects the hands and feet). A Brief Interview for Mental Status (BIMS) for Resident #1 revealed a score of 12 out of 15, which indicated moderately impaired cognitive functioning. Resident #1 required substantial/maximal assistance (Helper does more than half of the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort.) for shower/bathing, upper body dressing and lower body dressing. Resident #1 was dependent (Helper does all of the effort, resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) on putting on/taking off footwear. Resident #1 required substantial/maximal assistance for rolling left to right in bed, sitting to lying in bed, Lying to sitting in bed, sitting to stand, chair/bed transfer and toilet transfer. This resident was dependent on staff for wheelchair assistance. This MDS documented that Resident #1 had no diabetic foot ulcers identified nor did she have an infection of the foot and was not on a turning repositioning program. It documented that Resident #1 had no other open lesions on the foot. Care Plan dated 9/23/24 directed staff as follows: Check all of the body for breaks in skin and treat promptly as ordered by the doctor. Don't use over the counter remedies for corns and calluses, refer to a podiatrist to treat. Educate the resident and family that diabetes is a chronic disease and that compliance is essential to prevent complications of the disease. Review complications and prevention with the resident and family. Elicit verbal understanding from the resident and family. The nails should always be cut straight across, never cut corners and file rough edges with emery board. The Medication and Treatment Administration Record (MAR/TAR) for September and October 2024 failed to identify an intervention for Resident #1's wound to the left foot. The progress notes for Resident #1 revealed: 1. On 9/23/24 at 12:56 admitted resident #1, an assessment completed by Staff D, MDS Coordinator, no skin issues were identified and no swelling in the feet. 2. A late entry on 9/23/24 at 12:57 PM, a wound on the left foot, resident #1 placed on enhanced barrier precautions and staff was notified. Documented by Staff E Assistant Director of Nursing (ADON). 3. On 9/27/24 Staff F, Medical Director (MD) conducted a in house visit for Resident #1 and ordered a Chest x-ray (CXR) due to resident wheezing. 4. On 10/26/24 at 2:11 PM Resident #1 fell to the floor. 5. On 10/29/24 Resident #1 was seen by Staff F and aware of the fall. 6. On 11/10/24 a Certified Nursing Assistant (CNA) reported to a nurse that there was blood on EZ stand platform (stand up lift) after a transfer of Resident #1 and blood on a sock. The CNA noted a wound bottom of Resident #1's left (lt)foot. The wound bed was black and foul smelling and measured 3 centimeters (cm) x 3 cm with a blood blister above this that was intact that measured 1.5 cm x 1 cm. The foot was cleansed, a protective foam boot was applied. The top of the lt foot was red, warm, and Resident #1 had a temperature of 97.1 and denied pain. The nurse notified Staff F, Physician and received a new order for (antibiotics) Cephalexin 500 milligrams (mg) given three times a day (TID) for 7 days. The daughter was notified. 7. On 11/12/24 Staff F examined the diabetic wound, continued betadine treatment two times a day (BID) and ordered a consult by the wound nurse. An X-ray was ordered to rule out osteomyelitis (Infection of the bone) and Levofloxacin 250 mg for 7 days, in addition to the Cephalexin antibiotic. 8. On 11/11/24 the wound nurse documentation of a diabetic wound that measured 3.5 x 3 cm, an in house acquired wound, unknown how long the wound was present, the odor had increased. During an interview on 4/24/25 at 9:32 AM, Staff E, ADON stated she had worked in this facility for 1.5 years, and had taken over the wound nurse position recently. Staff E explained in the past, if a wound was identified, the nurse would notify the physician, receive an order for treatment, then notify the family. Staff E stated when Resident #1 was admitted in September 2024, Staff D, MDS Coordinator would have completed the admit assessments. Staff E stated she had identified the wound to Resident #1's left foot and notified the staff nurse. Staff E stated the expectation was that the nurse would have notified the physician, received an order for treatment and notified the family. Staff E stated it was the nurses responsibility at that time. Staff E stated she did not see the wound again until it was identified by a CNA in November 2024. Staff E stated that was when she had taken over the admit assessments, for early identification of wounds. Staff E stated the facility had a large number of agency nurses last fall, communication was difficult and she didn't want to see anyone get hurt due to that negligence. Staff E stated she was the current wound specialist and if staff finds a wound, she would assess it, all of the body parts, then scan the results to Staff G, Doctor of Nursing Practice (DNP) who will provide an assessment, order a treatment and monitor the wound until it is healed. Staff E stated nurses conduct weekly wound checks. Staff E stated Resident #1 was placed on skin assessments on Wednesday's during showers and was compliant with care. During an interview on 4/24/25 at 10:09 AM, Staff G, DNP stated she became the wound nurse in November 2024. Staff G stated she had examined Resident #1 on 11/21/24. Staff G explained that when Staff E, ADON becomes aware of a wound, she would scan a note to Staff G's office and will put the resident on the wound sheet and if the resident had a consent on file then Staff G would come to the facility and examine the resident. Staff G stated Staff E had been her contact person since 11/2024. Staff G stated her assessment of Resident #1's left foot wound revealed 95% slough (a yellow, white devitalized tissue that accumulates in a wound bed) with moderate serosanguinous drainage and did not note an odor. Staff G stated she had ordered betadine moistened gauze, secured with tape two times a day (BID) and apply foam boots (Prevolone). Staff G explained the picture of Resident #1's left foot that she had initially reviewed could not have developed overnight. Staff G was not aware of when Resident #1 acquired the wound or she would have documented, staff did not advise her when it was first identified. Staff G stated Resident #1 was transferred with a mechanical lift at that time. Staff G stated she was not aware if the facility staff conducted daily diabetic foot checks. Staff G stated Resident #1's wound was healed, fully resolved, by 2/13/25. Staff G stated she feels the facility staff are making good progress. A policy titled Procedure for Identifying a New Skin Area dated 11/9/20 revealed: 1. Assess the area and notify the physician by fax, phone or in person if the provider is in the facility. 2. Implement treatment if ordered. 3. Notify family, power of attorney (POA) or responsible party. 4. Complete an incident report in Point Click Care (PCC) computer. 5. Notify the DON if the skin area requires treatment at a higher level of care (hospital or ER). A policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 2001 revealed: 1. The nurse and physician will assess significant risk factors (immobility, weight loss, history of ulcers). 2. The nurse shall describe and document a full assessment of the pressure sore, assess pain, the resident's mobility status, current treatments and all active diagnoses. 3. The staff will examine the skin of a new admission for ulcerations or altercations in skin. 4. The physician will assist to determine etiology and characteristics of the wound infection. 5. The physician will help identify the contributing factors to skin breakdowns (medical comorbidities such as diabetes). 6. The physician will help identify medical interventions related to wound management (treatment). During an interview on 4/23/25 at 3:39 PM, The Director of Nursing (DON) stated the expectation of the nursing staff was that assessments are to be completed on a timely basis and temporary interventions put into place until the Interdisciplinary Team (IDT) can evaluate the situation. The DON stated he felt that the nurses can evaluate and respond quickly. Management had discussed annual competencies for nursing. The management conducted monthly inservices a daily huddle with therapy and dietary.

Based on observations, staff interviews, clinical record review, and policy review, the facility failed to follow enhanced barrier precautions (EBP) practices for residents with indwelling medical devices for two of three residents reviewed for infection control (Resident #54 and Resident #117). The facility also failed to ensure infection control policy & procedure manual updated on an annual basis. The facility reported a census of 62 residents. Findings include: 1. Infection control manual review completed on 10/3/24 at 8:30 AM. The manual did not include a cover page to indicate the enclosed policies and procedures had been reviewed and approved annually. An interview on 10/3/24 at 8:45 AM, the Director of Nursing (DON) reported policies and procedures are approved annually during the facility's January Quality Assurance and Performance Improvement (QAPI) meeting. The DON provided a copy of January's QAPI sign-in sheet as well as a copy of a Record of Adoption form, which was not completely filled out. The form provided no information as to what policies or procedures were approved, did not have the medical director signature, nor did it indicate a date of approval. The DON reported that January 2024 QAPI meeting minutes did not reflect approval of the infection control manual. All that was attached to the meeting minutes was the incomplete Record of Adoption form. The undated policy Facility Policies and Procedures-Annual Review stated policies and procedures are reviewed and revised by the Quality Assurance and Assessment Committee: a. When changes in regulations or professional standards of practice necessitate revisions. b. When additional procedures are needed according to the facility assessment and/or individual resident needs. c. At least annually. The policy further stated administrators, the medical director, and department leaders are sent draft revisions with an opportunity to review and respond to changes. Final revisions are posted for staff with a summary of changes and effective date. 34817 2. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had a diagnosis of sepsis due to e-coli (bacteria). The MDS revealed the resident had a tube feeding. The Care Plan initiated 9/19/24 revealed the resident required tube feedings. The Care Plan lacked directives for staff to use enhanced barrier precautions (EBP). During observation on 10/2/24 at 7:25 AM, Staff A, Licensed Practical Nurse (LPN) prepared and administered medications and enteral feeding through Resident #117's gastrostomy tube (g-tube) (a tube in the stomach). Staff donned gloves and placed supplies and medications on an over-bed table without a barrier. Staff A did not wear a gown during the procedure when she handled the g-tube and when she administered medications and tube feeding through the g-tube. During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported EBP's still a new process. EBP's entailed wearing a gown and gloves whenever she touched or worked with a resident with a catheter, g-tube, or open wounds. During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported the facility didn't have a policy for EBP's, he expected staff to follow the CDC guidelines. EBP's should be used whenever a resident had a wound, catheter, and any medical devices such as a catheter, g-tube, or PICC line. A Personal Protective Equipment (PPE) policy revised 10/2018 revealed PPE provided for personnel who perform tasks that may involve exposure to blood or body fluids. PPE included wearing a gown and gloves. The type of PPE required for a task was based on the risk of an exposure. The Center for Disease Control (CDC) guidelines for Enhanced Barrier Precautions in Nursing Homes (https://www.cdc.gov/long-term-care-facilities/media/pdfs/Letter-Nursing-Home-Staff-508.pdf) revealed the CDC recommends EBP to prevent the spread of multi-drug-resistant organisms (MDROs) in healthcare settings. EBP guidelines include a gown and gloves worn during high-contact care activities with residents who are at higher risk of acquiring or spreading an MDRO. EBP used when cared for a resident with an indwelling medical device. 3. The MDS assessment dated [DATE] revealed Resident #54 had a diagnosis of cancer. The MDS indicated the resident took an antibiotic and had an IV access. The Care Plan initiated 9/3/24 and revised on 9/30/24 revealed the resident on antibiotic therapy. The Care Plan directed staff to administer medication and monitor the IV site for signs of redness, warmth, drainage or swelling. The Care Plan lacked information about the resident's peripherally inserted central catheter (PICC) line and Mediport (port), and the need to use EBP. During observations on 10/1/24 at 8:08 AM, Staff B, LPN, accessed and flushed Resident #54's PICC line with normal saline, and initiated an IV cefazolin (antibiotic) infusion through the resident's PICC line. At 8:20 AM, Staff B, flushed the resident's port with normal saline, then administered cefazolin into the port. At 8:53 AM, Staff B checked the IV cefazolin infusion and pump and reported the infusion completed. Staff B donned a pair of gloves, removed the IV tubing from the PICC line, cleansed the end of the PICC line with an alcohol swab, and flushed the PICC line with normal saline. Staff B cleansed the PICC line with an alcohol swab, and attached a new cap on the PICC line. Staff B removed her gloves and washed her hands. Staff B did not wear a gown during the procedure while she handled and cared for the PICC line and port. During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported the facility didn't have a policy for EBP's, he expected staff to follow the CDC guidelines. EBP's should be used whenever a resident had a wound, catheter, and any medical devices such as a catheter, g-tube, or PICC line.

Based on clinical record review, staff interview, and the Resident Assessment Instrument (RAI) Manual the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one of sixteen residents reviewed (Resident #4). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment completed on 9/13/24 revealed Resident #4 readmitted to the facility on [DATE] from the hospital and had a diagnosis of coronary artery disease. The MDS documented the resident took an anticoagulant medication during the 7-day look-back period. The Care Plan initiated on 4/18/23 revealed the resident on anticoagulant therapy but the problem was resolved (removed) from the Care Plan on 4/30/23. The Order Summary revealed Eliquis (Apixaban) (an anticoagulant) 5 milligrams (mg) by mouth two times a day for DVT (deep vein thrombosis) (blood clot) for three months started on 3/22/24 and discontinued on 6/22/24. The Medication Administration Record (MAR) revealed Eliquis 5 mg by mouth two times a day related to coronary artery disease discontinued on 7/9/24 at 2:30 PM. The MAR dated 9/2024 revealed an order for aspirin 81 mg by mouth every morning. During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported she obtained information from the resident's record, interviewed the resident and family, and also gathered information about the resident while she provided cares in order to complete and update the resident's Care Plans. Staff C reported Resident #4 no longer took Apixaban. The medication was discontinued on 7/9/24. The RAI Manual Version 3.0 revealed MDS assessment section N0410E marked when a resident took an anticoagulant such as warfarin, heparin, or a low- molecular weight heparin. Record the number of days the resident received an anticoagulant medication during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin.

Based on clinical record review, observation, staff interview, and policy review the facility failed to develop and implement a comprehensive person-centered Care Plan for one of sixteen residents sampled (Residents #54). The facility reported a census of 62 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 admitted to the facility on [DATE] and had diagnoses of cancer and a pleural effusion. The assessment documented the resident took an antibiotic during the 7-day assessment look-back period and received IV (intravenous) (into a vein) medications during the 14-day look-back period. The Care Plan initiated on 9/3/24 and revised on 9/30/24 revealed Resident #54 on IV antibiotic therapy. The Care Plan directed staff to administer antibiotic medications as ordered by the physician, and monitor for the effectiveness and side effects of the medication. The Care Plan lacked information about the resident's PICC (peripherally inserted central catheter) line or Mediport (port) (an implanted device that provides access to a vein for delivering medications and fluids), as well as the interventions to monitor and manage these devices. The Order Summary Report revealed PICC and port dressing change every 7 days and PRN (as needed) started on 9/3/24. Resident #54's Medication Administration Record (MAR) for October 2024 documented orders for cefazolin 15 milligrams (mg) IV in the morning, for a port infection, had a start date 9/4/24 at 6:00 AM. The MAR also instructed to administer cefazolin 2 grams (gm) IV twice a day for MSSA (methicillin-susceptible staphylococcus aureus) (a bacterial infection) started on 9/3/24 at 9:00 PM. The Skilled Nursing assessment dated [DATE] revealed the resident had a diagnosis of multiple myeloma and took chemotherapy. The assessment documented the resident received IV antibiotic medications, and had a PICC line and an implanted port. The Progress Notes dated 9/7/24 at 9:36 AM revealed the resident had a chest port to the right chest and a PICC line to his left upper arm. During observation on 9/30/24 at 2:11 PM, Resident # 54 had a PICC line in his left arm and a port to his right chest. During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported she obtained information from the resident's record, interviewed the resident and the family member(s), and also gathered information about the resident while she provided cares in order to complete and update the resident Care Plans. Staff C reported the resident's Care Plan developed at admission and updated any time a resident had a change in status. Staff C reported the PICC line and Mediport should be listed on the Care Plan if a resident had these medical devices. During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported the resident's Care Plan updated whenever needed, and Care Plans reviewed during the resident's care conferences. An interdisciplinary team reviewed the Care Plans. A Comprehensive Person-Centered Care Plan policy revised 3/2022 revealed a comprehensive care plan developed for each resident. The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment. The care plan included measurable objectives and time-frames and described the services furnished to attain or maintain the resident's highest practicable physical and psychosocial well-being.

Based on clinical record review, observations, staff interview, and policy review the facility failed to check and verify placement of a gastrostomy tube (g-tube) before medications and enteral feeding administered through the gastrostomy tube for one of one residents reviewed with a gastrostomy tube (Resident #117). Facility staff also failed to flush the gastrostomy tube with water after each medication administered. The facility reported a census of 62 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had diagnoses of sepsis due to e-coli (bacteria), gastroesophageal reflux disease (GERD), diabetes, and dysphagia. The MDS revealed the resident had coughing and choking during meals or when she swallowed medications, and had a tube feeding. The Care Plan initiated 9/19/24 revealed the resident required tube feedings. The Care Plan directed staff to check tube placement, check gastric contents/residual volume before each feeding started and hold the feeding per the physician's orders depending upon the amount of aspirate. The Order Summary Report dated 10/2024 revealed an order to crush medications as needed unless contraindicated but lacked directives for checking g-tube placement or residual. During observation on 10/2/24 at 7:25 AM, Staff A, Licensed Practical Nurse (LPN) prepared medications for Resident #117. Staff A crushed each medication in a clear plastic envelope then took the medications to the resident's room. The medications included the following: 1. Diltiazem 60 milligrams (mg) 2. Aspirin 81 mg 3. Levothyroxine 100 micrograms (mcg) 4. Vitamin D3 5000 units 5. Vitamin B12 1000 mcg 6. Pregabalin 200 mg 7. Metformin 500 mg 8. Biotin 10000 mcg 9. Azithromycin 250 mg 10. Culturelle 1 package Staff A donned gloves, obtained a glass of tap water and placed the glass on an over-bed table. Staff A poured 300 milliliters (ml) of Glucerna 1.2 calories into a graduate container and placed the container on an over-bed table. Staff A connected a syringe to the resident's g-tube and administered 60 ml of water. Staff A poured an envelope of crushed medication into a small plastic cup, added 10 ml water, and used the tip of the syringe to stir the medication and water. Staff A drew the medication solution into the syringe, attached the syringe to the g-tube, and administered the medication. Staff A continued to repeat the process of placing crushed medication into a plastic cup, adding water to the cup, stirring the medication, and administered each medication individually until all medications were administered. On 10/2/24 at 7:52 AM, Staff A rinsed the syringe and plastic cup with water in the bathroom. Staff A changed her gloves, then connected the syringe to the resident's g-tube, poured 60 ml of water into the syringe, then poured Glucerna formula into the syringe. Staff A allowed the contents to gravity flow until all of formula instilled. Staff A then poured 60 ml of water into the syringe, removed the syringe, and plugged the g-tube port. Staff A removed her gloves and washed her hands. Staff A did not check placement of the g-tube prior to administering medications, water flushes, and tube feeding through the g-tube. Staff A also did not administer a water flush between each medication administered. During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported placement of a g-tube checked prior to administration of medication and tube feedings. Staff C reported a stethoscope used to listen over the gastric area to hear air as it is pushed through the syringe to verify g-tube placement. Staff C stated a syringe attached to the g-tube and the handle of the syringe pulled back to check for residual or gastric contents. Staff C reported the g-tube should be flushed with 15 ml of water between each medication administered through a g-tube. During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported he expected a g-tube be checked for placement by listening with a stethoscope prior to administration of medications or tube feedings. The g-tube residual checked per physician's orders. The DON reported he expected g-tube medications be administered separately unless they had a physician's order to mix (cocktail) the medications. The DON stated a 15 ml water flush should be administered between each g-tube medication. An Administering Medications through an Enteral Tube policy dated 2001 revealed guidelines for safe administration of medications through an enteral tube. Each medication administered separately and g-tube flushed between medications. Use warm, purified water for diluting medications and for flushing the g-tube. The procedural steps included: a. Wash hands b. Prepare the medications c. Verify placement of feeding tube d. Flush tubing with at least 15 ml warm water e. Dilute the medication with at least 30 ml of water f. Administer each medication separately g. Flush with 15 ml warm water between medications if administering more than one medication. h. Flush the g-tube with 15 ml of water after the last medication administered i. Clamp the g-tube j. Administer the feeding.

Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to provide assessments and timely intervention regarding skin conditions and wounds for one of sixteen residents observed (Resident #15). The facility reported a census of 62 residents. Findings include: The quarterly Minimum Data Sample (MDS) for Resident #15, dated 09/06/2024, which documented relevant diagnoses of cancer, heart failure, diabetes mellitus (diabetes), cerebrovascular event, Non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, and depression. It documented her brief interview for mental status (BIMS) score as 12, indicating moderate cognitive impairment. The Care Plan, last revised 06/17/2024, revealed staff were to check all of the body for breaks in skin and treat promptly as ordered by doctor. It also revealed staff were to monitor and document any signs and symptoms of hyperglycemia, such as dry skin. A direct observation on 09/30/2024 at 03:09 PM revealed Resident #15 had a red lesion with a dark colored scab in the center on her right cheek bone. Resident #15 was observed picking at the wound at this time. A direct observation on 10/01/2024 at 12:11 PM revealed the wound had gotten visibly darker. In an interview on 10/01/2024 at 02:51 PM with Staff D, Registered Nurse, stated she had been aware of the wound for a little over a week. She believed it had been documented either through a nursing Progress Note or placed on a skin assessment sheet in the skin assessment chart, located on the unit. Staff brought the book to this surveyor and could not find a skin assessment had been performed. Staff then stated she must have forgotten. She stated the medical director had not been made aware of this wound yet. Review of nursing Progress Notes failed to document a skin assessment for this wound. In an interview on 10/02/2024 at 09:33 AM with Staff E, Unit Manager, stated the skin issue was a recurrent patch of dry skin on Resident #15's face. She acknowledged the skin assessment had not been performed, and stated her expectation is for staff to fill out a skin assessment sheet when they notice a new or reopened wound and to place a note in the electronic health record (EHR) for tracking. Review of a facility provided document titled Resident Assessments, last revised in March of 2022, documented all staff members are to participate in resident assessment.

Based on clinical record review, staff interview, facility policy review, and the Resident Assessment Instrument (RAI) Manual, and policy review, the facility failed to complete and transmit a resident Minimum Data Set assessment upon a resident's discharge within the required timeframe for one of sixteen residents reviewed (Resident #58). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 5/12/24 revealed the Director of Nursing (DON) signed the assessment as completed on 5/15/24. The MDS assessment dated [DATE], revealed Resident #58 admitted to the facility on [DATE], and discharged from the facility on 5/22/24. The MDS assessment revealed the DON signed the assessment as completed on 6/2/24. The Electronic Health Record (EHR) software program revealed the 5-day MDS assessment completed on 5/15/24 but not submitted to CMS (Center for Medicare Services). The EHR also revealed the discharge return not anticipated MDS assessment dated [DATE] was completed on 6/2/24 but not submitted to CMS. During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported she had worked at the facility in the MDS Coordinator role since 3/2024. Staff C reported the MDS assessments completed on each resident at least every 90 days. She obtained information from the resident's record, interviewed the resident and family, and also gathered information about the resident while she provided cares in order to completed the MDS assessments. Staff C reported she submitted the MDS assessment to CMS once all of the MDS sections were completed. Staff C reported Resident #58's discharge MDS not submitted when the discharge MDS assessment was completed because he had a private insurance plan. He did not have a Medicare Part A policy, so the MDS assessment did not need to be submitted. Staff C reported Resident #58's admission MDS assessment was submitted to CMS for tracking purposes only. A Resident Assessments policy revised 3/2022 revealed assessments completed at intervals designated by OBRA (Omnibus Budget Reconciliation Act) (the Nursing Home Reform Act) and PPS (Prospective Payment System) requirements. The resident assessment coordinator ensured resident assessments completed timely. OBRA required discharge assessment completed for all residents including discharge return anticipated and return not anticipated. The RAI Manual Version 3.0 revealed the discharge return not anticipated MDS assessment must be completed when the resident discharged from the facility and the resident not expected to return to the facility within 30 days. The discharge return not anticipated MDS must be completed within 14 days after the discharge date , and submitted within 14 days after the MDS completion date.

Based on clinical record review, facility document review, and staff interview, the facility failed to treat a resident with respect and dignity when providing cares one of three residents reviewed for dignity (Resident # 9). The facility reported a census of 61 residents. Findings include: A Quarterly Minimum Data Set (MDS) Assessment documented Resident#9 had the diagnoses including non- traumatic brain dysfunction, dementia, high blood pressure, and stroke. The Brief Interview for Mental Status (BIMS) documented the resident scored a 3 out of 15, which indicated severe cognitive loss for daily decision making skills. The MDS revealed the resident required maximum assist of two staff members for transfers from surface to surface, and total dependence for cares including toileting, and showers. The MDS indicated that the resident used a manual wheelchair for moving about the facility with total dependence of staff. A facility Self Report dated 8/5/24 revealed Staff A, Certified Nurse Aide (CNA) reported an allegation that Staff B, Certified Medication Aide (CMA), while assisting a resident who became verbally aggressive and combative with cares, attempted to place a glove in the resident's mouth. The self report additionally documented Resident #9 stated he wished he wasn't in the facility and Staff B responded to the resident in an unkind and demeaning manner. On 8/6/24 at 12:53 pm, Staff A, CNA stated she was in the room of Resident #7, which he shares with his spouse, on the evening of 8/4/24 with Staff B, CMA. She stated both residents have behaviors. She explained she and Staff B were getting both residents ready to go to dinner and Resident #7 was speaking about not wanting to live in the nursing facility. She reported Staff B replied to Resident #7 that his children don't care about him and that is why he lived there. She stated Staff B needed to change the resident's soiled clothing and after she was through, Staff B removed her soiled gloves and balled the gloves up into her hand and put them towards the mouth of Resident #7 while telling him to Shut up. She stated Resident #7 closed his lips. She stated she could not say if Staff B was trying to put the gloves in the resident's mouth but they were near his mouth. Staff A stated the rest of the shift was busy and the incident slipped her mind and she did not report this until the following day. She stated she reported it to Staff C, Licensed Practical Nurse (LPN) the morning of 8/5/24. On 8/6/24 at 3:52 pm, Staff C, LPN stated Staff A reported her concerns regarding Staff B and Resident #7 to her, stating Staff B was being aggressive and mean to the resident. She stated she immediately called the manager on duty for the facility and reported this to her. The facility provided an educational memo to all staff on 8/6/24. The memo included direction to staff as follows; a. Emotional Abuse defined as verbal or non-verbal behavior that causes psychological harm. b. Reports should be made even if you are unsure about the validity of the suspicion, it is better to report and let authorities investigate. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. The facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, revision date July 2019, documented the following: Key Definitions: Personal degradation of a dependent adult. Personal degradation means a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person. Personal degradation includes the taking, transmission, or display of an electronic image of a dependent adult by a caretaker, where the caretaker ' s actions constitute a willful act or statement intended to shame, degrade, humiliate, or otherwise harm the personal dignity of the dependent adult, or where the caretaker knew or reasonably should have known the act would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person

Based on clinical record review, observation and staff, resident, family and physician interviews, the facility failed to ensure staff provided sufficient transfer assistance and careplanned interventions to prevent accidents for 2 of 5 residents reviewed (Residents #13, #4 and # 20). A staff member attempted to move Resident #13 alone, although the resident required the assistance of 2 staff. Resident #13 fell from the edge of bed and received a [MEDICAL CONDITION]. Facility staff failed to ensure planned fall prevention interventions were in place for Resident #4. Staff also failed to use a gait belt to transfer Resident #20. The facility identified a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 had [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive and memory impairment. Resident #13 sometimes had the ability to make herself understood and understand others. She displayed physical and verbal behaviors 1 to 3 days a week. The resident required the assistance of 2 staff with bed mobility, transfers, dressing and personal hygiene; she did not walk during the assessment timeframe. The assessment documented she had no history of falls. The resident's Care Plan (with the problem area not dated) indicated she had an activities of daily living (ADL's) self care performance deficit related to (r/t) decreased mobility, chronic pain and limited range of motion (ROM) to her right upper extremities (RUE) and her bilateral (both) lower extremities (BLE). The interventions/tasks included the following: a. Bed mobility with 2 staff assistance. b. Transfers with 2 staff assistance with an EZ stand lift device and she used a wheel chair for locomotion propelled by staff. A care card available in the facility's Point Click Care (PCC) computer program available for all staff (also not dated) indicated the residents ADL requirements included the following: a. Bed mobility with 2 staff assistance. b. Transfers with 2 staff assistance with an EZ stand lift device and used a wheel chair for locomotion propelled by staff. A Fall Risk Assessment Form dated 9/12/18 indicated a score of 40 which placed her at a medium risk for falls. An Incident Report form dated 11/29/18 at 8:30 a.m. documented the nurse was called to the resident's room by a Certified Nursing Assistant (CNA) with the resident on the floor. The CNA's reported Resident #13 slid off the bed to the floor with cares. The resident layed on the floor with her body resting over the legs of the EZ stand lift device with her feet toward the window, her head toward the room door, dressed on the lower half of her body with a pajama top and well fitted shoes on her feet. The resident's left leg extended out and her right leg bent at the the knee and rested under her left leg. Staff guided the resident's head to the floor without having hit her head. The bed had been in the low position with the EZ stand legs partially positioned under the bed. The resident screamed at the CNAs stating it hurt. The nurse lifted the resident slightly and pulled the EZ stand out from under the resident. The resident rested on the floor with a pillow under her head. The nurse asked if her legs could have been extended out and the resident stated yes as the resident moved her legs with the nurse's assistance. The resident lifted her legs up and down herself and per baseline. Staff lifted the resident to bed with the assistance of 4 as the resident yelled 'it hurts' and 'I slid off the bed'. The resident could not provide details due to (d/t) anxiety and confusion. Morning medications including routine [MEDICATION NAME] (narcotic pain medication) given. Staff contacted the physician who ordered a STAT (immediate) X-ray order for the right hip and right lower extremity (RLE) including the knee, tibula, fibula and femur. Vital signs obtained recorded a blood pressure (B/P) 164/85, pulse (P) 91, respirations (R) 24, temperature (T) 98.6 degrees Fahrenheit (F) and a pulse oxygenation (PO2) rate of 90% and the resident as alert and oriented x 2. Staff left a message for the resident's son with a follow up call after the X-ray results were received at 11:15 a.m. Staff obtained orders and sent Resident #13 to the hospital emergency room (ER). The resident transported to the ER for an evaluation and treatment per an ambulance service at 12:30 p.m. due to a 90 minute wait from the ambulance service. An X-ray report form dated 11/29/18 at 1:26 p.m. indicated Resident #13 received an obliquely oriented and displaced distal right femoral diametaphyseal shaft fracture. A Main OR (operating room) Intraop final report form dated 11/30/18 at 12:51 p.m. recorded Resident #13 received a surgical repair of her right femur fracture. During an interview on 3/15/19 at 10:53 a.m., Staff G, Certified Nursing Assistant (CNA) stated it had been a long time since the incident but her idea had been to get the resident halfway dressed while she waited for Staff F, CNA for assistance. Staff G stated she did not recall where the EZ stand lift device was located in the room because it had been along time ago but when she brought the device into the room the belt (which supported the resident during a transfer) had already been halfway connected to the device. Staff G never planned to connect the resident to the device independently. A typed statement dated 11/29/18 at 1:10 p.m. by the Director of Nursing (DON) included the following documentation following an interview with Staff G: Staff G had been a CNA assigned to the resident at the time of the event. At approximately 8:15 a.m. Staff G went into the resident's room to get her ready for breakfast. Staff G stated when she came into the room, Resident #13was close to the edge of the bed and looked like she might roll off the side of the bed. Staff G stated she rolled the resident into the middle of the bed and changed her brief and pants. Staff G stated she changed the resident's brief and put her pants on up to the resident's knees. Staff G then brought the EZ stand into the room with her but left it by the closet (just inside the door). Staff G then sat the resident up on the edge of the bed (EOB) and the resident began to slide off the bed toward the staff member. Staff G stated she tried to keep the resident from sliding off the bed but could not stop her. When the resident slid off the bed Staff F came in and saw Staff G trying to hold the resident up. Staff G asked Staff F for help so Staff F went and got the nurse. Staff G stated Resident #13 wore shoes and the bed had been in the lowest position. Staff G stated again the EZ stand was not next to the bed but rather across the room. Staff G described the resident's position on the floor as with her head toward the room door and her feet toward the window. Staff G stated she tried to hold the resident's head to protect it. Staff G also stated she stood at the head of the bed when the resident slid from the bed. Staff G stated Staff F went to get the nurse and returned immediately with Staff E, LPN (Licensed Practical Nurse). Staff G stated that Staff E instructed her to position a pillow under the resident's head to support it and to provide comfort. The resident complained of pain to both of her legs and yelled for them to get her up off the floor. Staff E looked over the resident and told them it would be okay to get her up off the floor. Staff G remained at the resident's feet throughout the event and lifted her feet up on the bed with the assistance of Staff E at the resident's trunk/buttocks, Staff H, Registered Nurse (RN) at the resident's right arm and Staff F at the resident's left arm placed her on the bed with her head at the foot of the bed. Staff G accompanied all 4 staff members involved into the resident's room for a re-enactment. After the re-enactment, Staff G stated information given during the re-enactment was accurate and the lift must have been more like where Staff E stated it was positioned. During interview on 3/14/19 at 3:47 p.m. Staff F stated she was across the hall from Resident #13 when she heard screaming and yelling. Staff F entered the room of Resident #13 and saw Resident #13 on the floor right next to the bed on her back. Her right leg had bent and her left leg was semi straight with Staff G standing between the bed and the EZ stand device closest to the window as she tried to hold the resident up and to keep her from sliding. Staff F turned around and got Staff E. When they returned, Staff F confirmed the EZ stand was not connected to Resident #13, but sat real close. Staff F remembered the resident wore just socks and was fully dressed. The resident screamed, saying she was in pain and needed to go to the hospital. The nurse assessed the resident by checking her vitals. ROM was not performed until they positioned Resident #13 in bed because her leg appeared injured. It took 4 staff members to move the resident from the floor to the bed at which time they immobilized her leg as much as they could because she was in so much pain. Resident #13 went to the hospital. Staff F confirmed that Resident #13 required the assistance of 2 with bed mobility at the time of the fall and fracture. Staff F had also observed Staff G transfer other residents alone while using an EZ stand in the past; a standard of practice for her. During additional interview on 3/15/19 at 10:44 a.m., Staff F described the resident as positioned with her bottom on the floor between the legs of the EZ stand with her right leg bent and positioned under her left leg, which extended out over the leg of the EZ stand. Staff F confirmed the resident as needing the assistance of 2 with cares and she had not known Staff G planned to provide assistance to the resident alone rather waiting for her to complete cares with the resident she had been assisting when Staff G requested her assistance with Resident #13. During an interview 3/15/19 at 1:16 p.m. Staff E stated she worked as the charge nurse the morning of Resident #13's fall and fracture when Staff G sat the resident on the EOB in preparation to transfer her to the wheel chair and while she waited for Staff F. The EZ stand device had been positioned in front of the resident as she was on the EOB with the legs of the EZ stand spread apart and the sling partially attached on one side of the device and extended partially around the resident but not connected on both sides. The resident fell down to the floor with her buttocks partially on the left leg of the EZ stand and partially on the floor between the legs. The resident's right foot had caught under the right leg of the EZ stand device while her left leg extended over the right leg of the EZ stand. Staff E gently removed the EZ stand as the resident extended her right leg on her own but at an odd angel. The nurse then assessed the resident but did not perform ROM but assessed her legs for rotation and because the resident moved her legs on her own. Staff E stated that 3 staff lifted the resident off the floor with Staff F positioned at the resident's head, herself on one side and Staff G on the other side, as they supported the resident's entire body. Resident #13 complained of pain on the floor and when positioned in the bed, she stated the pain had gotten worse. The nurse called the physician, the resident's family and etc. and sent her to the hospital. Staff E could not recall the resident's bed mobility status at that time but confirmed Staff G should not have sat the resident on the EOB without assistance because the resident was known to be combative. During an interview on 3/15/19 at 10:20 a.m. Staff H recalled the incident had been in (MONTH) as she arrived to at work and on her way to her office. As she talked with another resident, she heard Staff E on the other hall as she came out and stated she required assistance and then returned to the resident's room. When Staff H entered the resident's room she found her positioned on the floor with Staff F, G and E present. The staff members had a gait belt on the resident and all the resident's furniture out of the way and the EZ stand device positioned by the bathroom. Resident #13 was on the floor with her head towards the door and her feet towards the window and on her back. The resident wanted to get up, so they positioned a person on each side of her and one at her head and one at her feet, counted 1-2 and 3 and lifted her onto the bed with her legs bent and the right knee out at a 45 degree angel but with no more deformity than normal. The resident had her lower body dressed and she recalled Staff E removed the resident's shoes at that time. The resident had not complained of pain. Staff E was pretty sure the resident needed the assistance of 2 with bed mobility at that time. During an interview on 3/14/19 at 2:30 p.m. the DON stated through her investigation, she learned Resident #13 was positioned up on the EOB by Staff G. The resident was a 2 person assist at that time and Staff G performed the task on her own. The DON stated Staff G changed her story through the investigation and after they re-enacted the event. The DON expected staff to transfer any resident that required an EZ stand lift device with 2 people. Plus the resident required 2 person assistance with bed mobility as care planned. During an interview on 3/14/19 at 4:40 p.m., the resident's primary care physician stated he would expect facility staff to use the assistance of 2 staff as directed in the care plan and if so, the fall could have been prevented. On 3/14/19 at 4:35 p.m. Staff A, CNA stated that any resident who required an EZ stand device required 2 staff assistance at all times and when a resident required 2 staff assistance with bed mobility it had never been acceptable to have assisted the resident with 1 staff member. During an interview on 3/15/19 at 12:30 p.m. Staff B, CNA confirmed any resident who required an EZ stand device required 2 staff assistance at all times and when a resident required 2 staff assistance with bed mobility, it had never been acceptable to assist the resident with 1 staff member. On 3/15/19 at 12:33 p.m. Staff D, CNA stated that any resident who required an EZ stand device required the assistance of 2 at all times and when a resident required 2 staff assistance with bed mobility, it was not acceptable to move the resident with 1 staff member. Resident #13 required 2 staff assistance with bed mobility. 2. According to the MDS assessment dated [DATE], Resident #4 scored 4 on the BIMS test, indicating severe cognitive impairment. The resident required extensive assistance with transfers. The resident's [DIAGNOSES REDACTED]. The Progress Notes dated 10/1/18 at 8:45 a.m. documented staff noted the resident lying on the floor in his room per Certified Nursing Assistant (CNA). The resident lay on his back with his legs extended towards the bathroom and his head towards the foot of the bed and his wheel chair upright off to the side of the resident, unlocked. The call light was on bed in the off position, and the room lights were on. The resident was fully dressed with shoes and socks on. He reported wanting to go to the bathroom. An Investigation Report documented the fall occurred 10/1/18 at 8:45 a.m. Staff put a low bed in place as the immediate intervention. The Progress Notes dated 10/9/18 at 8:47 p.m. documented the cleaning lady reported Resident #4 laying on floor. The nurse noted the resident was sitting up on the floor at the foot of the bed with his legs extended out and the wheel chair sat in front of him. The call light sat on the side of bed, not activated, his wheelchair was not locked and he wore well-fitting shoes. An Investigation Report documented the resident fell on [DATE] at 12:30 p.m. Resident #4 stated he wanted to go to bed. Staff planned to keep the resident in the common area after meals as the immediate intervention put in place to prevent further falls. The current Care Plan revised 8/24/18 identified the resident at a high risk for falls. The interventions included encouraging the resident to stay in the common area while awake and out of bed, initiated 10/11/8. The Progress notes dated 11/13/18 at 7:40 p.m. documented staff noted the resident on the floor next to the bed on his right side side, legs extended out, fully clothed, with shoes on. The call light sat in reach on the bed and the wheelchair had rolled away from the resident. The Progress Notes dated 11/26/18 at 12:13 p.m. documented yelling heard, staff approached the resident's room and noted an empty wheelchair against the overbed table pushed up against the bedside table. The resident laid face up underneath the bed with his feet resting on the base of the overbed table. The wheelchair was not locked, the call light rested on the overbed table and he wore shoes and the bed was in the high position. Staff noted a scant amount of bleeding and an elevated area to the back of the resident's head. At 2:30 p.m. Resident #4 complained of dizziness and nausea. Staff notified the physician of the fall and his complaints with a subtle change to baseline assessment. Staff received orders to transfer Resident #4 to the emergency room (ER) for evaluation and treatment; he left by ambulance at 3:30 p.m., remaining alert with complaints of nausea. The resident returned to the facility at 8:45 p.m. by ambulance. He had no complaints of pain and his vitals were stable. An investigation documented the date and time of the incident 11/26/18 at 12:30 p.m. The report documented staff last saw Resident #4 at 12 p.m. wheeling in the hall and coming from the dining room. The resident stated he tried to sit on the bed and looked for the call light. The resident was last toileted at 11 a.m. prior to lunch and wore shoes. Current fall interventions listed in the care plan were to encourage the resident to stay in the common area while awake and out of bed, non-slip footwear, and close to nurse's station. The bed was not in the low position. The report documented interventions listed in the care plan not being utilized appropriately: encourage the resident to stay in the common area while awake and out of bed. During an interview on 3/15/19 at 10:30 a.m. the Assistant Director of Nursing (ADON) stated Staff E wrote the Incident Report, and the ADON did the investigation. When the ADON wrote the intervention to encourage Resident #4 to stay in common area when out of bed was not utilized appropriately, she meant it (the intervention) didn't work. During an interview on 3/15/19 at 1:05 p.m. Staff E stated she worked the day in (MONTH) Resident #4 fell and went to the ER. Resident #4 would always try and self transfer after meals. She didn't recall if she saw him come back from lunch that day, but they wanted him to stay in the common area until someone could assist him. She didn't recall if she saw him or if she encouraged him to stay in the common area. She said if she had seen him she would have encouraged him to stay in the common area. She did not see him go to his room and didn't know if anyone else did. Staff E said he didn't follow the intervention (to stay in the common area) and he liked being independent. During an interview on 3/15/19 at 1:25 p.m. the DON stated Staff M CNA was assigned to the hall the day the resident fell (11/26/18). During an interview on 3/15/19 at 1:40 p.m. Staff M stated she could not recall the events of the day Resident #4 fell in (MONTH) and whether she saw him return from the dining room or if she saw him wheeling to his room. 3. According to the MDS assessment dated [DATE], Resident #20 demonstrated long and short term memory problems and severely impaired skills for daily decision making. The resident required extensive assistance with transfers. The resident's [DIAGNOSES REDACTED]. The current Care Plan revised 10/5/17 identified the resident with an activity of daily living (ADL) self care performance deficit related to decreased mobility and dementia. The interventions directed to transfer her with the assistance of 2. During an observation on 3/14/19 at 3:44 p.m. Staff J CNA and Staff I CNA transferred Resident #20 by putting their arms under her arms and holding onto her pants without using a gait belt. Staff I had a gait belt around his waist and a gait belt hung on a hook in the room. Staff L RN observed the cares. During an observation on 3/15/19 at 12:40 p.m. Staff K CNA and Staff B CNA transferred the resident with a gait belt from the wheel chair to the bed. During an interview on 3/15/19 at 12:45 p.m. the ADON stated they were made aware of the transfer on 3/14/19 without a gait belt and they addressed the issue. She said staff were to use a gait belt with all residents who required assistance of 1 or 2 to transfer. During an interview on 3/15/19 at 1:25 p.m. the DON stated Staff I was currently on suspension, because he transferred without a gait belt before. She said Staff J was fairly new and received a written warning.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to protect Resident #4 and Resident #2 from hazards to self. The sample consisted of 5 residents and the facility reported a census of 71 residents. Resident # 4 was left unattended in an elevated bed, fell and fractured a vertebrae. Resident # 2 exited the facility without staff knowledge (elopement). Findings include: The Face Sheet for Resident # 4, identified [DIAGNOSES REDACTED]. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 6/11/14 which identified the resident had both long and short term memory problems as well as severely impaired decision-making skills. The MDS reflected the resident would miss part of the message intent. The resident was completely dependent on staff for transfers and could not maintain balance during surface to surface transfers without staff assistance. The Care Plan Report dated 8/26/14 identified the resident had a problem with the potential for falls. The interventions directed staff to: transfer the resident with a mechanical lift and the use of two staff members. On 8/26/14 the staff added interventions that included a low bed, a special lip mattress (raised edges that help provide boundaries) and a floor mat. The 6/11/14 Fall Risk Assessment documented a score of 18. The score of 18 represented the resident to be at a high risk for falls. The Clinical Notes Report dated 8/28/14 at 5:06 PM documented a late entry for 8/26/14 at 6:30 AM. On 8/26/14, staff noted Resident # 4 sitting upright on the floor, next to the resident's bed. The resident slipped off of the bed and voiced mild pain to the buttocks. The resident's pain increased when staff tried to move the resident ' s right leg. When staff turned the resident onto his/her back (by 3 staff), the resident voiced severe pain so the staff rolled the resident off of the back position. The resident had no red or ecchymotic (bruised) areas. The ARNP (Advanced Registered Nurse Practitioner) was notified and the resident was transferred to the hospital emergency room (ER) for an evaluation. The Clinical Notes Report of 8/28/14 at 5:06 PM revealed Resident # 4 returned to the facility at 2:00 p.m. The resident had re-fractured an old spine fracture. There were no new orders. The 8/26/14 6:30 AM Occurrence Report identified staff found Resident # 4 on the floor complaining of severe center lower back pain. The 8/26/14 11:40 am ER report reflected Resident # 4 suffered a vertebral compression fracture. The 8/26/14 12:14 PM Final Report identified Resident # 4 returned to the facility. During an interview on 10/29/14 at 11:32 AM, Staff L LPN (Licensed Practical Nurse) reported hearing someone call for help. Staff L found Resident # 4 sitting on the floor. Staff L did not remember the height of the resident's bed and said staff routinely didn't leave residents alone in raised beds. During an interview on 10/29/14 at 12:06 PM, Staff K stated she remembered leaving Resident # 4 alone in a raised bed. The bed height was about 3 - 3.5 feet off of the floor, approximately waist high on Staff K. Staff K then left the room to get help to transfer Resident # 4. Staff K stated she wanted to get the resident up for the day and planned to be gone only very briefly. While Staff K was gone, Resident # 4 exited the bed and the nurse found the resident on the floor. Staff K stated she now keeps all occupied beds at the lowest level when not performing resident cares. On 10/31/14 at 8:45 am Staff A (licensed practical nurse) was interviewed and stated Staff K left the resident unattended. The CNA reported the resident "just laid there" during cares. The bed was not in the low position when the CNA left the room. The staff members were expected to not leave residents in raised beds while unattended. On 10/31/14 at 10:17 AM, the Director of Nursing (DON) was interviewed and stated Staff K left Resident # 4 unattended in a raised bed. The DON stated she expected staff to lower occupied beds and not leave residents alone in raised beds. On 10/30/14 at 3:45 PM, observation revealed Resident # 4 lay in bed and visited with family members. The resident had a lipped mattress with the head of the bed raised approximately 30 degrees. A family member reported raising the resident's bed slightly for the visit. The family member also stated s/he removed the falls matt away from the bed and placed it at the foot of the resident's bed. 2. Resident #2 had a MDS assessment with a reference date of 7/30/14 which reflected a Brief Interview for Mental Status (BIMS) score of 3 of a possible 15. A score of 3 identified a severe cognitive and memory impairment. The resident had fluctuating difficulty focusing attention and had disorganized thinking. The resident did not wander during the assessment period. Resident #2 needed extensive staff assistance to transfer, walk in his/her room and depended upon staff for moving off of the unit. The resident used a walker and/or wheelchair. The Care Plan dated 8/4/14 identified a problem with the resident becoming tired at times and had demonstrated a modified impairment with cognitive skill for daily decision making. The Care Plan directed the staff to escort the resident to and from activities and to break tasks into steps while providing verbal prompts during cares. The resident could ambulate short distances with assistance, but primarily used a wheelchair pushed by staff. Staff encouraged the resident to be independent in the wheelchair. The Geriatric Services note dated 8/6/14 at 9:45 AM recorded Resident # 2 had [DIAGNOSES REDACTED]. The resident displayed exit seeking/sun downing (confusion and behaviors increase later in the day) daily. The 7/30/14 Elopement Risk Assessment checklist reflected Resident # 2 as not independently mobile, and therefore not an elopement risk. The 10/11/14 5:55 PM Occurrence Report reflected a staff member ran past the nurse ' s station yelling they saw Resident # 2 outside of the facility. Three staff ran outside and found the resident in a wheelchair and in the facility parking lot. Staff turned the resident around and returned him/her inside the facility. The resident received no injury. Staff placed the resident on 15 minute checks. The 10/13/14 2:35 PM Clinical Notes Report (Nurses' Notes) revealed the same information. Review of the Clinical Notes Report from 07/17/14 at 2:37 PM through 10/13/14 revealed no other exit seeking or elopement attempts. The undated incident summary entitled with the resident's name reflected the staff found Resident # 2 outside of the facility on 10/11/14 at 5:55 PM. The resident self-propelled in a wheelchair. Staff last observed the resident in the dining room around 5:15 to 5:20 PM. Staff assisted the resident to the table. At approximately 5:30 PM, staff took the resident back to the common area (lounge in front of the nursing station) and placed the resident by the aviary. The receptionist assigned to the front desk reported she did not see the resident leave or hear the doors open. The receptionist had been at the front desk. Before the 10/11/14 incident, the facility left the front door unlocked from 8:00 am until 7:00 PM. After the incident, the facility kept the front doors continuously locked. The facility also initiated every 15 minute checks on Resident # 2 after observing outside. Staff surmised Resident # 2 exited via the unlocked front door due to the location when found outside of the facility. The resident had been verbally aggressive and threatened to leave the facility in August 2014. The resident was redirected without incident. The facility then placed Resident # 2's picture at the front desk for increased monitoring per the facility system. The resident began receiving Seroquel (an antipsychotic medication). There were no reports of the resident attempting to leave the facility or being exit seeking since 8/6/14. Observation on 10/28/14 at 1:25 PM revealed Resident # 2's picture at the front desk. Staff J, the receptionist, identified Resident # 2 and the 4 other residents as potential exit seekers. During an interview at approximately 2:00 PM on 10/28/14, Staff A (Assistant Director of Nursing) reported the facility posted pictures of residents identified as at risk for exit seeking at the front desk. This might be a resident undergoing some sort of an acute episode. If identified as an exit seeker (elopement), the resident typically transferred to the locked unit. On 10/31/14, at 8:45 am, Staff A, (licensed practical nurse) reported Resident # 2 had talked about going home. However, the resident referred to their room as home. The resident will usually calm down if taken to his/her room and toileted and assisted to bed. On 10/28/14 at 4:22 PM, Staff B, (the receptionist) stated she worked the front desk from 4 to 7 PM when Resident # 2 eloped from the facility on 10/11/14. Staff B did not leave the desk unattended on 10/11/14 and did not see or hear the resident leave. However, Staff B thought the receptionist area had been poorly designed during the recent facility remodel (project). If sitting, Staff B could not entirely see the front door. Additionally, Staff B did other things such as answer the phone, direct visitors, etc. Staff B watched a resident if she knew the resident was there. During the interview, the surveyor stood behind the receptionist's chair. It did not appear the seated receptionist could see the entire front door. On 10/28/14 at 6:05 PM, Staff D, (certified nursing assistant) stated she saw Resident # 2 outside in the facility parking lot, perhaps 50 yards from the front door. The resident wheeled towards the street. The parking lot was long and narrow, with parking spaces on each side. The far end of the parking lot sloped towards the street. The facility didn't lock the front door at the time of the incident until 7:00 PM and the doors automatically opened if someone went close to the doors. Until 10/11/14, Resident # 2 was not an exit seeker. The resident was angry earlier in the shift. Staff D stated had not seen Resident # 2 that angry before. The resident tried to leave the table and the dining room during supper. Nothing else was different regarding Resident # 2 except the anger and he/she did not want to eat. Around 6 PM, Staff D and Staff F did cares for the resident who resided in room 159. The staff members looked up and saw Resident # 2 outside. Staff F went outside to get Resident # 2. On 10/29/14 at 3:16 PM, Staff F (certified nursing assistant) reported being surprised Resident # 2 went outside. Staff F didn't know that Resident # 2 wandered. On 10/11/14, Staff F and another staff member was in room 159 and saw Resident # 2 slowly wheeling down the facility driveway. Staff F didn't know how Resident # 2 had gotten out of the facility. The inner front doors opened if given a little push. The second set of outer door then automatically opened. When Staff F reached Resident # 2, she asked why the resident tried to leave the facility. Resident # 2 didn't know, but she/he didn't want to go back inside. Staff F hadn't seen the resident earlier in the shift. During the interview, Staff F walked in the parking lot to demonstrate Resident # 2's location when Staff F reached the resident. The resident was more than halfway to the street, at approximately the 4th parking space on the left side of the parking lot, if standing in the street facing away from the facility front door. During a phone interview on 10/30/14 at 11:20 AM, Staff G, (licensed practical nurse) reported Resident # 2 had a history of [REDACTED]. The resident occasionally hung out around the front door. The resident typically self-propelled their wheelchair slowly. On 10/11/14, other staff saw that Resident # 2 outside of the facility. Staff G went outside with other staff to retrieve Resident # 2. At the time of this incident, the facility didn't lock the front doors. Staff G thought the doors opened with a handicapped accessible button. According to the 10/11/14 schedule, Staff M, (certified nursing assistant) cared for Resident # 2 on 10/11/14 during the 6:00 AM to 2:00 PM shift. During an interview on 10/30/14 at 12:55 PM, Staff M stated Resident # 2 yelled at another resident's family member on 10/11/14. The visitor changed the television channel. After lunch, Resident #2 self-propelled around the facility. Staff M found the resident in another part of the facility, by the library. Resident # 2 also went behind the nursing station. Staff M thought the resident might have a urinary tract infection. However, Resident # 2 did not say anything about leaving. Staff M did not expect resident # 2 to elope as the resident did not give any indication. On 10/31/14, at 10:17 AM, the Director of Nursing (DON) reported Resident # 2 once talked about leaving the facility for food. This incident occurred during the warm months. This seemed like routine agitation for the resident. Once the resident had a medication adjustment, and the resident's picture put at the front desk, the concern seemed resolved. Staff B reported being at the front desk, but did not see Resident # 2 exit the facility. The DON didn't know if the sitting receptionist could see the front door. On 10/31/14 at 9:46 AM, Staff E, (licensed practical nurse) reported Resident # 2 had not said anything about wanting to leave and had no previous attempts to exit the facility. On 10/11/14 during supper, in the dining room, Resident # 2 tried to get up from the wheelchair. A certified nursing assistant directed the resident to sit back down, and then took him/her out of the dining room. The next thing Staff E knew, Staff F ran up from the C hall (parallel to the parking lot) yelling Resident # 2 was outside. Staff E, F, and G ran outside and brought Resident # 2 back into the building. Staff E had not expected the resident to do anything like that as the resident hadn't given any indication that they might exit the facility. The resident wore a long sleeved shirt, sweat pants, and shoes. During an observation on 10/31/14 at 12:50 PM, Staff H, (maintenance), pushed on the locked inner front door. The door beeped when Staff H pushed the handle. Staff H reported both sets of doors automatically opened if the doors were not locked. Someone could exit the building undetected via the unlocked double doors. Observation of the front lobby at the time revealed 2 sets of double doors at the front entrance. There was a sensor "eye" above the inner doors and an automatic door sign. The receptionist desk sat to the left (if standing facing the door). The desk was an opening in the wall that was from about 3.5 feet from the floor to the ceiling. On the left side of the desk area (if facing the desk) was the hallway to the resident living area. During a phone interview on 10/31/14 at 4:03 PM Staff C, (certified nursing assistant) reported she hadn't been assigned to Resident # 2 for a while before the incident. Staff C hadn't seen the resident try to elope hadn't heard the resident talk about it and knew of no previous elopement attempts. Staff C didn't know about the elopement until the next day. On 10/11/14, Staff C supervised the dining room during supper. Resident # 2 stated she/he wanted to go home to eat and the resident tried to exit the dining room, but ran into another resident's wheelchair. The resident wanted to go back to his/her room. Staff C took Resident # 2 to the common area and left the resident with back towards the aviary. Staff C typically took residents out of the dining room and to the common area. The assigned staff then took the residents back to their rooms. The resident seemed much calmer out of the dining room. Staff C thought the resident sun-downed and needed to be around fewer people. The resident just didn't want to be in the dining room. The resident stopped talking about wanting to go home by the time they reached the aviary and didn't give any indication she/he planned to elope. Staff C didn't speak to the nurses at the nurse ' s station. Staff C took other residents back to the common area but didn't remember seeing Resident # 2 in the hallway.

Based on record review and interviews with staff, physician, and podiatrist, the facility failed to provide timely interventions for wound care for one (1) of five (5) residents. Record review identified Resident #2 developed an area of concern on his/her great toe on July 6, 2012. Staff interviews and clinical record review determined timely treatments were not provided to promote healing or to aid in the prevention of wound care and the resident developed an infection in the bone. Interviews with the physician and podiatrist revealed they expected the nursing home staff to apply dressing on the resident's toe and treatment should have been started right away. The facility reported a census of 61 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment tool dated 06/26/12, Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS documented Resident #2 required the extensive assistance of one staff with transfers, dressing and to use the bathroom. Resident #2's [DIAGNOSES REDACTED]. A Care Area Assessment Summary dated 07/02/12 documented Resident #2 had no open areas at the time, but he/she was at risk to develop skin breakdown related to his/her [DIAGNOSES REDACTED]. A Care Plan Report dated 06/19/12 identified Resident #2 at risk for altered skin integrity, and indicated he/she was prone to developing unexplained bruises and had poor circulation to his/her lower extremities. The interventions included: a. Check skin daily for areas of redness with all cares provided. Report any changes to the nurse. b. Check feet and legs for redness, skin tears, swelling, or pressure areas with cares provided. Report any signs of skin breakdown. The frequency directed 1 time daily starting on 6/20/12. c. Administer skin treatments per physician order [REDACTED]. A CNA Weekly Shower Skin Check dated 06/28/12 documented Resident #2 had a shower. The sheet documented Resident #2 received nail care, staff found areas of concern and marked areas on the body chart. The sheet indicated the areas were not new. The CNA Weekly Shower Skin Check forms dated 07/02/12 and 07/05/12 documented Resident #2 chose not to take a shower. The Nurse's Notes dated 07/06/12 at 6:00 p.m. documented Resident #2 complained of slight pain to the left lower extremity with pedal pulses palpable times 4. Resident #2 had 1+ [MEDICAL CONDITION] to the left lower extremity. His/her right great toe appeared red, swollen and had slight clear/yellowish drainage with a foul odor. Resident #2 stated being unaware how long the toe appeared red and swollen. Staff called the physician and obtained new orders. At 11:35 p.m., the notes documented the left great toe swollen, and warm to touch with [DIAGNOSES REDACTED] (redness). The Nurse's Notes dated 07/07/12 at 6:00 p.m. documented the left great toe remained red/swollen, with pedal pulses palpable times 4, and 1+ [MEDICAL CONDITION], with elevation encouraged. The Nurse's Notes dated 07/08/12 at 6:00 p.m. documented Resident #2 received Tylenol for pain to the left great toe. Pedal pulses were palpable times 4. The left lower extremity had 1+ [MEDICAL CONDITION], and the left great toe remained warm, swollen, and tender to touch, with a small amount of clear/yellowish discharge. Resident #2 encouraged to elevate his/her foot. At 11:00 p.m. Resident #2 continued on antibiotic therapy for the left great toe. The toe remained swollen with some redness. The Nurse's Notes dated 07/09/12 at 1:15 p.m. documented Resident #2 continued antibiotic therapy for the left great toe and noted the toe continued to be swollen and red. At 9:00 p.m. Resident #2 continued on antibiotic therapy for the left great toe which continued swollen, red, and tender to touch. Resident #2 received Tylenol per request for left great toe pain. The Nurse's Notes dated 1:00 p.m. documented Resident #2's family came back to the facility from the podiatrist appointment and told them Resident #2 admitted to the hospital for his/her left great toe. A Non-Pressure Weekly Documentation Form dated 07/06/12 documented Resident #2 had redness of the left great toe. The redness, generalized over the entire left great toe, had no drainage. The entire toe appeared bright red except for where the skin tears were on the underside of the toe. Resident #2 started on oral Keflex (antibiotic). On 07/09/12 the form documented "same". A Non-Pressure Weekly Documentation Form dated 07/09/12 documented Resident #2 had a 1.4 by 0.1 by 0.2 centimeter (cm) skin tear to the under side of the great toe. The skin tear appeared a jagged edged open area skin flap, white in color. A Non-Pressure Weekly Documentation Form dated 07/09/12 documented Resident #2 had a 0.4 cm by 0.1 by 0.2 cm jagged edged open area skin flap, black in color. A Non-Pressure Weekly Documentation Form dated 07/09/12 documented Resident #2 had a 1 by 1.1 cm dark red/brown mushy area on the underside of the toe. A Non-Pressure Weekly Documentation Form dated 07/09/12 documented Resident #2 had 1.1 by 1.2 cm white/gray skin surrounding the 2 skin tear areas. A Physician's Telephone Order dated 07/09/12 directed to apply [MEDICATION NAME] and a band aid to the end of Resident #2's left great toe 2 times a day. A Treatment Record dated July 2012 added [MEDICATION NAME] and bandaid to the end of the left great toe 2 times a day until healed on 07/09/12. The record showed an arrow to start the order on 07/10/12, with no initials recorded. The record showed Resident #2 had an order for [REDACTED]. A Clinic report dated 07/10/12 documented Resident #2 presented to the podiatry clinic for evaluation of a swollen, red left hallux (toe). They noted drainage coming from the end of the toe. Resident #2 had longstanding diabetes mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The vascular exam documented pedal pulses nonpalpable bilaterally, and epicritic sensation diminished. They noted ulceration on the distal aspect of the left hallux with purulent discharge. No foul odor or crepitus (crackling). Resident #2 had [MEDICAL CONDITION] and [DIAGNOSES REDACTED] of the left hallux. The plan included ulceration debridement, wound cultures, and x-rays of the left foot. They spoke with Resident #2 and his/her family member, as well as the physician regarding admission to the hospital for a vascular consult and intravenous antibiotics. A Vascular Surgery Consult dated 07/11/12 documented Resident #2 admitted to the hospital on [DATE] with a left foot infected ulcer. Resident #1 had an ulcer present on the left greater toe for an unknown duration of time. The physical exam documented the left foot swollen with 1+ [MEDICAL CONDITION]. The left greater toe had an ulcer at the end which tracked to the bone. he left foot felt warm to palpation. A Physician Discharge Summary dated 07/17/12 documented Resident #2 admitted to the hospital for [MEDICAL CONDITION] and a chronic infected ulcer to his/her left great toe. While at the hospital, a bone scan had been obtained which indicated osteo[DIAGNOSES REDACTED] (infection in the bone) of the left distal phalanx (bone) of the great toe. The summary indicated they amputated the distal phalanx with a plantar skin flap for closure. (The distal phalanx is the limb bone(s) located at the tip of the finger(s).) During an interview on 08/02/12 at 2:01 p.m. Staff A Certified Nursing Assistant (CNA) stated Resident #2 was mostly independent. She stated once in a while he/she would have incontinence concerns. Staff A stated Resident #2 dressed him/her(self). Resident #2 would be up and dressed by the time she got to work. Resident #2 walked to meals by him/her(self). She stated skin checks were done with showers and she did not do Resident #2's showers so she did not check his/her skin. During an interview on 08/02/12 at 2:11 p.m. Staff B CNA stated Resident #2 was independent, getting him/her(self) up, and dressing him/her(self). She made sure Resident #2 got to meals and got him/her ice water. Staff B stated she did not do Resident #2's baths and that was when skin checks were done, so she did not do skin checks on Resident #2. During an interview on 08/02/12 at 2:15 p.m. Staff C CNA, Restorative Aide stated she did Resident #2's baths as he/she liked baths done early. Staff C stated baths were completed on Mondays and Thursdays. Staff C did not do Resident #2's baths the week the facility discovered his/her red toe. Staff C reported she did Resident #2's bath on 07/09/12 and reported the red toe to the nurse, who stated she already knew about his/her toe. Staff C stated she did a head to toe skin check with showers and filled out a shower sheet. During an interview on 08/02/12 at 3:00 p.m. Staff D Director of Nursing (DON) stated Resident #2 told his/her family member about his/her toe, and the family member told the nurse. Staff D stated the physician came to the facility every Tuesday and they were going to have the Physician see Resident #2, but the family member made an appointment with the podiatrist, and took him/her. Staff D stated Resident #2 only liked certain caregivers and could get angry at times. Staff D stated Resident #2 refused showers the week they discovered the toe issue. During an interview on 08/02/12 at 3:16 p.m. Staff E Skin Nurse stated staff did skin checks during resident showers. Staff E stated she assessed known skin areas every week. Staff E stated she did not know of anything additional they did for diabetics regarding foot checks. Staff E stated Resident #2 did not have good feeling in his/her feet. During an interview on 08/02/12 at 4:43 p.m. Staff F CNA stated Resident #2 was pretty independent and she did not help him/her with bedtime cares, he/she would already be in bed. Staff F stated she did not do skin checks on Resident #2 including his/her feet, because they were done with showers. Staff F reported they did a head to toe check with showers. During an interview on 08/02/12 at 5:06 p.m. Staff G CNA stated Resident #2 was independent with care. She said she got water and other drinks for him/her. She did not check skin including feet because she did not give Resident #2 his/her showers. Staff G stated skin checks were completed during showers. During an interview on 08/02/12 at 5:35 p.m. Staff I Licensed Practical Nurse (LPN) stated he did the skin assessments as indicated. Staff stated he did the assessment on 07/04/12 on Resident #2. He stated he did a head to toe assessment, front and back. He said the assessment would be done in the evening. Staff I stated he did not note anything with Resident #2's toe on 07/04/12. Staff I stated after they discovered Resident #2's toe redness, he/she went on oral antibiotics. Resident #2 did not have a dressing or treatment. During an interview on 08/03/12 at 8:42 a.m. Staff J CNA stated she did not check Resident #2's feet because the nurses did that. During an interview on 08/03/12 at 9:41 a.m. Staff K LPN stated the day they discovered Resident #2 had a sore toe, his/her family member came and looked at it. Staff I stated the toe was red and swollen about 1-1/2 times it's normal size. Staff K stated the toe had drainage from underneath the toenail. Resident #2 had swelling up to the mid-calf. Staff K stated at that time Resident #2 did not have an open area on the underside of the toe. Staff K stated that occurred sometime after they discovered the sore toe. Staff K stated they got an order for [REDACTED]. Staff K stated Resident #2's family member told her to smell the resident ' s foot on 7/06/12, and according to Staff K the resident ' s foot smelled bad. Staff K stated when she called the physician's office she told them the toe had drainage under the nail and they asked if she could get a culture and she did not think she could. Staff K stated she did not ask for a treatment because the toe was not open, the drainage came from under the nail. Staff K stated she did a skin sheet. (Clinical record review identified no skin sheet by Staff K could be located). During an interview on 08/03/12 at 10:29 a.m. Staff E stated on 07/09/12 when she looked at the toe and measured the skin tears, the toe had drained and Resident #2's sock stuck to it. Staff E stated when she found the skin tears on the underside of the toe, and they got an order for [REDACTED]. Staff E stated she did not find a skin sheet by Staff K so she did one. Staff E stated she probably did not do the skin sheet on 07/06/12 because it was late in the afternoon when they told her about it and she was on her way out. During an interview on 08/03/12 at 10:39 a.m. the Physician stated she would expect staff to do a dressing if they noted a skin tear to the toe, or if the toe was draining. The Physician stated she would expect a treatment order to be started right away. The Physician stated Resident #2 was susceptible to problems with his/her feet due to diabetes and [MEDICAL CONDITION] and would expect staff to monitor his/her feet. During an interview on 08/06/12 at 12:10 p.m. Resident #2's family member stated on 07/06/12 Resident #2 told him/her about the sore toe and she looked at it. The family member notified the nurse. The family member stated Resident #2 didn't know how long the toe had been red, but it was starting to bother him/her. The family member stated Resident #2 had redness and swelling up to the knee. The family member didn't notice open skin that day, but stated it started breaking down the next day. The family member stated Resident #2 continued to wear his/her shoes and ambulate per usual. The family member stated they did encourage Resident #2 to elevate his/her leg. The family member stated Resident #2 did dress him/herself, but he/she thought they were checking Resident #2's feet. The family member stated because of his/her diabetes, Resident #2 didn't have good feeling in his/her feet. The family member stated by the look of this he/she knew it was bad so he/she made an appointment with the podiatrist. The podiatrist made arrangements for Resident #2's admission to the hospital. During an interview on 08/07/12 at 8:38 a.m. the Podiatrist stated osteo[DIAGNOSES REDACTED] usually took about a week to develop. He stated Resident #2 required vascular intervention, he/she had [MEDICAL CONDITION] and no pedal pulses palpable. The Podiatrist stated a draining toe was not normal and would need to be dressed for protection and to absorb drainage, because the drainage came from somewhere. He said it would be common sense not to put a red, swollen toe into a shoe.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self or elements in the environment and failed to revise the care plan to meet the needs of the residents for 2 of 4 residents reviewed with accidents (Resident #4, #5). Resident #5 was cognitively impaired and had 7 falls from 11/18/11 to 3/23/11. The facility failed to implement effective interventions to assist with the prevention of falls. The facility utilized interventions such as "tell resident not to clean" and "remind to use call light". Resident was cognitively impaired and staff documented in the care plan the resident was noncompliant. The planned interventions did not provide increased supervision/assistive devices that increased resident safety. Three of the incidents prior to the 3/23/12 hip fracture involved the resident in the bathroom but staff did not increase toileting. The toileting intervention remained the same throughout the resident's stay at the facility. Resident #4 had eleven falls from 10/10/11 through 3/27/12. The facility failed to implement any intervention that increased supervision/assistive devices to prevent accidents. The facility identified a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS), with observation end date of 2/12/12, assessed Resident #5 with a brief interview of mental status score of "4" (severe cognitive impairment). The MDS identified the resident to require limited assistance with bed mobility and ambulation. The resident required extensive assistance with transfers, dressing, eating, toileting, personal hygiene and bathing. The MDS identified the resident as continent of bowel and bladder. The MDS did not identify a toileting plan. A" balance during transitions and walking" test identified the resident as unsteady but able to stabilize without human assistance. The resident utilized a walker. The resident had [DIAGNOSES REDACTED]. The MDS did not identify the resident with falls since the prior assessment, even though the resident had 3 falls since 11/18/11. The resident was 63 inches tall and 113 pounds. An activity of daily living (ADL) resident care area assessment (CAA,) dated 2/19/12, revealed the resident readmitted to the facility for rehabilitation after a fall with forehead laceration. The resident was able to transfer and ambulate, but due to weakness, confusion and poor balance, the resident required one staff assist. The CAA identified the resident as not always compliant to ask for assistance and wait for assistance. The facility moved the resident closer to the nurses ' station so staff can check on the resident more often. On 4/18/12 at 12:30 p.m. Staff E identified the date the resident moved closer to the nurses ' station as 2/7/12. A fall CAA dated 2/19/12 documented since 2/4/12 staff encouraged and reminded the resident to ask for assistance of one staff before transfers/ambulation. The resident was alert to self only with increased confusion. The resident required frequent reorientation to time, place and safety measures. History of Falls: An incident report dated 11/18/11 at 11:15 p.m. stated staff observed the resident sitting on the floor at the bed side. The resident reported sliding off the bed. The report indicated the resident had no apparent injury. A care plan dated 12/28/11 contained an addendum dated 11/18/11 which directed staff to provide therapy. An incident report dated 11/21/11 at 10 p.m. documented the staff observed the resident on the floor in the bathroom. The resident stated he/she tried to clean the corner of the floor. The resident did not sustain injury. The incident report identified the resident's cognitive condition as alert and confused. A care plan dated 12/28/11 contained an addendum dated 11/21/11 which directed the staff to instruct the resident to not clean the bathroom floor. An incident report, dated 2/4/12 at 6 p.m. documented the resident fell in the bathroom. The report identified the resident as confused and had swelling to the head. Staff sent the resident to the emergency room (ER). The nurse ' s notes, dated 2/4/12 at 6:40 p.m. indicated a nurse aide found the resident on the bathroom floor with blood gushing from the forehead. The report documented the resident as unresponsive for 10 seconds and, upon regaining consciousness, the resident appeared very confused. The staff arranged to have the resident transported to the hospital. The hospital admitted the resident for care. The nurse ' s notes identified the resident returned to the facility on [DATE] at 6 p.m. with bruises and lacerations noted on the right eyebrow. The hospital diagnosed the resident with subdural hematoma and confusion. The nurse ' s notes documented the resident needed assistance with ambulation due to confusion. On the same date at 10 p.m., the nurse ' s notes clarified the resident's [DIAGNOSES REDACTED]. Observation revealed slight swelling and bruising to the right side of the face with sutures in place to the right eyebrow area. The nurses ' s note indicated Hospice documented an entry at 10:00 p.m. which identified the resident had occasional hallucinations. On 2/7/12 at 4:30 a.m. staff observed the resident standing next to the exit by room 142 with the exit alarm sounding. The staff assisted the resident back to bed. On 2/7/12 the resident moved to "B" hall which placed him/her closer to the nursing station than the resident was when he/she resided on "A" hall, but still half way down the hall. The care plan did not identify a new intervention for falls after return from the hospital. An incident report dated 2/13/12 at 4:30 p.m. documented the staff found the resident on his/her bottom in room. The incident report identified the resident as confused. The resident did not sustain an injury. A care plan dated 2/22/12 contained an addendum dated 2/13/12 that directed staff to "remind the resident to call for assistance before toileting", (even though staff identified the resident as confused and noncompliant). The nurse ' s notes, dated 2/22/12 at 5 p.m. identified the resident with increased agitation, yelling and name calling and refusing care. Staff attempted to redirect the resident without effect. Staff administered Ativan (antianxiety) for the behaviors. An incident report dated 2/22/12 at 8:05 p.m. documented the staff heard the resident calling for help. Upon entering the resident room, staff observed the resident on the floor on his/her left side at the foot of the bed. The resident complained of mid to low back pain and right hip pain. Observation also identified a skin tear to the right forearm measuring 8 centimeters (cm.) by 2 cm. with bright red blood. The resident was transported to the hospital for examination. The transfer form identified the resident as having occasional incontinence. The care plan did not identify the resident with occasional incontinence. The resident returned to the facility on [DATE] with no new orders. The ER report identified the resident with confusion. A care plan, dated 2/22/12 documented "hospice would increase aide visits as resident allows due to increased confusion". This intervention did not contain immediate supervision interventions or interventions to assist with the prevention of falls when Hospice did not visit the resident. Review of the Hospice notes identified 19 visits during January 2012. After the 2/22/12 incident, Hospice visited the resident 19 times from 2/22/12 to 3/23/12 hip fracture occurrence. The Hospice notes did not identify the amount of time spent with the resident or which shift the visits took place on. An incident report dated 3/18/12 at 9:45 p.m. revealed staff found the resident at the top of the hall lying on the floor. The resident could not state where he/she planned to go. The resident sustained [REDACTED]. by 0.5 cm. to the right upper arm. A care plan dated 2/22/12 contained an addendum dated 3/18/12 which directed staff to" keep personal items in reach of resident while in bed " . The incident report did not indicate the resident tried to get personal items when the resident fell or that retrieval of personal items even played a role in the fall. An incident report dated 3/23/12 at 10:10 p.m. revealed staff found the resident on the floor across from the bathroom. The resident identified self as trying to get to the bathroom. Observation showed redness to the left upper back measuring 3 cm. by 5 cm. and redness to the left upper thigh measuring 6 cm. by 7 cm. Staff notified the physician who directed staff to monitor the resident overnight and have x-rays in the morning. After the fall, staff educated the resident on using the call light if the resident needed anything. The incident report indicated the family response to the fall was the family voiced concern that staff did not toilet the resident enough. Staff responded by assuring the family she would remind the nurse aides to toilet the resident. A portable x-ray report, dated 3/24/12, identified the resident with a minimally displaced subcapital (hip) fracture presumed to be acute. On 3/26/12, the staff had the resident transported to the emergency room for an evaluation and admitted to the hospital. The transfer form identified the resident as occasionally incontinent of urine, which was not reflected on the resident's care plan at the time of the fall. An orthopedic progress note, dated 3/26/12, documented the resident fell on [DATE] and admitted to the hospital on [DATE] for pain control. The report identified that the resident's family did not want surgical intervention for the fracture. The resident returned to the facility on [DATE] with orders for pain control and bedrest. A pain clinician progress note dated 3/27/12 identified the left hip as "aching". The clinician identified strategies for controlling the resident's pain. The resident's 3/28/12 pain control orders included: Fentanyl 200 microgram patch every 3 days, Endocet 7.5 milligrams (mg.)/325 mg twice per day and Lidoderm Patch 5% apply topically on for 12 hours and off for 12 hours to left hip. The care plan, dated 2/22/12 to 5/16/12 directed staff to remind/assist resident to use bathroom before meals, at bedtime, before activities and as needed. Staff Interviews regarding the 3/23/12 fall: On 4/16/12 at 6:30 p.m. Staff G (Licensed Practical Nurse) stated she observed the resident on the floor. The resident talked about going to the bathroom and then denied having to go to the toilet. When staff got the resident up, the resident began to complain about knee and hip pain. Staff G administered Endocet (narcotic for pain) and notified the physician. Staff G stated she did not know when the resident used the toilet prior to the fall. Staff G stated around 9 p.m. she was in the room; the resident was in bed and denied the need for the toilet. On 4/17/12 at 3:25 p.m. Staff B (nurse aide) stated she was not working in Resident #5's hall when the fall occurred. Staff B identified a new staff (Staff A) as the staff working on the hall that night. Staff B stated after the resident fell she squeezed into the door of the resident's room because the resident's body was wedged in front of the door and staff could not get in the room. The resident tried to take her/his self to the toilet. Staff B identified the resident as in bed all day and if staff dressed the resident for bed, Staff B stated she was sure they toileted the resident. Review of the time sheets identified Staff A did not work on 3/23/12. On 4/25/12 at 1:02 p.m., the facility emailed the surveyor a statement from Staff E. Staff E stated she spoke with Staff B when she investigated the incident and Staff B informed her the staff toileted the resident during bedtime care. Staff E also documented that Staff G offered the toilet at 8:30 p.m. and the resident refused. On 4/16/12 at 12:47 p.m., observation revealed the resident in a low bed with floor mats at each side of the bed. The resident stated him/her fell and hurt his/her hip. When asked about the call light, the resident appeared very confused and did not seem to understand. 2. A Minimum Data Set (MDS) assessment with an observation end date of 1/25/12 assessed Resident #4 with brief interview for mental status score of "5" (severe impairment). The resident required extensive assistance with bed mobility, transfers, dressing, eating and personal hygiene. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with falls since the prior assessment one with injury and one without injury. A fall risk assessment dated [DATE] assessed the resident with a score of "15". A score of 10 or above represents high risk. An incident/accident report dated 10/10/11 at 8:30 p.m. revealed a nurse aide found the resident sitting on the floor leaning next to the bed with no injury noted. The resident identified self as trying to get up. An incident/accident report dated 10/17/11 at 2:30 p.m. revealed a nurse aide found the resident lying on the floor by the bed. The resident did not sustain injury. An incident/accident report dated 11/5/11 at 4:50 a.m. revealed a nurse aide found the resident sitting on buttocks next to bed leaning back on recliner. The resident did not sustain injury and stated he/she did not know what occurred. An incident/accident report dated 11/29/11 at 6:15 a.m. revealed the resident attempted to climb out of bed. The bed was not locked. Staff found the resident on the floor by the window. Observation showed an abrasion to left middle toe and 3 small bruises to the right elbow. An incident/accident report dated 12/9/11 at 5:20 a.m. staff found the resident on the floor beside the bed with head beside easy chair. Observation showed abrasions to the right knee and shin. An incident/accident report dated 12/30/11 at 4:25 p.m. revealed staff found the resident on the floor next to the bed. Observation showed a skin tear to the left upper extremity measuring 1 centimeter (cm). The care plan dated 9/28/11 to 2/8/12 did not identify interventions after these falls. On 1/3/12, an x-ray report indicated the resident had an x-ray of the right hip due to pain after a fall. Review of the nurse ' s notes did not identify the resident had pain after the fall. The x-ray was negative for a fracture. An incident/accident report dated 1/23/12 at 8:30 p.m.; revealed staff found the resident lying on the floor. The resident denied injury. A care plan dated 2/8/12 identified the facility asked Hospice to evaluate for a new bed. This intervention was added to the care plan on 2/9/12. An incident/accident report dated 1/31/12 at 8:50 p.m. revealed a nurse aide found the resident sitting on buttocks on floor with back against the bed. The resident identified self as trying to get up. The resident denied injury. A care plan dated 2/8/12 identified the facility asked Hospice to evaluate the mattress for comfort. This intervention was added to the care plan on 2/9/12. An incident/accident report dated 2/2/12 at 12:15 a.m. revealed staff found the resident lying on the left side on the floor. The resident did not sustain an injury. A care plan dated 2/8/12 identified the facility evaluated the resident for a urinary tract infection. This intervention was implemented on 2/5/12. An incident/accident report dated 3/5/12 at 5:50 a.m. revealed staff found the resident on the floor next to the bed. The resident complained of a headache but did not sustain an injury. A care plan dated 2/8/12 directed staff to offer fluids during incontinence rounds to assist with restlessness. This intervention was implemented on 3/5/12. An incident/accident report dated 3/27/12 at 6:30 a.m. revealed staff found the resident lying on the floor beside the bed. The resident did not know what occurred. The bed in lowest position. The reported identified no injury observed. A care plan dated 2/8/12 identified the facility asked the physician to evaluate the resident for increased restlessness. This intervention was implemented on 3/27/12. A physician encounter form dated 3/27/12 identified the physician ordered BuSpar (antianxiety) 15 milligrams three times per day. None of these interventions identified the facility increased supervision or implemented assistance devices to prevent further accidents. On 4/17/12 at 10:20 a.m., observation revealed the resident ion bed with a wedge and pillows blocking one side of the bed and the other side of the bed against the wall. The bed appeared as regular height. On 4/17/12 at 3:25 p.m. Staff B (nurse aide) stated the wedge is used to keep the resident in bed. If the staff uses the wrong bottom sheet, the resident can get the wedge out or if the staff doesn't place it a certain way, the resident can remove it.