Every finding on record at Rehabilitation Center of Allison

Based on clinical record review, facility policy, resident, and staff interviews, the facility didn't provide necessary treatment and services for a skin tear for 1 of 4 residents (Resident #5). Staff failed to implement physician treatment orders for 10 days, which resulted in the wound bed deteriorating and the surrounding skin becoming soft and broken down. The facility reported a census of 40 residents. Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. She understood others and made herself understood. She didn't show behaviors or resist care. The MDS documented she required partial to moderate assistance from staff for activities of daily living (ADLs) and showed no skin issues. Resident #5 had falls without injury and falls with non-major injuries. Her diagnoses included cerebrovascular accident (CVA) (stroke) and chronic kidney disease (gradual loss of kidney function).The Plan of Care (POC) Focus with a target date of 7/12/26, documented Resident #5 had a risk for alteration in skin integrity related to limited mobility, anemia (low red blood cell count), and fragile skin. Interventions directed staff to administer treatment per physician's orders, follow facility policies for the prevention and treatment of skin breakdown, and observe skin condition during activities of daily living care.The Incident Report Progress Note dated 4/6/26 at 12:40 PM, documented Resident #5 walked back from physical therapy (PT) when her knee gave out. She sat in front of her recliner. Staff lowered her safely to the floor. Staff noted a 2 centimeter (cm) by 2 cm skin tear on the front of her right shin. Staff cleansed the area with wound cleanser and applied a bandage.The Incident Report dated 4/6/26 at 12:40 PM, revealed an order to change the bandage daily until the wound healed.The Non-Pressure Skin Condition Record dated 4/6/26, documented a skin tear to the right shin. Staff cleansed the area and applied a dressing. The area measured 2.0 cm by 2.0 cm.The Non-Pressure Skin Condition Record dated 4/13/26, revealed a dark pink/red tissue wound bed (the surface of the wound) with a reddened area surrounding the skin. The area measured 3.0 cm by 1.0 cm. The record documented a macerated (softened and broken-down skin from moisture) area measuring 2.6 cm by 0.7 cm around the skin tear.The Interdisciplinary Team (IDT) note dated 4/15/26 at 9:22 AM, documented Resident #5 Representative (son) wanted information about a fall. He talked about the wound on her leg. A Registered Nurse (RN) looked at the wound and assessed it. The Representative wanted the primary care provider (PCP) to look at the wound during the next visit.The April 2026 Treatment Administration Record (TAR) didn't contain the order from 4/6/26 to change the bandage daily until healed. The April 2026 TAR documented the dressing started on 4/16/26, with orders to cleanse the right shin and apply a bandage to the skin tear until healed, once a day on the day shift.The facility didn't have documentation of a treatment initiated earlier than 4/16/26.The Office Visit record dated 4/23/26, revealed Resident #5 had a skin tear to the right shin that healed appropriately. She used a Mepilex (absorbent foam dressing). The assessment noted a skin tear of the lower leg without complication.The Non-Pressure Skin Condition Record dated 4/30/26, revealed a partial thickness area with serous exudate (clear, watery drainage). The wound showed dark pink/red tissue and maceration measuring 3.0 cm by 0.5 cm and 2.0 cm by 0.5 cm around the skin tear.On 4/30/26 at 8:30 AM, Resident #5 sat in her recliner with a dressing on the right lower shin.On 5/5/26 at 11:00 AM, Resident #5 stated the area on her right shin hurt when she fell, but it didn't hurt anymore since it almost healed.On 5/5/26 at 11:11 AM, Staff C, Licensed Practical Nurse (LPN), stated she completed the dressing change earlier that morning. She stated the area almost resolved and staff could leave the dressing off. Staff C confirmed the skin tear hurt during dressing changes when staff first observed it.On 5/5/26 at 2:11 PM, Staff D, RN, acknowledged the April 2026 TAR didn't have the treatment orders for the skin tear on 4/6/26 and staff didn't put them on the record until 4/16/26. Staff D confirmed that according to the skin sheets, the area on the right shin deteriorated (got worse). She stated nurses should follow physician orders and perform daily dressing changes. She confirmed the clinical record didn't have documentation of daily treatments.The Skin Management Guide dated November 2023, instructed staff on identifying residents at risk for skin alterations and prevention techniques. The policy directed staff to complete a skin evaluation, notify the physician, and obtain treatment orders when a resident experienced a new injury.

Based on observation, clinical record review, staff interview, and facility policy/procedure, the facility failed to ensure Resident #1 received a timely medical evaluation and assessment following a fall, for 1 of 4 residents reviewed (Resident #1). The failure resulted in harm to Resident #1, who sustained a right hip fracture and experienced severe, prolonged pain for two days before receiving surgical treatment. The facility identified a census of 40 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. Resident #1 sometimes understood others and others sometimes understood Resident #1. No behaviors existed and Resident #1 didn't resist cares. Resident #1 had a joint movement (range of motion) limitation to the lower leg. Resident #1 depended on staff for bathroom cleaning (toileting hygiene) and needed substantial to maximal help to move from one surface to another (transfers). Resident #1 used a wheelchair for mobility. Resident #1 frequently had bladder leakage (incontinence) and always had bowel leakage. The MDS showed no falls, no pain, and the use of a blood thinner (anticoagulant) in the last 7 days. Diagnoses included anemia (low red blood count), heart failure (weak heart), hypertension (high blood pressure), renal insufficiency (reduced kidney function), diabetes mellitus (high blood sugar), aphasia (communication disorder), cerebrovascular accident (CVA) (stroke), reduced mobility, and weakness.The Care Plan with a target date of June 2026, identified acute pain as a focus area. Interventions included giving pain medication per physician (doctor) orders, evaluating the efficiency (how well it worked) of pain management, and evaluating pain levels as ordered. Staff had instructions to offer to lay the resident down to rest and notify the doctor if pain relief appeared inadequate or if pain interventions didn't work. The plan directed staff to notify the physician if current pain represented a significant change from past experiences. Staff also watched for non-verbal signs of pain and any behavior changes in usual routines, sleep patterns, functional abilities, joint movement, and any withdrawal or resistance to cares.The Fall, Suspected/Actual form dated 4/18/26 at 2:15 PM, documented a Certified Nursing Assistant (CNA) called a Nurse to Resident #1's room because they found Resident #1 sitting on the floor. The Nurse found Resident #1 sitting on the floor and assessed the surrounding area for potential triggers. The Nurse finished an initial assessment and noted no injury, and staff helped Resident #1 into a recliner.The Incident Report Note dated 4/19/26 at 6:40 PM, documented a Nurse went to Resident #1's room because Resident #1 was on the floor. According to a CNA, Resident #1's room door stayed closed and Resident #1 yelled for help. Resident #1 showed signs of pain when staff touched his right leg. Staff gave Acetaminophen (Tylenol) and Ativan (anti-anxiety medicine) for pain and anxiety.The Shift Follow up to Incident note dated 4/19/26 at 1:36 AM, labeled late entry, documented Resident #1 appeared restless and agitated. Staff noted facial grimacing (pained look) and Resident #1 complained of pain in the right knee and leg area. Resident #1 rated the pain at an '8' on a 1-10 pain scale (1 low to no pain, with 10 extreme pain).The General Progress Note dated 4/19/26 at 7:11 PM, documented Resident #1 fell on 4/18/26 at 2:15 PM. Staff finished an assessment and noted no visible injury, except for facial expressions of pain when staff touched Resident #1's right leg. A fall follow-up finished on 4/19/26 noted Resident #1's right knee appeared swollen and Resident #1 expressed pain when staff touched the area.The Health Status Note dated 4/20/26 at 7:48 AM, labeled late entry, documented a Nurse approached another Nurse with concerns for Resident #1 and asked for an assessment. After the assessment, a Nurse reported to the Charge Nurse (lead nurse) that Resident #1 needed transported to the hospital for further evaluation.The Communication with physician dated 4/20/26 at 8:05 AM, documented Resident #1 continued to have pain in his right knee and hip following the fall on 4/18/26, and yellow bruising (skin discoloration) appeared on the right knee. Staff used a full-body mechanical lift for transfers. A Nurse asked if an X-ray (bone image) to the right hip and knee appeared appropriate and received a call from a physician at 8:46 AM, for Resident #1 to go to the emergency room (ER) for evaluation.The Communication-with outside vendor dated 4/20/26 at 11:29 AM, labeled late entry, documented a call from a hospital ER nurse. The hospital nurse stated Resident #1 entered the hospital with a fractured (broken) hip and needed surgery the next evening.Resident #1's April 2026 Medication Administration Record (MAR) documented an order for Acetaminophen 500 milligrams (mg), 2 tablets by mouth every 6 hours as needed for pain. Staff gave Acetaminophen on 4/18/26 and 4/19/26 for a pain level of 3 out of a 1-10 scale.The Pain Level Summary with a look back period of 90 days revealed Resident #1 had pain scores of 3 on 4/18/26 at 3:43 PM and on 4/19/26 at 6:00 PM, 6:34 PM, and 8:16 PM. On 4/20/26 at 6:40 AM, Resident #1 had a pain score of 5.The ED to Hosp-admission (Current) report printed 4/21/26 included the following:a. The X-ray report dated 4/20/26, documented an indication of trauma (injury) with an impression of an acute intertrochanteric fracture (hip break) of the right proximal femur (upper thigh bone).b. The X-ray report dated 4/21/26, indicated Resident #1 had status Open Reduction Internal Fixation (ORIF) (surgical bone repair) of a right hip fracture. Skin staples appeared and Resident #1 had no other fractures.c. The Occupational Therapy (OT) Notes dated 4/24/26, documented Resident #1 admitted on [DATE] for an initial fall which resulted in a closed right hip fracture.Observation on 4/28/26 at 8:30 AM, revealed Resident #1 sat in a wheelchair in his room wearing a baseball cap. Resident #1 told his daughter he wanted to lie down. He had both feet on the foot pedals of the wheelchair.On 4/28/26 at 8:30 AM, an attempted interview with Resident #1 revealed mumbled speech and he didn't understand.On 4/28/26 at 10:40 AM, Staff F, Licensed Practical Nurse (LPN), stated Resident #1 complained of his right leg hurting after the fall on 4/18/26. Staff F didn't feel it represented an emergency situation at the time but acknowledged Resident #1 should've gone to the ER due to leg pain complaints. On 4/19/26 at approximately 4:30 PM, Resident #1 started to yell and scream that his right leg hurt and his right knee appeared swollen. Staff F called the Resident #1's Representative who told her to place ice on the knee.On 4/28/26 at 11:50 AM, Staff G, CNA, stated on 4/18/26 after Resident #1 fell, Resident #1 couldn't cross his legs without a lot of pain. Resident #1 cried and whimpered. Staff G stated Resident #1 needed to go to the ER due to the increase in pain and a change in transfers, as Resident #1 needed a mechanical lift with 3 staff members. On 4/19/26, Resident #1 still had a lot of pain and cried during transfers and cares.On 4/28/26 at 12:10 PM, Staff I, CNA, stated on 4/19/26, after the supper meal, Resident #1 sat in a wheelchair across from the nurse station, took his right leg off the foot pedals, rubbed his leg, crying and whimpering in pain. Staff I explained to Staff F that Resident #1 had a lot of pain. Staff F explained that Staff A, Registered Nurse (RN), stated, it is the weekend, what is the hospital going to do anyway, nothing is going to happen.On 4/28/26 at 12:20 PM, Staff C, LPN, explained on 4/20/26, the night aides cried and felt upset because the nurses working the weekend didn't take them seriously when they reported Resident #1 cried in pain when staff touched or moved his right leg.On 4/28/26 at 12:46 PM, Staff J, CNA, stated on 4/19/26, Resident #1 cried out in pain and whimpered during morning cares, saying ow, ow, ow. Staff J told Staff F that Resident #1 had pain and didn't eat, but Staff F stated they completed an assessment and didn't find changes since the fall on 4/18/26.On 4/28/26 at 1:01 PM, Staff K, LPN, reported they worked the overnight shift on 4/18/26 and learned Resident #1 fell around 2:15 PM. The staff told them Resident #1 grimaced in pain and attempted to hold his right leg. Staff K gave Resident #1 anti-anxiety medication and Tylenol. After learning Resident #1 complained of pain, on 4/19/26, Staff K pulled up his pant leg and saw a yellowish color on top of Resident #1's right knee. They attempted to do joint movement, but Resident #1 screamed in pain and fought the movement. Staff K instructed staff to use a mechanical lift for transfers but acknowledged they didn't complete joint movement or an assessment on Resident #1.On 4/28/26 at 3:33 PM, Staff D, RN, and the Director of Nursing (DON) both acknowledged Resident #1 should've gone to the ER after the fall on 4/18/26 due to his pain complaints. They expected if the nursing staff had doubt, they sent the resident out.On 4/29/26 at 12:30 PM, Staff H, LPN, stated the facility expected the staff to send residents out if they had pain or obtain an x-ray at the facility to rule out a fracture.On 4/29/26 at 1:40 PM, the Primary Care Provider (PCP), confirmed Resident #1 needed to go to the ER for an x-ray because of his right leg and knee pain complaints.The Pain Policy dated September 2023, instructed the facility to provide pain management to residents who required it, consistent with professional standards, the Care Plan, and resident goals. If pain medication appeared needed, staff gave it per order, and staff assessed the resident for effectiveness after administration. If pain remained unrelieved despite nursing measures, staff must notify the resident's physician.

Based on resident and staff interviews, policy review, the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 4 resident reviewed. (Resident #6 and Resident #7). The facility identified a census of 40 residents.Findings include:1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She understood others, made herself understood, and didn't show behaviors. Resident #6 depended on staff for toileting hygiene, upper and lower body dressing, and transfers. She required supervision for personal hygiene and used a wheelchair independently. Her diagnoses included cancer, heart failure (the heart doesn't pump blood as well as it should), hypertension (high blood pressure), diabetes mellitus (high blood sugar), and depression.The Care Plan with a target date of 6/30/26, documented Resident #6 preferred to self-administer medications with meals due to gastric (stomach) issues. She'd voice concerns if she didn't have them at specific times. She could see pills and notice if one dropped. Interventions directed staff not to keep medication at the bedside. Staff brought medications with applesauce to Resident #6 so she'd take them during her meal. Staff provided education on proper administration and storage.The Provider Visit Progress Note dated 4/21/26 at 9:15 PM, documented Resident #6 felt upset with the Certified Nursing Assistant (CNA) and Registered Nurse (RN) because she didn't receive medications at supper. Staff told her she couldn't have Tylenol (pain reliever) because she'd taken it too recently. The RN found medications, including Tums (antacid) and Tylenol, in cups on the bedside table. Resident #6 hadn't taken them. She stated she's legally blind and only sees shades and outlines, so she didn't know they're there. The RN reviewed her complaints about cancer medications. All medications for the 4/21/26 time periods appeared punched out of the packs. The RN told her staff gave her the medications properly. She appeared to settle down slightly.On 4/29/26 at 11:08 AM, observed Resident #6 lay in bed with two pillows on each side. A round blue pressure device circled her right ankle to keep it off the mattress, and a dressing covered the outside of her right ankle.On 4/29/26 at 11:30 AM, Resident #6 stated Staff A, RN, who only worked weekends, didn't give her the medications she needed one hour before meals. She claimed she once went all day without eating but couldn't recall the weekend. Resident #6 felt Staff A didn't treat her with the dignity and respect she deserves and felt like a nobody when Staff A worked. Resident #6 informed administration, but they didn't take action.2. Resident #7's Minimum Data Set (MDS) assessment dated [DATE], documented a BIMS score of 15, indicating intact cognition. She understood others and made herself understood without behaviors. She had a limited range of motion (ROM) in her arms and legs. She depended on staff for toileting hygiene, dressing, personal hygiene, and transfers. She used a wheelchair independently. Her diagnoses included neurogenic bladder (bladder dysfunction), cerebrovascular accident (stroke), paraplegia (lower body paralysis), and moisture associated skin damage (skin irritation).The Care Plan with a target date of 6/14/26, documented Resident #7 had behavior problems related to derogatory (insulting) and racist comments toward African American staff. Interventions directed staff to approach and speak in a calm manner and communicate clearly what behaviors aren't acceptable. Resident #7 stated she doesn't want Black men performing personal care, though they could bring medications.The Interdisciplinary Team (IDT) meeting notes dated 3/18/26 at 6:18 AM labeled Late Entry, documented Resident #7 and her daughter complained about agency staff. They claimed staff didn't listen, acted rude, and walked out before meeting her needs. The daughter stated she witnessed this. The facility initiated a grievance (formal complaint).On 4/29/26 at 11:40 AM, witnessed Resident #7 sitting in a motorized wheelchair in her room while dressed appropriately.On 4/29/26 at 11:40 AM, Resident #7 stated Staff A didn't treat her with the dignity and the respect she deserved. She felt she's a person and wanted treatment as such.On 4/29/26 at 4:33 PM, the Director of Nursing (DON) acknowledged staff should treat all residents with dignity and respect.On 5/5/26 at 10:30 AM, the Administrator acknowledged staff should treat residents with dignity and respect.The Resident Rights-Dignity and Respect policy dated April 2024, directed each resident has the right to considerate and respectful care and to treatment with honesty, dignity, and respect.

Based on clinical record review, resident and staff interviews, the facility didn't ensure timely notification of incidents to the legal representative or the Hospice provider for 2 of 4 residents (Resident #2 and Resident #4). The facility reported a census of 40 residents.Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of 4, indicating severely cognitively impaired. She understood others and made herself understood. She didn't show behaviors. Resident #2 required partial to moderate assistance from staff for toileting hygiene, upper and lower body dressing, and personal hygiene. She performed transfers and ambulation (walking) independently. She had two falls without injury and one fall with a minor injury. Diagnoses included heart failure (heart pumping problem), hypertension (high blood pressure), Alzheimer's Disease (progressive brain disorder), and non-alzheimer's dementia (cognitive decline).The Communication with Hospice dated 3/10/26 at 10:00 AM, documented a Registered Nurse (RN) informed the Hospice Nurse that Resident #2 had a fall the previous night at 6:50 PM. The Hospice Nurse asked why no one called to report the incident so a representative could examine Resident #2. The RN stated they didn't know why staff didn't call.The Communication with Hospice dated 3/10/26 at 1:00 PM, documented the Hospice Nurse called to confirm Resident #2 fell again the previous night. Staff confirmed reports of a fall two nights in a row. The Hospice Nurse stated Resident #2's wife didn't receive a call regarding the incidents and felt upset. Staff added a note to remind nurses to call families and providers when incidents happen.2. Resident #4's Minimum Data Set (MDS) assessment dated [DATE], documented she had a BIMS score of 12, indicating moderately impaired cognition. She understood others, didn't show behaviors, and didn't resist care. Resident #4 required substantial to maximal assistance with activities of daily living (ADL) (everyday tasks). She needed assistance with transfers and ambulation. She had falls prior to admission. Diagnoses included heart failure, hypertension, non-Alzheimer's dementia, history of falling, and abnormalities of gait (walking style) and mobility.The Incident Report dated 4/22/26 at 11:09 PM, documented a Certified Nursing Assistant (CNA) assisted Resident #4 to bed when she lost her balance and fell backward onto her bottom. Resident #4 wore appropriate footwear, a gait belt (safety strap), and used a wheeled walker while staff assisted her. Staff didn't notify the family at that time.The Communication with Hospice dated 4/23/26 at 11:08 AM, documented an RN informed Hospice that Resident #4 had a witnessed fall the previous night at 8:15 PM. Hospice staff didn't know about the fall and stated they'd call Resident #4 Representative (son) to provide an update.The Incident Report dated 4/27/26 at 11:35 PM, documented staff found Resident #4 sitting on the floor in front of the bathroom door with one leg bent inward and the other fully extended. No injuries appeared at that time. The record didn't show documentation of family notification for this fall.The Shift Follow up to Incident Note dated 4/28/26 at 1:16 AM, documented staff found Resident #4 on the floor. She also fell on 4/25/26 while attempting to transfer herself. Staff called Hospice at this time. Resident #4's left elbow appeared swollen, and she reported pain.The Communication with Hospice dated 4/28/26 at 1:25 AM, documented staff called the on-call Hospice regarding bruises on Resident #4's left elbow and older bruises on her right upper arm and elbow. Staff hadn't called the family regarding the fall that evening.Observation on 4/30/26 at 12:00 PM, showed staff pushing Resident #4 to the dining room in a wheelchair. She had her left arm elevated on a pillow, and her right pinky finger had buddy tape (taping fingers together for support) to the adjacent finger.On 4/30/26 at 1:44 PM, Resident #4 Representative stated he received a phone call from the Hospice Nurse on 4/26/26 at 1:50 AM. The nurse told him Resident #4 had a fall on 4/25/26. He stated he'd like notification of falls when they happen instead of hours later or the following day.On 5/5/26 at 3:01 PM, the facility Director of Nursing (DON) confirmed nurses should notify families immediately after an incident.

Based on clinical record review, resident and staff interviews, and facility policy, the facility didn't ensure 2 of 4 residents (Resident #6 and Resident #7) received showers in accordance with their Plan of Care (POC). The facility identified a census of 40 residents.Findings include:1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She understood others and made herself understood without behaviors. She depended on staff for shower/bathing. Her diagnoses included cancer, heart failure (pumping problem), hypertension (high blood pressure), diabetes mellitus (high blood sugar), and depression.On 4/29/26 at 11:30 AM, Resident #6 stated she only gets 1 shower a week and wanted 2 showers a week.The Plan of Care (POC) with a target date of 6/30/26, documented Resident #6 required assistance with activities of daily living (ADL) (everyday tasks) related to poor eyesight, impaired mobility, and incontinence (loss of bladder or bowel control). Interventions directed staff to assist Resident #6 with a shower or bath per the schedule two times per week.Review of the electronic health record (EHR) titled POC Response History, documented staff scheduled Resident #6 for showers on 3/11/26 and 3/29/26. She didn't receive a shower on those dates.Review of the EHR for April 2026, documented staff scheduled a shower for Resident #6 on 4/5/26. She didn't receive a shower on 4/5/26.2. Resident #7's Minimum Data Set (MDS) assessment dated [DATE], documented she had a BIMS score of 15, indicating intact cognition. She understood others and made herself understood without behaviors. She had functional limitations in her range of motion (joint movement) in her arms and legs. She depended on staff for showers, toileting hygiene, dressing, and personal hygiene. Her diagnoses included neurogenic bladder (bladder dysfunction), cerebrovascular accident (stroke), paraplegia (lower body paralysis), and moisture associated skin damage (skin irritation).The Plan of Care (POC) with a target date of 6/14/26, documented Resident #7 required assistance with ADLs related to a stroke and impaired mobility. Interventions directed staff to assist Resident #7 with a shower or bath per the schedule.On 4/29/26 at 11:40 AM, Resident #7 stated she hadn't received a shower twice a week. She stated she'd refuse a bed bath and wanted 2 showers a week.Review of the EHR for March 2026, documented staff scheduled Resident #7 for a shower on 3/16/26. She didn't receive a shower on 3/16/26.Review of the EHR for April 2026, documented staff scheduled showers for Resident #7 on 4/2/26, 4/6/26, and 4/9/26. She didn't receive showers on those dates.On 5/5/26 at 10:30 AM, the Administrator stated the facility expected staff to provide 2 showers or baths per week for all residents.The Hygiene-Bathing/Shower policy dated March 2024, directed staff to cleanse skin to promote cleanliness and prevent infection. Staff may complete hygiene by bed bath, tub bath, or shower.

Based on clinical record review, resident and staff interviews, and facility policy review the facility failed to ensure one 2 of 5 residents received adequate supervision to protect against hazards in the environment. (Resident #1 and Resident #4). Record review and staff interviews revealed Resident #1 room door required to be open and on 4/19/26, Resident #1 had his room door closed, was yelling for help and was found by staff sitting on the floor with complaints of right knee pain and sustained a right hip fracture. Record review and staff interviews revealed Resident #4 required assistance of two staff for transfer. On 4/22/26, one nursing staff person assisted Resident #4 to transfer. The resident lost balance and fell backwards onto the floor. The facility reported a census of 40 residents.Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. He understood others sometimes and staff understood him sometimes. He didn't show behaviors or resist care. Resident #1 showed functional limitation in range of motion (joint movement) to his lower extremity. He depended on staff for toileting hygiene and required substantial to maximal assistance with transfers. He used a wheelchair for mobility. He frequently showed incontinence (loss of control) of bladder and always showed incontinence of bowel. The MDS documented he had no falls and reported no pain. His diagnoses included anemia (low red blood cells), heart failure (pumping problem), hypertension (high blood pressure), renal insufficiency (kidney underperformance), diabetes mellitus (high blood sugar), aphasia (communication disorder), cerebrovascular accident (stroke), reduced mobility, and weakness.The Care Plan Focus with a target date of 6/18/26, documented Resident #1 had a risk for falls related to impaired cognition, weakness, impaired mobility, and history of falls. Interventions directed staff to perform frequent visualization (visual checks), keep the door open, check him frequently, and place a mattress next to the bed when he's in bed.The Behavior Note dated 4/16/26 at 4:34 AM, documented Resident #1 attempted to get his legs off the bed or roll close to the edge of the bed. Staff should leave the door open at night.The Incident Report Note dated 4/19/26 at 6:40 PM, documented a Registered Nurse (RN) responded to Resident #1's room and found him sitting on the floor. Staff told the RN that Resident #1's door remained closed while he yelled for help.The 5-day Investigation Report dated 4/24/26, documented camera footage showed staff entering Resident #1's room when he sat on the floor and called for help. Staff E, Certified Nursing Assistant (CNA), stated during an interview she performed hourly checks and heard yelling. She followed the voice and when she opened the door, she saw Resident #1 on the floor.On 4/28/26 at 8:30 AM, Resident #1 sat in a wheelchair in his room wearing a baseball cap. He told staff he wanted to lie down.On 4/28/26 at 8:30 AM, when the staff attempted to interview Resident #1, his speech sounded non-coherent and mumbling.On 4/28/26 at 10:40 AM, Staff F, Licensed Practical Nurse (LPN), confirmed Resident #1's room door needed to stay open at all times.On 4/28/26 at 2:05 PM, Staff E confirmed Resident #1's room door remained closed when she heard yelling. She confirmed the door should stay open at all times.On 4/28/26 at 11:50 AM, Staff G, CNA, confirmed Resident #1's room door needed to stay open at all times per the POC due to Resident #1 attempting to get up on his own.On 4/28/26 at 3:33 PM, Staff D, RN, and the Director of Nursing (DON) both confirmed the incident report showed the room door remained closed. They confirmed the POC required the door to stay open at all times due to Resident #1 attempting to transfer by himself.2. Resident #4's Minimum Data Set (MDS) assessment dated [DATE], documented a BIMS score of 12, indicating moderately impaired cognition. Staff understood her, and she didn't show behaviors or resist care. Resident #4 required substantial to maximal assistance with activities of daily living (ADLs) (everyday tasks). She needed assistance with transfers and ambulation (walking). She had falls documented prior to admission. Her diagnoses included heart failure, hypertension, non-Alzheimer's dementia (brain function decline), history of falling, and abnormalities of gait (walking pattern) and mobility.The Care Plan documented Resident #4 required assistance with ADLs and had a risk for falls. Interventions directed staff to use 2 staff members to assist with a walker and gait belt (safety belt) for transfers and ambulation.The Fall, Staff Assist Report dated 4/22/26 at 10:15 PM, documented an RN received a report that while staff assisted Resident #4 to bed, they lowered her to the floor. She wore appropriate footwear, a gait belt, and used a wheeled walker. She didn't hit her head. Resident #4 stated she just lost her balance and fell backwards.The Incident Report in the progress notes dated 4/22/26 at 11:09 PM, documented an aide assisted Resident #4 to bed when she lost her balance and fell onto her bottom.On 5/5/26 at 3:01 PM, Staff D confirmed staff should use 2 people for transfers if the POC directed it.On 5/5/26 at 3:01 PM, the DON acknowledged staff should transfer Resident #4 with 2 staff members at all times.

Based on resident and staff interviews, call light logs and the facility policy/procedure, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 3 of 4 residents reviewed (Resident #4, #6 and Resident #7). The facility identified a census of 40 residents.Findings include:1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. She understood others and made herself understood. She didn't show behaviors or resist care. Resident #4 required substantial to maximal assistance with activities of daily living (ADLS) (everyday tasks). She showed frequent incontinence (loss of control) of urine and occasional incontinence of bowel. Her diagnoses included heart failure (pumping problem), hypertension (high blood pressure), non-Alzheimer's dementia (brain function decline), history of falling, and abnormalities of gait (walking pattern) and mobility.On 4/30/26 at 2:22 PM, Resident #4 stated staff took over 15 minutes to answer her call light.Review of the Past Calls report from 4/25/26 through 4/26/26, for all shifts, documented Resident #4's call light stayed on for 32 minutes on 4/25/26.2. Resident #6's Minimum Data Set (MDS) assessment dated [DATE], documented a BIMS score of 15, indicating intact cognition. She understood others, made herself understood, and didn't show behaviors or resist care. Resident #6 depended on staff for ADLS. Her diagnoses included cancer, heart failure, hypertension, diabetes mellitus (high blood sugar), and depression.On 4/29/26 at 11:30 AM, Resident #6 stated staff took over 15 minutes to answer her call light.Review of the Past Calls report from 4/25/26 through 4/26/26, for all shifts, documented Resident #6 had call light wait times over 15 minutes on 4/25/26 at 11:44 PM for 16.11 minutes, on 4/26/26 at 8:59 AM for 27.28 minutes, and on 4/26/26 at 1:52 PM for 22.33 minutes.3. Resident #7's Minimum Data Set (MDS) assessment dated [DATE], documented a BIMS score of 15, indicating intact cognition. She understood others, made herself understood, and didn't show behaviors or resist care. She showed functional limitation in her range of motion (joint movement) in her arms and legs. She depended on staff for showers, toileting hygiene, dressing, and personal hygiene. Her diagnoses included neurogenic bladder (bladder dysfunction), cerebrovascular accident (stroke), paraplegia (lower body paralysis), and moisture associated skin damage (skin irritation).On 4/29/26 at 11:40 AM, Resident #7 stated staff took over 15 minutes to answer her call light. She stated she'd holler and yell until someone came to assist.Review of the Past Calls report from 4/25/26 through 4/26/26, for all shifts, documented Resident #7 had call light wait times over 15 minutes on 4/25/26 at 11:27 AM for 16.18 minutes and on 4/26/26 at 9:18 AM for 21.31 minutes.On 4/29/26 at 4:33 PM, the Director of Nursing (DON) acknowledged staff should answer resident call lights within 15 minutes.On 4/30/26 at 11:00 AM, Staff B, Certified Nursing Assistant (CNA), confirmed staff should answer call lights within 15 minutes. She stated staff shortages prevented this from happening consistently.On 5/5/26 at 10:30 AM, the Administrator acknowledged staff should answer call lights within 15 minutes. He verified the call light log showed residents waiting over the 15-minute expectation.The Call Light policy dated September 2023, directed staff to provide a prompt response to residents' calls for assistance. The facility ensured the call system stayed in proper working order. The policy instructed staff to answer call lights in a timely manner.

2. On 6/24/25 at 9:28 AM Resident #143 was noted to have multiple days' worth of facial hair growth. At that time, he explained he preferred to be clean shaven. Further explained he had a shower scheduled later that morning and would like to be shaven at that time. On 6/24/25 at 4:01 PM Resident #143 explained he did have his shower but the CNA failed to shave him. The Care Plan for interventions for Resident #143 included the information that historically he likes to be clean shaven. During an interview on 6/25/25 at 11:05 AM, Staff C explained men should be shaven daily. During observations on 6/25/25 at 10:22 AM and 6/26/25 at 8:51 AM the resident remained unshaven. During an interview on 6/26/25 at 10:24 AM Staff A explained men should be asked if they want to shave daily. On 6/26/25 at 10:26 AM, Staff A and the surveyor went to Resident #143's room. Staff A acknowledged the facial hair growth. She asked the Resident if he prefers to be clean shaven. He explained he asked to be shaved a couple days ago, but it didn't get done. He further explained he has his own razor but was told the facility had a razor they would use to shave him. Based on clinical record review, observation, resident and staff interviews, the facility failed to ensure residents are treated with dignity and respect for 2 of 2 residents reviewed (Residents #31 and #143). The facility reported a census of 39 residents. Findings include: 1. Resident #31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score 14 out of 15 indicating intact cognition. The MDS documented Resident #31 as independent (Resident completes the activity by themselves with no assistance from a helper for self-care.) for eating, oral hygiene, upper and lower body dressing, and mobility. The MDS documented Resident #31 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for shower/bathe self and tub/shower transfers. The MDS included diagnoses of coronary artery disease, diabetes mellitus, and leukemia. The Care Plan Focus identified Resident #31 has behavior problems related to becoming verbally aggressive towards staff and other residents. The following interventions directed staff to: a. Approach/speak in a calm manner. b. Assure the resident that concerns are validated and the staff is willing to address legitimate concerns. c. Communicate clearly and assertively what behaviors are unacceptable and inappropriate. d. Document behaviors and response to interventions. e. Intervene as necessary to protect the rights and safety of others. f. Monitor behavior episodes and attempt to determine underlying cause. A Progress Note dated 6/21/25 at 6:11 PM described an incident that occurred around lunch time between Staff M, Housekeeper and Resident #31. Resident #31 reported to Staff A, Licensed Practical Nurse (LPN) that Staff M would not leave her room. Staff M reported Resident #31 did not want the light on and stated she needed the light on to clean. Staff A directed Staff M to leave the room. Staff M failed to leave the room and continued dusting. When she finished, she left the room. Staff M failed to respect Resident #31's preferences to leave the light off and to leave the room when requested. In an interview on 6/24/25 at 9:31 AM Resident #31 reported she had been watching a movie and wanted to see the end of the movie when the incident with Staff M occurred. Resident #31 verbalized she asked Staff M to turn off the light when she was finished cleaning. She reported Staff M stepped out of the room and failed to turn the light off so she rose and turned off the light. Resident #31 reported Staff M re-entered the room to continue cleaning and turned the light back on. Resident #31 reported she did ask Staff M to come back later. In an interview on 6/24/25 at 11:40 AM, Staff M verbalized she recalled Resident #31 said it was okay to clean the room. Staff M revealed she had stepped out of the room to get a rag off of her cart. When she re-entered the room, the light had been turned off. Staff M reported she had turned the light back on. Resident #31 reacted by hollering at her that she did not want the light on. Staff M revealed if Resident would have asked, she would have come back at a later time to clean. Staff M acknowledged she had been trained on dependent adult abuse and resident rights. In an interview on 6/24/25 at 12:17 PM Staff A, LPN reported she had been called down to the resident's room on 6/21/25 at approximately 12:20 PM. Staff M and Resident #31 had not been heard talking when she entered the room. When Staff A informed Resident #31 that she had been called down to the room, Staff M and Resident #31 began bickering about the light being on/off. Staff A revealed to Staff M that she should have come back at a later time and directed Staff M to leave the room. In an interview on 6/24/25 at 12:51 PM with Staff N, Housekeeping Supervisor verbalized resident rooms are cleaned once per week unless the room needs it more often. On weekends resident rooms are vacuumed or mopped, check the garbage, restock bathroom and mop the bathroom floor. Staff N acknowledged the light should be on when cleaning. Staff N acknowledged if a resident did not want the room light on, the housekeeper should return at a later time. On 6/24/25 at 3:10 PM the Administrator acknowledged training videos had been assigned to review resident rights and abuse. Review of the Iowa Time Card report revealed Staff M had not punched out until 3:05 PM on 6/21/25. Review of the facility Patient Protection Guidelines, Abuse Prevention, Reporting and Investigation policy revised in May 2025 documented employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse, neglect, exploitation, mistreatment, misappropriation, patient rights, reporting reasonable suspicion of crime, and use of computers/phone/electronic devices specific to audio/video recordings.

Based on record review, policy review, personnel files review, resident and staff interviews the facility failed to prevent a staff member alleged of potential abuse of a resident (Resident #31) from contact with other residents. The facility reported a census of 39 residents. Findings include: Resident #31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score 14 out of 15 indicating intact cognition. The MDS documented Resident #31 as independent (Resident completes the activity by themselves with no assistance from a helper for self-care.) for eating, oral hygiene, upper and lower body dressing, and mobility. The MDS documented Resident #31 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for shower/bathe self and tub/shower transfers. The MDS included diagnoses of coronary artery disease, diabetes mellitus, and leukemia. The Care Plan Focus identified Resident #31 has behavior problems related to becoming verbally aggressive towards staff and other residents. The following interventions directed staff to: a. Approach/speak in a calm manner. b. Assure the resident that concerns are validated and the staff is willing to address legitimate concerns. c. Communicate clearly and assertively what behaviors are unacceptable and inappropriate. d. Document behaviors and response to interventions. e. Intervene as necessary to protect the rights and safety of others. f. Monitor behavior episodes and attempt to determine underlying cause. On 6/21/25 at 2:26 PM the Administrator contacted Iowa Department of Inspections, Appeals and Licensing to submit and initial report for potential dependent adult abuse. A review of the Progress Noted dated 6/21/25 at 6:11 PM documented an incident had occurred between Staff M, Housekeeper and Resident #31. The Progress Note revealed the nurse was paged by the housekeeper to the resident room. I got there, Resident #31 was pushing her lunch tray away and looked frazzled with flushed cheeks. I asked her if she was ok, she said yes I said I was asked to come down here she said yes, because she won't leave my room then the housekeeper said I paged because she put her hands on me I asked Resident #31 what happened as the housekeeper was dusting and said she didn't want the light on but I need the lights on to clean (Lights are off at this time) I said so she put her hands on you? The housekeeper said yes as Resident #31 yelled yes, because she pushed me! Then the housekeeper said because you grabbed me! I stopped them and asked the housekeeper to leave the room and told her when the resident says not right now then they need to come back at a later time. She continued dusting, finished, then left the room. I stayed and asked Resident #31 if she was ok, she stated no I said tell me what happened. She said the housekeeper came in and wanted to clean and I didn't want her to turn the light on to do the cleaning but she kept insisting that she had to have the lights on to clean and she couldn't see without the lights! She said I grabbed her to get her away from the light then the housekeeper pushed me I asked if I could see her skin, she said for what? I stated to see if it left any marks she said no, she didn't push me that hard she stated I just think when I ask if they can wait to do something than it can wait until later. I am in my room today because my teeth, bottom plate, is bothering me and it hurts to chew. I asked if she wanted something for the pain and she stated no, I don't like to take any more medications then what I have to I told her I could tell people to stay out of her room this weekend so she could rest if she would like and she said no, I don't mind if they come to do what they need to do just not when I don't want them in here. They can come back. I told her she is right, asked if she was ok again, she said she will be. Assessment of Resident including range of motion & Pain: within normal limits Vital Signs - If FALL include Ortho B/P: 130/79,80, 95%, 98.8, 18, no pain Describe Any Injury Noted: none noted at this time List Any Treatment Provided: emotional support List Relevant Interventions That Were In Place At The Time of The Incident: Removed the housekeeper from the situation Preliminary Recommendations, if any, for consideration as further preventative measures:: respect resident wishes List Responsible Party Notified: daughter Which Physician Was Notified - Include Date & Time of Notification: Primary Physician notified at 1822 During an interview on 6/24/25 at 9:31 AM Resident #31 recalled the incident from 6/21/25. Resident #31 revealed she had wanted to finish watching a movie and had the lights off in her room. Staff M, Housekeeper had wanted to clean the room. Resident #31 allowed Staff M to enter the room. Staff M left the room and had not shut the light off so Resident 31 shut the light off. Staff M re-entered the room and turned the light on. Resident #31 revealed she rose from her chair to go shut the light off. Staff M had been near the light switch. Resident stated she had reached over Staff M's right shoulder as she was reaching for the light. Resident #31 revealed Staff M had raised her hand up with fingers open, her elbows along her side. Resident #31 acknowledged staff did not extend her arms nor was any force or pressure felt as Resident #31 continued to move forward. Resident did not appear fearful, agitated or anxious as she recalled the incident. Resident acknowledged she had no injuries. During an interview on 6/24/25 at 11:40, Staff M recalled the incident. Staff M revealed as Resident #31 reached for the light the resident had grabbed her arm. Staff M acknowledged there had been no marks left on her arm. Staff M acknowledged she had raised her hands up as the resident was coming towards her. Staff M could not recall if her hands actually touched the resident. Staff M revealed when her hands were up the resident was less than 6 inches away from her. Staff M acknowledged when she left the residents room she continued cleaning other resident rooms. Staff M acknowledged she went in to approximately 18 (all of east hall way and approximately half of the south hallway rooms) rooms. Staff M revealed residents had been in all rooms but 2. Staff M acknowledged no other staff members had accompanied while she continued to clean resident rooms. During an interview on 6/24/25 at 12:17 PM, Staff A revealed she had directed Staff M to leave Resident #31's room. Staff A acknowledged she separated Staff M from the resident but failed to separate Staff M from all other residents. During an interview on 6/24/25 at 1:50 PM, Staff D, LPN acknowledged she had been the nurse on call on 6/21/25 and had received a call from Staff A. Staff D directed Staff A to get statements and to call the Administrator. Staff D acknowledged she failed to provide direction to remove Staff M from potential contact with all residents. During an interview on 6/24/25 at 3:10 PM, the Administrator acknowledged she had been notified around 1:00 PM on 6/21/25. When the Administrator returned the call to the facility, Staff A thought Staff M had already left the facility. Review of the Personnel File for Staff M revealed a Dependent Adult Abuse training certificate dated 12/30/22. Review of the Personnel File for Staff A revealed a Dependent Adult Abuse training certificate dated 4/6/25. Review of the facility policy Patient Protection Guidelines, Abuse Prevention, Reporting and Investigation with a revision date of May 2025 directed the following: Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse, neglect, exploitation, mistreatment, misappropriation, patient rights, reporting reasonable suspicion of crime, and use of computers/phone/electronic devices specific to audio/video recordings. Protection Upon receiving a report of an allegation of resident abuse, neglect, exploitation, injuries of unknown origin or misappropriation, the facility shall immediately implement measures to prevent further potential abuse of resident from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances (3) separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with residents.

Based on clinical record review, policy review, and staff interview the facility failed to thoroughly investigate an allegation of abuse. The facility failed to conduct resident and staff interviews for the date of the incident to determine the extent of the allegation or determine if other residents had been affected. The facility reported a census of 39 residents. Findings include: Resident #31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score 14, indicating intact cognition. The MDS documented Resident #31 as independent (Resident completes the activity by themselves with no assistance from a helper for self-care.) for eating, oral hygiene, upper and lower body dressing, and mobility. The MDS documented Resident #31 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for shower/bathe self and tub/shower transfers. The MDS included diagnoses of coronary artery disease, diabetes mellitus, and leukemia. The Care Plan Focus identified Resident #31 has behavior problems related to becoming verbally aggressive towards staff and other residents. The following interventions directed staff to: a. Approach/speak in a calm manner. b. Assure the resident that concerns are validated and the staff is willing to address legitimate concerns. c. Communicate clearly and assertively what behaviors are unacceptable and inappropriate. d. Document behaviors and response to interventions. e. Intervene as necessary to protect the rights and safety of others. f. Monitor behavior episodes and attempt to determine underlying cause. The Progress Note Incident Report for 6/21/25 6:11 PM documented by Staff A, LPN revealed Resident #31 stated Staff M, Housekeeper had pushed her while in the residents' room. Staff A completed an assessment of Resident #31 including range of motion and pain and documented to be within normal limits. Vital signs - blood pressure: 130/79, pulse 80, O2 saturation 95%, temperature 98.8, and respirations 18, Resident had no pain. Describe any injury noted: none noted at this time List any treatment provided: emotional support List relevant interventions that were in place at the time of the incident: removed the housekeeper from the situation. Preliminary recommendations, if any, for consideration as further preventative measures: respect resident wishes. Staff A notified the resident representative and primary physician. The Investigation Report submitted by the facility had been received on 6/23/25. The facility investigation lacked documentation of interviews with other residents and staff. It further lacked documentation of investigation if Staff M had contact with other residents following the incident. Recommendations in the Investigation Report listed re-education for housekeeping and dietary employees but lacked training or re-education for other department employees. In an interview on 6/24/25 at 12:17 PM, Staff A reported she had notified the nurse manager on call for 6/21/25 at approximately 12:38 PM. Staff A had been directed to obtain written statements and to call the Administrator. Staff A revealed the Administrator had called back at approximately 2:30 PM and reported to the Administrator that Staff M had finished her shift and left the facility. Staff A acknowledged she failed to keep a potential abuser from contact with other residents. In an interview on 6/24/25 at 1:50 PM, Staff D, LPN acknowledged she had been the nurse manager on call for 6/21/25. Staff D verbalized she had directed Staff A to obtain written statements from everyone and disclosed it was a possible allegation of abuse that would need to be reported. Staff D sent a text message to the Administrator to inform her of the nurse calling in regards to the incident. In an interview on 6/24/25 at 3:00 PM, the Director of Nursing (DON) acknowledged she had been notified by the Administrator about the incident on 6/21/25 at approximately 2:30 PM. The DON reported she had been out of town and the Administrator did not direct her to do anything. The DON verbalized the Administrator had reported the incident to the Iowa Department of Inspections, Appeals and Licensing. In an interview on 6/24/25 at 3:10 PM, the Administrator reported she had called the Iowa Department of Inspections, Appeals and Licensing on 6/21/25 at 2:26 PM. The Administrator provided 2 hand written statements from Staff A and Staff M. The Administrator reported she had no other statements on file for the investigation of the incident. In an interview on 6/25/25 at 9:55 AM, the Administrator reported she had not interviewed any other residents as part of her investigation. The Administrator acknowledged she had spoken with Staff A, Staff M, Staff O, Laundry and Staff P, Dietary Manager and no other staff members that had worked on 6/21/25. The Administrator verbalized she had been continuing her investigation and reiterated she had 5 days to submit a summary. On 6/26/25 at 1:37 PM the Iowa Department of Inspections, Appeals and Licensing had received additional information to the facilities Investigation Report. The Investigation Reported included 1 additional staff statement and re-education of all staff on residents' rights, including the right to refuse care can control of their environment.

Based on schedule review, time card review, staff interview, and facility policy review the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. The facility reported a census of 40 residents. Findings include: According to a calendar dated February 2025 compared to Attendance on Demand forms dated 2/1/25 through 2/28/25, the facility failed to staff an RN on 2/8/25 as required. During an interview 3/14/25 at 3:20 PM the Director of Nursing (DON) confirmed 2/8/25 as the only day she couldn't account for the required 8 hours of RN coverage.

Based on clinical record review, staff interview and facility policy review the facility failed to implement Care Plans for two (2) of 3 residents reviewed (Residents #1 and #2). The facility reported a census of 40 residents. Findings include: 1. The Care Plan Focus with a target date of 4/25/25 identified Resident #1 required assistance with activities of daily living (ADLs). Resident #1 used a wheelchair for mobility and cognitive impairment. She liked to have her stuffed animals with her. Resident #1 chose to wear a pair of safety glasses that aren't prescription. She used a foot bolster on her wheelchair pedals to keep her feet up. a. Resident #1 transferred with assistance from 2 staff and a lift device for all transfers. On 3/14/25 at 1:03 PM observed with the Director of Nursing (DON), Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA, as they placed a gait belt assistive device on Resident #1, then transferred her from the wheelchair to her bed with the assistance of 2 staff and no lift device. According to an email dated 3/21/25 at 1:18 PM the DON, present at the time of Resident #1's transfer, confirmed she observed the same transfer. 2. The Care Plan Focus with a target date of 5/19/25 indicated Resident #2 required assistance with ADLs related to impaired cognition and weakness. She used a wheelchair for mobility and wore glasses. Resident #2 wore socks with her sandals to protect her toes. a. Resident #2 used a mechanical lift device for all functional transfers. (not dated) An Incident Report form dated 3/17/25 at 1:30 AM indicated the staff found Resident #2 on the floor and assisted her from the floor to the bed with the assistance of (3) staff and a gait belt assistive device.

Based on electronic health records (EHR) review, staff interview and facility policy review the facility failed to provide complete and accurately documented electronic health records for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 28 residents. Findings include: A Controlled Medication Utilization Record form generated from the facilities pharmaceutical provider dated 9/30/24 indicated the facility received 60 Lorazepam/Ativan 0.25 milligram (mg) tablets (which were 30 - 0.5 mg tablets cut in half by the pharmacy) on 9/30/24. The order directed to administer twice daily (BID) and one (1) by mouth (po) every 12 hours as needed (PRN) for Resident #2. Further review of the form reflected an unknown staff member crossed off the number 30 in the quantity received section of the form and changed it to 60 1/2 tablets but failed to sign and date the change. In addition, the form included an entry on 10/1/24 at 10:17 AM that Staff B, Licensed Practical Nurse (LPN) administered 1 Lorazepam pill. During an interview on 10/30/24 at 4:00 PM the Director of Nursing (DON) confirmed the above stated signature as Staff A, LPN, and not Staff B. During an interview on 10/30/24 at 3:31 PM Staff A, confirmed she crossed off the documented 30 pills written on the sheet by the pharmacy and changed the count to 60 1/2 tablets, in addition to proceeding to sign/[NAME] the name of Staff B for the administration of the Lorazepam. During an interview on 11/7/24 at 11:24 AM Staff B confirmed Staff A signed/forged her signature on 10/1/24 at 10:17 AM on Resident #2's Ativan Controlled Medication Utilization Record form dated 9/30/24. According to an email on 11/7/24 at 2:24 PM the Administrator confirmed the nurses had the responsibility to report discrepancies to their supervisor. The facilities Controlled Medications policy last revised 6/16/16 explained the facility had systems which accounted for the receipt, usage, disposition and reconciliation of controlled medications. The Procedures included the following: If discrepancies are noted during the verification of the delivery from the pharmacy, the pharmacy, DON, and/or Administrator need contacted for further assistance. If discovered after normal working hours, the facility should contact the dispensing pharmacy's on-call pharmacist with the DON and/or Administrator. The staff would initiate a new MP5211 form (Individual Resident's Controlled Substance Record) for each controlled medication if the pharmacy failed in providing a controlled substance flow sheet. When using the MP5211 form, document the medication name, medication amount, dosage, method of administration, pharmacist name (may write the name of the pharmacy rather than the pharmacist's name), amount ordered, amount received, signature of nurse receiving medication, and date.

Based on observation, clinical record review, staff interview and manufacturer ' s recommendations, the facility failed to administer insulin according to manufacturer ' s recommendations for 1 of 1 residents reviewed for administration of insulin utilizing an insulin pen (Resident #36). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) of 6 indicating severe cognitive impairment. The MDS further revealed the resident had a diagnosis of diabetes mellitus. Review of the August 2024 Medication Administration Record for Resident #36 revealed an order to inject 6 units insulin Aspart solution subcutaneously three times a day. On 8/28/24 at 11:16 AM observed Staff B, Licensed Practical Nurse (LPN) prepare Resident #36 ' s insulin pen with 6 units of Aspart insulin. Staff B failed to prime the insulin pen. Following preparation of the insulin pen, observed Staff B administer 6 units of insulin subcutaneously into Resident #36 ' s stomach. Following administration of the insulin, Staff B immediately removed the insulin pen. Review of manufacturer ' s recommendation for the NovLog FlexPen provided by the Director of Nursing (DON) documented before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: a. Turn the dose selector to select 2 units. b. Hold the NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. c. Keep the needle pointing upwards, press the push-button all the way in until the dose selector returns to 0. Further review of the manufacturer ' s recommendations for the NovLog FlexPen under giving the injection revealed the following: a.Insert the needle into the skin. b.Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer. c.Keep the needle in the skin for at least 6 seconds, and keep the push button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given. During an interview 8/28/24 at 11:34 PM the DON acknowledged Staff B, LPN failed to prime the insulin pen and failed to keep the insulin pen in place for a period of time following administration as expected. On 8/28/24 at 3:55 PM, the Administrator revealed the facility did not have specific policies related to medication administration or insulin administration as they would follow professional nursing standards.

Based on observation, clinical record review and staff interview, the facility failed to complete pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis (Resident #32). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #32 had a Brief Interview for Metal Status (BIMS) of 99 indicating the resident was unable to complete the assessment. The MDS further revealed the resident had a diagnoses of stage 5 chronic kidney disease (kidney failure and end stage kidney disease) and had received dialysis in the last 14 days while a resident at the facility. Observation on 8/26/24 at 2:15 PM, Resident #32 was out of the facility at dialysis. A Physician's order dated as active 8/2/24 at 2:00 PM, directed staff to complete a dialysis assessment after dialysis one time a day every Monday, Wednesday, and Friday. A Physician's order dated as active on 8/2/24 at 6:00 AM, directed staff to complete the dialysis evaluation prior to dialysis and once daily on non-dialysis days one time a day. Resident #32's care plan directed the following: o Resident #32 received dialysis on Monday, Wednesday, and Friday. o Resident #32 will have no signs or symptoms (s/sx) of complications from dialysis with a target date of 10/13/2024. o Assessments, vital signs and weights, if abnormal or not normal limits, will be communicated to the dialysis center prior to and post dialysis. o Dialysis port located on upper chest. o Dialysis site care per provider recommendations. o Resident #32 scheduled to have hemodialysis treatment every Monday, Wednesday, and Friday at the dialysis center. o In the event of an emergency such as a power outage or inclement weather that prevents Resident #32 from receiving dialysis as scheduled, the residents providers instructions are to: (specify what the nephrologist/dialysis center instruction has been given example special diet, medication, transport to alternate dialysis site) o Monitor/document/report PRN any s/sx of infection to access site: redness, swelling, warmth or drainage. o Monitor/document/report PRN (as needed) for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Clinical record review revealed the following: 7/12/24- pre and post dialysis assessments not completed 7/15/24- pre-dialysis assessment not completed 7/22/24- pre-dialysis assessment not completed 7/24/24- pre and post dialysis assessments not completed 7/26/24- post dialysis assessment not completed 7/29/24- pre and post dialysis assessments not completed 8/2/24- post dialysis assessment not completed 8/5/24- pre-dialysis assessment not completed 8/9/24- post dialysis assessment not completed 8/12/24- post dialysis assessment not completed 8/16/24- pre and post dialysis assessments not completed During an interview 8/27/24 at 12:10 PM, the Director of Nursing (DON) acknowledged pre and post dialysis assessments for Resident #32 had not consistently been completed as expected and stated she and the Nurse Consultant had just looked at the resident's dialysis assessments. On 8/27/24 at 2:27 PM the Administrator revealed the facility did not have a specific policy for dialysis. The Administrator further revealed their Regulatory Nurse Consultant frequently referred to the pathway and sends it out when there are updates.

Based on observation, policy review, and staff interview the facility failed to keep their hands off the drinking rim surfaces of the glasses and failed to cover foods for transport during meal service. The facility reported a census of 42 residents. Findings include: During an observation of the noon meal on 3/25/24 from 11:27 AM to 12:30 PM Staff A Registered Nurse, Staff B Dietary Aide, Staff C Certified Nursing Aide (CNA), and Staff D Certified Medication Aide served 14 glasses to 14 residents in the dining area handling the cups with fingers on the drinking rim surface of the glasses. Staff also failed to completely cover 2 desserts and failed to cover 1 dessert at all when transporting them to resident rooms. On 3/27/24 at 10:12 AM the Administrator explained the facility lacked a policy on dining or food handling. On 3/27/24 at 10:35 AM the Food Service Supervisor reported she expected staff not to touch the food on the plates or bowls when serving, and not to touch the rims of glasses residents drink off of. She expected everything on the tray for in-room dining to be covered for transport. 42134 During an observation on 3/25/24 at 11:37 AM Staff F, door greeter, served 1 cup to a resident touching the drinking rim of the cup. Staff G, cook, served 1 cup to a resident touching the drinking rim of the cup. During an observation on 3/25/24 at 11:48 AM, Staff F delivered a room tray to Resident #8. The tray was taken from the dining room to his room with the milk and dessert not covered. During an observation on 3/25/24 at 12:00 PM, Staff H, CNA, served a coffee cup to a resident by placing their palm over open surface of cup with all fingers and thumb on drinking surface of the cup. During an observation on 3/25/24 at 12:06 PM, Staff G served a resident 2 cups by placing their palm over the open surface of cup with all fingers and thumb on drinking surface of the cups.

Based on observation, clinical record review, policy review, and staff interview the facility failed to administer the appropriate dose of medication to 1 of 8 residents reviewed (Resident #17). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #17 documented a Brief Interview for Mental Status (BIMS) of 13/15 indicating no cognitive impairment. It further documented diagnoses including: hypertension, heart failure, coronary artery disease, cardiomyopathy (disease of the heart muscle), and intellectual disabilities. During an observation on 3/26/24 at 8:13 AM Staff E, Licensed Practical Nurse (LPN) administered a 10 mg tablet of Lisinopril (an anti-hypertensive medication to reduce blood pressure (BP)) to the resident. Physician orders dated 3/8/24 documented Lisinopril 5 mg daily for essential hypertension. The resident's Care Plan lacked direction for monitoring signs and symptoms of hypotension (low BP) and medication side effects of the anti-hypertensive medication. The Progress Note dated 3/08/24 at 10:52 AM documented the physician's verbal order to decrease the Lisinopril to 5 mg daily as the resident's BP was still dropping low. The Progress Note dated 3/08/24 at 10:53 AM documented the order for Lisinopril Oral Tablet 5 mg to be given daily. The resident's guardian was called and informed of the order. An incident note dated 3/14/24 at 10:10 PM documented the resident stood up from a sitting position on her bed and became tipsy. Staff assisted the resident to the floor and she was assessed by nursing. There was no injury. On 3/27/24 at 12:06 PM the Administrator explained the facility lacked a policy on medication administration. In an interview on 3/26/24 at 2:49 PM Staff E confirmed she gave the resident the whole 10 mg tablet of Lisinopril during the morning medication pass. She confirmed the order in the computer was dated 3/08/24 for 5 mg. She acknowledged she looked right at the order and still gave the 10 mg dose. She reported that the resident's medication had not been changed since the order was given and the resident had been receiving the 10 mg tablet daily from 3/9-3/26 for a total of 18 incorrect doses. The Director of Nursing (DON) confirmed the presence of the Progress Note indicating the verbal order was received. She reported the fax to the pharmacy for the new dose was never sent. She noted the facility would follow up with a medication error report and the pharmacy called for the new dose. During an interview on 3/27/24 at 12:37 PM the DON explained she expected staff to take their time and double check the following before passing medications: resident name, the order, the MAR, and the medication card. She expected staff to give the right drug at the right time to the right patient.

Based on clinical records review and staff interviews, the facility failed to monitor a [CONDITION(S)] resident's weight, vital signs, access site; failed to have a contract with the local [CONDITION(S)] facility, and failed to have a shared communication system with the local [CONDITION(S)] center for 1 of 1 resident (Resident #27). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #27 identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact memory and cognition. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 05/10/21 at 02:25 PM Resident #27 stated that [CONDITION(S)] is done on Monday, Wednesday, and Friday at the local [CONDITION(S)] facility. In an interview on 05/11/21 at 11:34 AM Staff A, Registered Nurse (RN), informed vitals and assessments are documented in Point Click Care (PCC), an electronic health record, and the facility did not have additional books or documentation elsewhere. In an interview on 05/11/21 at 12:03 PM, the Director of Nursing (DON) revealed they have daily assessments in PCC the nursing staff completes. The DON stated that the local provider for [CONDITION(S)], would contact facility if there was a major concern identified. The DON revealed they did not have a policy on pre and post [CONDITION(S)] assessments. The DON also revealed that they did receive some sheets from the local provider for [CONDITION(S)] and if they did they would be scanned into PCC, but did not get them every day that Resident #27 went to [CONDITION(S)]. Record review of Resident #27 in PCC revealed documentation for the daily assessments of monitoring included: temperature, pulse, respirations, blood pressure, oxygen level, current monthly weight, level of consciousness, apical pulse, lung sounds, skin turgor, and port assessment. In an interview on 05/12/21 at 10:11 AM, the Dietitian revealed she reviewed the weights and vitals from a monthly report received from the local provider for [CONDITION(S)]. The Dietician stated the [CONDITION(S)] center would call the facility if there were any major concerns. In an interview on 05/12/21 at 11:10 AM, the DON informed they did not have a policy on pre and post [CONDITION(S)] assessments. The DON revealed the nursing staff completed one [CONDITION(S)] assessment a day, seven days a week, whether or not Resident #27 had [CONDITION(S)]. In an interview on 05/12/21 at 11:43 AM, the DON revealed the local [CONDITION(S)] center is considered outpatient and provided off site. The DON commented the facility did not have a contract with the [CONDITION(S)] center for this reason. The DON stated the facility did have a peritoneal contract since staff would come in to provide the service. -

Based on clinical record review and staff interview the facility failed to refer 4 of 4 residents reviewed with a qualifying mental illness [DIAGNOSES REDACTED]. (Resident #13, #14, #22 & #24). The facility reported a census of 22 residents. Finding included: 1. The Minimum Data Set (MDS) assessment for Resident #24 dated 5/25/19, included a [DIAGNOSES REDACTED]. The last PASRR completed for the resident dated 3/29/17, indicated a negative level one screen. The PASRR listed a suspected [DIAGNOSES REDACTED]. The admission record included a [DIAGNOSES REDACTED]. The Physician order [REDACTED]. During and interview on 6/12/19 at 4:09 p.m., the Director of Nursing, DON stated the facility should submit a new PASRR if there is a new psychiatric diagnosis. During interview on 6/13/19 at 8:40 a.m., the facility Nurse Consultant, RN stated the facility had not been submitting a PASRR with a new psychiatric [DIAGNOSES REDACTED]. During an interview at 10:36 a.m., the Nurse Consultant stated they do not have a policy on PASRR they follow federal regulations regarding the pre admission screening and resident review. 2. The Minimum Data Set (MDS) assessment for Resident #13 dated 4/23/19, included [DIAGNOSES REDACTED]. The MDS included a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). The last PASARR Negative Level I Screen dated 3/16/16, documented the resident had no major mental illness. Clinical record review revealed no further Level 1 submitted for review with a [DIAGNOSES REDACTED]. 3. The Minimum Data Set (MDS) assessment for Resident #14 dated 4/30/19, included [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS score of 9 (mild cognitive impairment). The last PASARR Negative Level I Screen dated 11/10/17, documented the resident had no major mental illness. Clinical record review revealed no further Level 1 submitted for review with a [DIAGNOSES REDACTED]. 4. The Minimum Data Set (MDS) assessment for Resident #22 dated 5/14/19, included [DIAGNOSES REDACTED]. The MDS documented a BIMS could not be completed, indicating severe cognitive deficit. The last PASARR Negative Level I Screen dated 2/8/17, documented no major mental illnesses. Clinical record review revealed no further Level 1 submitted for review with a [DIAGNOSES REDACTED].

Based on observation, record review and resident and staff interview the facility failed to follow therapy recommendations for 2 of 4 residents reviewed with a restorative program.(Resident # 4 and #10). The facility identified a census of 22 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 3/19/19, included [DIAGNOSES REDACTED]. The MDS identified the resident had short and long term memory problems with severely impaired decision making. The MDS documented the resident required total assist of two for bed mobility, transfers, toileting and dressing. The care plan revised 8/10/15, included an approach to please see restorative documentation sheet. A Physical Therapy (PT) Restorative Therapy Alert dated 2/28/19, included a directive to provide bilateral lower extremity exercises/range of motion to ankle, straight leg raise, heel slides and hip abduction up to 5 times a week for 10 repetitions. An Occupational Therapy (OT) Restorative Therapy Alert dated 2/28/19, included a directive to provide upper extremity range of motion exercises to shoulder, elbow, forearm, wrist and finger up to 5 times a week for 10-12 repetitions. During observation on 6/10/19 at 10:39 a.m., the resident sat in reclining Geri-chair with bilateral hands clenched at chest in a tight fist with positioning carrot in right hand. During interview on 6/12/19 at 12:36 p.m., the Director of Nursing, DON stated Staff A, Certified Nursing Assistant, CNA had been responsible for restorative programs and did them with their cares every day. The documentation did not show he had done them because he had been doing it with resident cares. On 6/13/19 at 8:43 a.m., Staff B, Occupational Therapist, OT stated during interview staff should be doing exercise per OT recommendations on the resident from (MONTH) to try and maintain range of motion due to her risk for contractures and skin problems. The restorative program flow sheet for the resident provided by the facility on 6/13/19 at 10:34 a.m., revealed no documentation of passive range of motion to upper and lower extremities since 5/2/19. 2. The MDS for Resident #10 included a Basic Interview for Mental Status (BIMS) score of 15 (cognitively intact). The MDS documented the resident required extensive assist of one to two for mobility, transfers, dressing and toileting. The MDS indicated the resident had a lower extremity limitation in range of motion. The MDS listed [DIAGNOSES REDACTED]. The care plan with a revision date 12/28/18, directed staff to complete Physical therapy/Occupational therapy evaluation and treatment as per medical doctor order. Please follow any recommendation they give regarding my care. A Physical Therapy Restorative Therapy Alert dated 1/24/19, directed staff to complete lower extremity exercises/range of motion to ankle, hip and hamstring using 2 pound weights and theraband 3-5 times a week for 15 repetitions for 2 sets. An Occupational Therapy Restorative Therapy Alert dated 1/25/19, directed staff to provide bilateral upper extremity range of motion exercises to shoulder, elbow, forearm and wrist with 2 pound dumb bells 3-5 times a week for 15 repetitions, 2 sets. She may also complete omnicycle level 3 times 15 minutes. On 6/11/19 at 10:21 a.m., the resident reported during interview she had therapy in the past but is not currently working on anything with restorative staff here at the facility. They have not been doing any exercises with me lately and not sure why. During interview on 6/13/19 at 8:14 a.m., Staff C, Physical Therapy Assistant, PTA stated the resident is currently getting physical therapy services but she is on hold due to skin problems for the past 3-4 weeks. The resident has been going to exercise group 3 times a week. She stated occupational therapy recommendations should still be followed and should still be doing upper extremity exercises even while getting physical therapy so do not loose strength in upper extremities. During interview on 6/13/19 at 8:49 a.m., Staff B, OT stated even if the resident is receiving physical therapy she should still be following the recommendations from Occupational Therapy since the time of last discharge for upper body extremities to maintain strength. Staff should not stop exercise program just because receiving another discipline of therapies. During interview on 6/13/19 at 9:13 a.m., Staff A, CNA stated he does restorative and is the only one that does it for the building. He does attempt to complete most of it as getting residents up in the morning with their cares. If they have specific exercises with equipment do that during the day once they are up and come down to the therapy room. He has been completing the exercises just not able to get the documentation done. The documentation is not complete due to I get busy and do not have time to complete. No one currently does restorative when he is off work. During interview on 6/13/19 at 10:33 a.m., the facility Nurse Consultant stated they do not have a policy on restorative therapy, staff should follow therapy recommendations. Review of the restorative programs flow sheet provided by the facility on 6/13/19 at 10:34 a.m., revealed there was no documentation of restorative programs being completed since 5/2/19. A policy titled Nursing Rehabilitation/Restorative Care dated 1/20/11 stated based upon the completion of a comprehensive assessment of a resident, the facility should attempt to incorporate restorative programs that will assist a resident to maintain or improve their physical functioning.

Based on observation, clinical record review and resident and staff interviews, the facility failed to ensure Resident #9 ' s environment remained free from hazards as possible. Record review identified Resident #9 smoked cigarettes and according to his/her care plan did not need supervision to smoke cigarettes safely. Resident #9 reported he/she had sustained burns from the cigarettes. Staff interviews revealed the resident had not been burned by cigarettes and the various injuries were from the resident bumping the door. The resident ' s care plan lacked any provision to reduce the hazards when the resident smoke cigarettes and to ensure a safe environment. The facility reported a census of 46 residents with one of one resident reviewed for smoking hazards. Findings include: The Minimum Data Set (MDS) for Resident # 9 dated 11/18/14, documented [DIAGNOSES REDACTED]. The MDS documented the resident required no assistance for bed mobility or transfer. The resident scored a 15 on the Brief Interview for Mental Status (BIMS) cognitive test, which indicated the resident had no cognitive impairments. The MDS identified the resident had no signs or symptoms of delirium (no inattention, no disorganized thinking, no altered level of consciousness or mood or behavioral concerns). Clinical record review revealed the only smoking assessment had been completed on 3/25/13. The assessment documented the resident had been able to do the following safely: light cigarette, hold a lit cigarette safely, able to put ashes in ashtray safely, able to safely extinguish the cigarette and able to exhibit safety awareness when smoking. The smoking assessment documented the following: a. resident had physical limitations that would impact safety, poor eyesight. b. resident took medications that would impact safety. c. resident had medical [DIAGNOSES REDACTED]. d. resident could be independent with smoking, supervision recommended with smoking to help in and outside. The resident ' s care plan (no start date) identified the resident smoked and had a smoking assessment completed. The care plan documented the resident could smoke independently and may need staff assistance to help him/her with door code to enter or exit. The care plan revealed the resident was blind in his/her right eye and had glaucoma in his/her left eye. The care plan noted the resident may not make good decision and staff should educate him/her but respect his/her choices. The care plan included no problem of unsafe smoking, or interventions for such a problem. The care plan documented the resident may use the E-Cigarette and had signed an agreement of his/her responsibility, however no date of when E-Cigarette had been initiated. A nursing progress note dated 11/1/14 at 10:16 a.m., documented the resident had small scabbed areas noted on each hand. Areas with no drainage, just dry scabs. Skin sheets sent to doctor. The entry made no mention of how the areas developed. A progress note dated 11/6/14 documented the nursing staff obtained an order for [REDACTED]. The noted identified staff reviewed the resident ' s responsibility agreement and this was placed in the resident ' s chart. The resident ' s family member would be assisting to obtain the cartridges. (E-cigarettes use a vapor, no flame). The resident ' s record lacked any information that the E-cigarettes had not been used.) A progress note dated 11/20/14 at 1:42 p.m., documented skin sheets sent to doctor regarding areas right posterior hand from tape of I.V. after procedure 11/18/14. A physician progress notes [REDACTED]. The report documented " They report that it ' s from when the resident had a sore on hand burned hand. They are not healing slowly typical for resident. " No pain with the areas. A nursing progress note dated 12/10/14 at 7:48 a.m., documented the resident reported scabbed areas on knee. Areas small dry scabs with no drainage or signs of infection, skin sheets faxed. A non-pressure skin condition record for the left hand dated 12/15/14, documented a start date of 11/1/14. The first assessment on the form dated 12/15/14, documented for first finger. The assessment had been crossed out and the bottom of the form documented healed, " OK documentation. " The next assessment on the same form dated 12/15/14, documented the resident had a 1.0 centimeter (cm) x 0.5 cm brown dry scab on the left hand middle finger. Treatment documented had been to observe and assess. The form indicated the intervention to address the area on the left hand middle finger as a pressure reduction mattress. The note had been signed by the facility Director of Nursing. The assessment included the following measurements: a. 12/22/14-1.0 cm x 0.7 cm, thick brown scab. b. 12/29/14-0.4 cm x 0.4 cm, thick brown scab. c. 1/5/14-1.8 cm x 1.5 cm, thick brown scab. A non-pressure skin condition report for the resident ' s right hand/fingers documented a start date of 11/1/14, and included the following measurements: a. 12/22/14-brown dry scabs, treatment to observe and assess: 1.3 cm x 1.3 cm, 0.4 cm x 0.4 cm, 1.0 cm x 0.7 cm, 0.4 cm x 0.3 cm, 0.5 cm x 0.7 cm, 0.3 cm x 0.7 cm. b. 12/29/14-brown dry scabs, treatment to observe and assess, specialty intervention mattress, 0.6 cm x 0.5 cm, 0.8 cm x 0.8 cm, 0.6 cm x 0.8 cm, 0.5 cm x 0.5 cm, 0.9 cm x 0.4 cm, 0.7 cm x 0.7 cm, 1.5 cm x 1.0 cm, 0.6 cm x 0.7 cm, 1.4 cm x 1.4 cm. c. 1/5/15-right wrist 1.3 cm x 1.3 cm brown dry scab, 0.5 cm x 0.6 cm brown dry scab, 1.0 cm x 1.0 cm, brown dry scab, 0.5 cm x 0.3 cm brown dry scab, 0.5 cm x 0.4 cm brown dry scab. During observation on 1/6/15 at 1:40 p.m., the resident sat in a chair in their room. At that time, observation revealed numerous reddened and scabbed areas on the resident ' s bilateral hands. During an interview with the facility Director of Nursing on 1/7/15 at 1:10 p.m., she stated Resident #9 had no burns on his/her hands. She reported the scabs on the resident ' s hands had been from tape that had been removed while at the hospital. An interview with Resident #9 on 1/7/15 at 2:00 p.m., the resident stated only one of the scabs, which had been on their right hand had been from a piece of tape that had been removed at the hospital. The resident stated when he/she had gone outside to smoke the "cherry" from the cigarette had fallen off and burned the left middle finger, through a glove. Resident #9 reported a nurse had noticed it when he/she returned back in from smoking and he/she stated had not even known because they could not feel his/her hands. Observation at this time revealed a scab over the left dorsal (back of the hand, side with fingernails) middle finger, slightly reddened around it. The resident stated that had not been the only time he/she had been burned by a cigarette ash while smoking. On 1/17/15 at 2:45 p.m., the facility Assistant Director of Nursing stated they had not been aware the resident had a burn on this/her hands. The facility corporate nurse stated at 3:30 p.m., on 1/7/15, they had not been able to find any recent smoking safety assessments for the resident (the most recent was dated 3/25/13). Observation of Resident #9 on 1/8/15 at 9:00 a.m., showed the resident sat in their room. The surveyor noticed the resident wore gym/track pants and had a circular hole in the pants over the resident ' s left anterior thigh, approximately the size of a cigarette burn. The resident verified the hole in his/her clothing had been from a cigarette, and stated this had happened prior to admission to the facility. The resident stated he/she had dropped a cigarette on their pants and pulled down his/her pants to the knees to show the surveyor other areas of altered skin integrity. Resident #9 stated an area on their left knee had been from a cigarette burn and one on the right knee had been from bumping the door. The resident showed the surveyor a pair of gloves and stated he/she had been wearing the gloves when he/she burned his/her left middle finger. The resident stated the maintenance man had been aware of the hole had been a cigarette burn hole, and had patched the gloves. The resident showed the surveyor a patch in the gloves over the area which would cover the knuckle of the left middle finger. On 1/8/15, immediately following the resident interview, the surveyor interviewed the facility Maintenance Director, who verified they had patched the residents gloves, and also gloves of other resident ' s who smoked cigarettes. The Maintenance Director then stated he thought the hole had been a burn from the resident ' s wheelchair wheel. On 1/8/15 at 11:06 a.m., the surveyor attempted to contact the Physician Assistant (PA) that dictated the resident had a burn on their hand from the 12/9/14 visit. At that time the PA had not been available and the surveyor left a message regarding the facility and the resident. The PA failed to return the surveyors call. During interview with the facility Director of Nursing on 1/8/15 at 11:08 a.m., they stated they did not know what the facility policy had been for safe smoking assessments for residents. Following the DON interview, on 1/8/15, the facility Corporate Nurse stated the facility had not been aware the resident had burned him/her(self) with a cigarette. She reported they talked with the resident after the surveyor had visited with the resident that morning and Resident #9 verified they had burned their hand from a cigarette. The corporate nurse stated the resident had now indicated he/she would be agreeable to wearing fire retardant gloves, and the facility had now ordered the gloves. During an interview on 1/8/15 at 12:05 p.m., Staff E, (Licensed Practical Nurse/LPN) stated they believed the resident ' s scabs on their hands were due to the resident bumping their hands on the brick while outside smoking. Staff E stated the resident had diminished pain sensation and would hurt themselves and not know it. On 1/8/15 at 12:10 p.m., Staff F (Certified Nurse Aide, CNA) verified she had cared for the resident and had noticed the areas on the resident ' s hands. Staff F stated they would not even know what caused the sores on the resident ' s hands. On 1/8/15 at 12:12 p.m., Staff G (CNA) verified she had worked with the resident and stated she did not know the resident had any sores on their hands. On 1/8/15 at 12:18 p.m., the facility Administrator brought the surveyor an addendum and stated it had been provided by the PA. The addendum had been dated 1/8/15 at 12:06 p.m.. The note documented the following: the nurses had been reviewing the resident ' s progress notes and noted the comment in the History of Present Illness (HPI) regarding his/her hand. The addendum documented, " when he/she had a sore on their hand burned his/her hand " was not accurate and there are missing words. It should read, " They report that it is from when resident had a sore on his/her hand and his/her skin reacted to the tape and the tape burned his/her hand." (The addendum did not include an electronic signature, as the other progress note had.) On 1/8/15 at 12:25 p.m., the facility DON stated they had spoken with the resident ' s family and asked if the resident had ever explained how he/she gets injuries on their hands and knees. The DON stated the family reported the resident ' s family stated the resident bumped themselves when going through the doors with their wheelchair. The DON stated the resident ' s family member reported he/she liked to pick things on the resident ' s skin. At that time the surveyor asked the DON if they had educated the family member on the consequences of picking the resident ' s sores. The DON stated no because the family member had been a health care professional. On 1/12/15 at 1:07 p.m., the surveyor interviewed the facility Administrator via phone. The Administrator stated the progress note had been provided to the facility by the PA after the facility had called the PA for clarification of the progress note. On 1/12/15 at 1:09 p.m., the surveyor attempted to contact the PA and a message had been left. During interview with the Physician Assistant (PA) on 1/12/15 at 3:13 p.m., he stated the facility had contacted him and informed him the State surveyors had been reviewing Resident #9 ' s clinical record. The PA stated he had not been aware the resident had burned him/her(self), and that the PA's nurse had done rounds with them on the date of the progress note, 12/15/14. The PA stated that when the facility had called about the progress note the PA had their nurse refresh their memory and had been able to provide the facility an addendum based on that. The PA stated the dictation machine did not type the initial progress note correctly and he needed to add words to the progress note. The PA stated he would believe Resident #9 if he/she reported they had burned him/her(self). The PA stated the resident probably did burn him/herself, and the resident is basically blind sitting outside smoking, probably doesn't pay attention to what he/she was doing and lets ashes fall on him/her(self). The PA again stated the facility called the other day and said the surveyor had been looking at this so they had talked to the nurse who had been there on rounds with them. The PA stated the resident wanted to be able to keep smoking and thought he/she would be told to quit if the resident told the PA about burning him/her(self). The PA had initially stated he believed the areas on the resident ' s hand were burns from tape and when asked if they had ordered any treatment for [REDACTED]. At the exit conference 1/8/15, the Administrator stated the resident had not obtained the E-Cigarettes.