Every finding on record at Rehabilitation Center of Belmond

Based on record review, policy review, and interviews, the facility failed to ensure 1 of 1 resident (Resident #7) reviewed for pressure ulcers received the necessary care and services to promote the healing of an existing pressure ulcer and prevent the development of new ulcers. Specifically, the facility failed to clean and apply medication to Resident #7's wounds on four separate shifts, failed to document weekly pressure ulcer measurements including depth, and failed to identify the wounds as pressure ulcers on the appropriate clinical record. The facility reported a census of 42 residents.Findings include:The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: NOTE:Regardless of the staging system or wound definitions used by the facility, the facility isresponsible for completing the MDS utilizing the staging guidelines found in the RAI (Resident Assessment Instrument) Manual.Stage 1 Pressure Injury (PI): Non blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below).Stage 2 Pressure Ulcer (PU): Partial thickness skin loss with exposed dermis Partial thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar is not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).Stage 3 Pressure Ulcer: Full thickness skin loss Full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI.Stage 4 Pressure Ulcer: Full thickness skin and tissue loss Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full thickness skin and tissue loss Full thicknessskin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If theanatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur.Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent nonblanchable deep red, maroon or purple discoloration Intact skin with localized area ofpersistent non blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer intothe appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, ordermatologic conditions.A Minimum Data Set, dated [DATE], documented diagnoses for Resident #7 included a body mass index (BMI) of 60.0 to 69.9 (extreme obesity), aphasia (language impairment disorder), and a cerebral infarction (stroke). A Brief Interview for Mental Status documented a score of 7 out of 15, which indicated severely impaired cognition. It documented that Resident #7 refused to roll left to right on the bed, lie to sit on the side of the bed, walk 50 feet with 2 turns and walk 150 feet. It documented that this resident had one Stage 2 pressure ulcer. An Office Visit to Wound Center document dated 11/21/25, documented that Resident #7 had a pressure injury of buttock stage 2. Wounds were debrided on left inner buttocks and right buttocks. The wound measurements included in this documentation included length, width and depth for both the left and right wounds. Resident #7's Non-Pressure Skin Condition Record lacked documentation from 12/11/25 through 2/25/26 on their bilateral medial thigh. The records documented the date the ulcer/s were first observed was 9/3/25. The records with the first observed date of 9/3/25 were dated 9/3/25 through 12/10/25. The records that started with an assessment done on 2/25/26 through 4/15/26 had a first observed date of 1/16/26. Resident #7's April 2026 Medication Administration Record (MAR) lacked documentation to clean wounds to bilateral medial thighs with wound cleanser. Apply Triad (wound paste) twice a day (BID) for wound care on the following dates: a. 4/7/26 for the 2 PM to 10 PM shiftb. 4/12/26 for the 6 AM to 2 PM shiftc. 4/13/26 for the 6 AM to 2 PM shiftd. 4/16/26 for the 2 PM to 10 PM shiftOn 4/22/26 at 9:36 AM, the Assistant Director of Nursing (ADON) confirmed Resident #7 did have a pressure area. The ADON stated that the wound clinic had diagnosed Resident #7 with a Stage 2 pressure ulcer. The ADON stated the facility had thought it was a moisture related wound. This ADON said that the ulcer is located on her right upper central thigh, kind of in the fold area. She stated that Resident #7 sat all day and the facility staff did encourage Resident #7 to stand and move but she often refused. On 4/23/26 at 10:33 AM, the ADON stated the facility was unable to find the missing weekly wound records. This ADON acknowledged the records the facility provided didn't identified the wounds as pressure ulcers. Most of the weekly documentation for the records didn't include depth measurements and 1 of the records had 2 wounds instead of 1 wound on each weekly assessment documentation. The ADON acknowledged they should have measured the depth, they should have identified the weekly wound records, and documented them on a Pressure Ulcer wound record and not a Non-Pressure weekly wound record. Additionally, they should have documented each wound on a separate record. She reported they thought the wound nurse was off work and the DON working at the time took over the wound nurses' duties, including the weekly measurements of pressure ulcers. The DON no longer worked at the facility and they couldn't find the records. The ADON acknowledged the facility couldn't provide several weekly Pressure Ulcer wound records. On 4/23/26 at 12:14 PM, Staff A, previous Director of Nursing (DON), explained the Skin Nurse went on vacation, she believed for 2-3 weeks, but she couldn't really remember the dates. Staff A stated she worked at the facility from December 2025 to February 2026. She added if she did the pressure ulcer wound records, they would be in the skin book or in the progress notes. She reported if the records weren't in either of the 2 places, then she didn't do the assessments. Staff A said she always tried to make a skin note/progress note and a skin sheet. Staff A repeated she was the DON during that time and left the facility in March of this year and started either in July or September of last year. The Skin Management Guide revised November 2023 defined a pressure ulcer as localized damage to the skin and underlying soft tissue, usually over a bony prominence. The guide directed a licensed nurse to complete a body audit weekly or as ordered and document the findings on the electronic Treatment Administration Record (eTAR). The nurse should document new findings in the progress notes. Additionally, wound rounds need completed weekly on pressure injuries and complex wounds. The licensed nurse should document the wound location, tissue type, cause of wound, and full measurements (length, width, and depth).

Based on review of the nursing schedules and staff interviews, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) hours per day on 4/5/26 and 4/12/26. The facility reported a census of 42 residents. Findings include:Review of the facility's nursing schedules for April 2026 lacked 8 hours of RN coverage on 4/5/26 and 4/12/26. In E-mail communication dated 4/21/26 at 12:49 PM, the facility Administrator reported the facility didn't have 8 consecutive hours of RN coverage on 4/5/26 and 4/12/26. In E-mail communication dated 4/22/26 at 1:08 PM, the Nurse Consultant explained the facility didn't have a policy for RN coverage as they just follow the regulation. During an interview on 4/22/26 at 2:15 PM the Administrator acknowledged the facility didn't have 8 hours of continuous RN coverage on 4/5/26 and 4/12/26. The Administrator added they had a plan in place moving forward for coverage.

Based on clinic record review, staff interviews, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #10 and #133) for significant medication errors. Resident #10 didn't receive his insulin medications the morning of 12/15/24. In addition, Resident #10 received short acting insulin with a blood sugar (BS) below 200 mg/dl (milligrams per deciliter) when the physician order directed staff to hold the insulin with a BS below 200 mg/dl. In addition, a nurse gave Resident #133 (a noninsulin treated diabetic) insulin instead of Resident #10 using Resident #10's insulin pen. The facility reported a census of 30 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 5, indicating severe cognitive impairment. The MDS listed Resident #10 as independent with bed mobility and transfers. Resident #10 used a walker for ambulation. The MDS included diagnoses of coronary artery disease (impaired heart blood vessels), hypertension (high blood pressure), renal disease, and type 2 diabetes with hyperglycemia (elevated blood sugar). The MDS documented Resident #10 received insulin injections 7 days and took a hypoglycemic medication during the look back period. A Progress Note titled Incident Report - Medication Event dated 12/15/24 at 1:36 PM reflected Resident #10's Basaglar 17 units and Fiasp 7 units didn't receive his morning dose of insulin, due to the nurse gave it to another resident. The note identified Resident #10's BS as 259 and he didn't show any signs or symptoms of hyperglycemia. The facility notified Resident #10's Physician and his wife of the medication error. A Progress Note titled Incident Report - Medication Event dated 12/30/24 at 7:18 PM documented Resident #10 blood sugar as 137 at 4:50 PM and he received 7 units of Fiasp insulin. The note indicated the nurse didn't realize the parameter to hold the insulin with a BS below 200 mg/dl. The note documented the facility notified Resident #10's Physician and his wife of the medication error. An undated facility form titled Medication Administration Times reflected the following schedule: a. AM = 6:00 AM to 10:00 AM b. MM (mid-morning) = 9:00 AM to 12:00 PM c. MA (midafternoon) = 3:00 PM to 5:00 PM Resident #10's December 2024 Blood Glucose/Insulin Administration Record directed staff to administer the following insulin medications: a. Basaglar (long acting insulin) KwikPen 100 unit/ml (milliliters), inject 17 units subcutaneously (SQ) one time a day related to type 2 diabetes mellitus with hyperglycemia. The report reflected signatures indicating administration for the following: i. 12/15/24, the date of Medication Error when Resident #133 received Resident #10's insulin. The record lacked correction of the error. b. Fiasp (short acting insulin) 100 units/ml inject 7 units before meals. Hold if BS is 200 md/dl or below. The report reflected signatures indicating administration for the following: i. 12/15/24 AM: the date of Medication Error when Resident #133 received Resident #10's insulin. The record lacked correction of the error. ii. 12/31/24 MA: BS - 175. Resident #10's January 2025 Blood Glucose/Insulin Administration Records identified the nurse administered Fiasp Insulin 7 units on the following days/times when he had a documented blood sugar below 200 mg/dl: *1/1 - AM - BS = 155 *1/4 - AM - BS = 142 *1/4 - MM - BS = 142 *1/10 - AM - BS = 70 *1/10 - MM - BS = 116 *1/12 - AM - BS = 111 *1/12 - MM - BS = 111 *1/13 - AM - BS = 102 *1/22 - MA - BS = 192 *1/24 - AM - BS = 168 *1/24 - MM - BS = 168 *1/25 - AM - BS = 122 *1/26 - AM - BS = 117 *1/29 - MA - BS = 116 *1/30 - MA - BS = 181 Resident #10's February 2025 Insulin Administration Records identified the nurse administered Fiasp Insulin 7 units on the following days/times when he had a documented blood sugar below 200: *2/1 - AM - BS = 103 *2/1 - MM - BS = 144 *2/2 - MA - BS = 166 *2/6 - MA - BS = 117 *2/9 - MA - BS = 130 *2/10 - AM - BS = 179 *2/10 - MM - BS = 179 *2/10 - MA - BS = 135 *2/14 - MA - BS = 157 *2/17 - MA - BS = 128 *2/19 - MA - BS = 154 *2/22 - AM - BS = 131 *2/23 - AM - BS = 151 *2/23 - MM - BS = 151 *2/26 - MM - BS = 183 *2/28 - MM - BS = 194 Resident #10's clinical record lacked notification of his Physician and/or his wife of the medication errors related to the administration of Fiasp insulin on multiple occasions when he had a blood sugar below 200 mg/dl. On 4/16/25 at 12:04 PM, Staff A, LPN (Licensed Practical Nurse), verified the check mark on the Insulin Administration Record meant the resident received the medication. On 4/16/25 at 4:30 PM, the Corporate Nurse reported the facility notified Resident #10's Physician regarding the administration of the Fiasp insulin with a BS below 200. 2. Resident #133's MDS assessment dated [DATE] identified a BIMs score of 3, indicating severe cognitive impairment. The MDS listed Resident #133 as independent with bed mobility and required partial/moderate assistance with transfers and ambulation. The MDS included diagnoses of hypertension (high blood pressure), renal (kidney) disease, and diabetes mellitus. The MDS documented Resident #133 didn't receive insulin injections and didn't take hypoglycemic medication during the lookback period. A Progress Note titled Incident Report - Medication Event dated 12/15/24 at 12:46 PM reflected the nurse accidentally gave Resident #133 another resident's insulin medication. The note documented Resident #133 received Basaglar insulin 17 units and Fiasp insulin 7 units. According to the note Resident #133 had a BS of 197 at 12:10 PM. The note documented the nurse notified a Physician at 12:15 PM. The Physician gave new orders to check Resident #133's BS every 30 minutes for 4 hours and then every hour until 8:00 PM. The note indicated the facility notified Resident #133's responsible party at 12:20 PM. A Progress Note titled New Order Follow Up Note dated 12/16/24 at 4:34 AM documented the nurse checked Resident #133's BS every 2 hours without signs and symptoms of hypoglycemia (low blood sugar) noted. His BS ranged from 115 130 mg/dl during the shift. An untitled facility document provided by the Administrator during the survey documented on 12/15/24, Staff B, LPN, administered Basaglar 17 units and Fiasp 7 units to Resident #133 in error. The investigation documented Staff B went into the wrong room to administer Resident #10's insulin. Staff B discovered the medication error when they gave Resident #10's noon insulin. At that time, they realized she didn't give this resident insulin for his morning dose. The report documented the Pharmacist came to the facility on [DATE] to review the medication incident. The facility spoke with Staff B and she reported as she got ready to give insulin to Resident #10, another nurse gave her a freestyle libre (glucose monitoring system) for Resident #10. Staff B reported she entered Resident #133's room instead. She reported she looked for the glucose sensor on the resident, but she couldn't find it. She thought maybe he removed it. Staff B reported she checked a fingerstick BS and reported he had a result above 200. Staff B reported she didn't question if she had the correct resident or not because he had an elevated blood sugar. She pulled the insulin from the medication cart and put on new needles. Staff B reported she gave the Basaglar and Fiasp doses to Resident #133. Staff B reported she realized she gave the insulin to the wrong resident when she went to give the noon meal insulin. At that time, she called the ER (emergency room ) Provider to let him know what happened and received orders to check Resident #133's blood sugar every 30 mins until 4:45 PM then every hour until 8:00 PM then every 2 hours until 6:00 AM. Staff B reported she used the same pen of Fiasp to give the noon dose to Resident #10. On 4/16/25 at 12:21 PM, Staff B, verified she was the nurse that made the insulin errors with Resident #10 and Resident #133. Staff B described it as literally a freak accident. She reported being new to the facility, worked as an agency nurse, and not 100% familiar with the residents. Staff B reported another nurse handed her a freestyle libre for Resident #10. She said she walked into Resident #133's room, felt his arm, and couldn't locate the glucose sensor, she thought maybe it fell off. Staff B reported when she checked a fingerstick BS, it had a high result. Staff B reported she abandoned the 6 rights of medication administration and made a very bad mistake. She reported she didn't realize until later when she went to give the noon insulins that she gave the insulin to the wrong resident. She reported she realized the error when she looked at Resident #10's picture on the medication administration record. She said she went down right away to assess Resident #133 and check his blood sugar. She reported she notified the ER Physician and received new orders to check Resident #133's. She said she also called Resident #133's family. She added she assessed Resident #10 since he didn't receive his morning insulin. She reported Resident #133 didn't respond to the insulin he received. Staff B reported she gave both insulins from an insulin pen. She said she put brand new needles on the insulin pens before she gave the insulin to Resident #133. She reported after she gave the insulin to Resident #133 she disposed of the needles and put the insulin pens back in the drawer in the medication cart. She reported she used the insulin pens to give Resident #10 insulin that day after she had given the insulin to Resident #133. Staff B reported she received a phone call from the DON (Director of Nursing) and a Pharmacist after the medication error occurred. Staff B reported she couldn't recall what day she received the phone call from the DON and Pharmacist. Staff B reported the Pharmacist told her if that ever happened again that it was in the best interest of the patient to discard the insulin pens even if they used a new needle. Staff B reported she didn't know any better at the time. Staff B reported after the medication error occurred she made her own plan to follow the 6 rights of medication administration and complete extra checks to ensure she gave the right medication to the right resident. A facility form titled One on One Inservice Record dated 1/3/25 documented Staff B received a verbal review via phone call, regarding the following topics: a. 6 rights of medication administration b. Inhaler, eye drops, and insulin pens are single patient use c. Discard contaminated medications and obtain new ones for the medication cart. On 4/16/25 at 3:09 PM, the DON reported she expected staff to follow physician orders for administering the insulin. A facility policy titled Medication Administration - Medication Pass revised May 2023 defined the purpose of the policy as to safely and accurately prepare and administer medication according to physician order and resident needs. The procedure for medication administration outlined the following steps: a. Open EMAR (electronic medication administration record) to patient record and review physician medication order against medication label b. Read transcribed physician order on EMAR: patient name, medication name, dosage, route and interval ordered c. Remove medication from cart d. Compare EMAR with medication label for accuracy e. Read special medication administration instructions f. Obtain vital signs, if applicable, and record results on EMAR g. Prepare medications for administration h. Administer medication Knock on door and request entrance Introduce self, explain medication administration need and provide privacy Identify patient Describe name of medication and reason for use to patient and answer any questions if needed Administer medication according to specific procedures A facility policy titled Medication Error and Medication Discrepancy Report revised July 2005 directed to prepare and administer drugs and biologicals in accordance with physician orders, manufacturer's specifications, and accepted professional standards and principals. The policy indicated the facility had systems designed to minimize medication errors. The policy instructed to conduct an investigation and corrective action after discovery of errors to prevent recurrence. The policy defined a significant medication error as one which, in the charge nurse's professional judgment, causes the resident discomfort or jeopardizes their health and safety, based on the resident's condition, the drug category of the medication involved, and the frequency or duration of the error at the time of discovery. A facility policy titled Physician Orders/Transcription of Orders revised July 2023 documented active orders should be followed and carried out as written/transcribed.

Based on clinical record review, observations, staff interviews, and policy review the facility failed to assure a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to promote healing of an unstageable pressure ulcer for 1 of 2 residents reviewed (Resident #24). The facility reported a census of 30 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the following definition of pressure ulcers: Stage I is an intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but didn't obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. Resident #24's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. The MDS listed Resident #24 as independent with bed mobility and transfers. The MDS included diagnoses of coronary artery disease, hypertension (high blood pressure), renal disease (kidney), emphysema, adult failure to thrive, and nonrheumatic aortic valve stenosis (narrowing of aortic valve). The MDS documented Resident #24 didn't have a risk for developing pressure ulcer/injuries and didn't have any unhealed pressure ulcers/injuries. The MDS reflected Resident #24 received hospice care. The Care Plan Focus with a target date of 1/20/25 indicated Resident #24 had a potential for pressure ulcer development related to his disease process. The Care Plan directed the following interventions: Staff to apply lotion to his skin with AM (morning) and HS (bedtime) cares. -Staff to provide him reminders/occasional assistance to turn/reposition approximately every 2 hours, more often as needed or requested. -Pressure reducing device on bed and in the wheelchair. The Health Status Note dated 1/16/25 at 6:20 AM documented the staff found a fluid filled blister on Resident #24's right inner heel. The nurse painted the area with betadine and covered it with gentle border dressing. The clinical record lacked documentation of a completed incident report, that someone notified the Physician of the fluid filled blister, and lacked a new skin intervention to reduce pressure to the right heel. Review of Resident #24 Physician orders lacked a Physician order for the staff to apply betadine and a dressing to the right heel on 1/16/25. A Non Pressure Skin Condition Record dated 1/16/25 documented Resident #24 complained of right heel pain. A fluid filled blister was observed that measured 3.5 cm (centimeters)(length) x 4.5 cm (width) with a scan amount of serous (clear to pale yellow) drainage. The specialty intervention marked on the form was a chair cushion. The section on the form to address treatment to the area documented NA (not applicable). The Health Status Note dated 1/17/25 at 9:45 AM documented Resident #24 had a shower that morning. When the nurse removed the dressing from the right heel they saw a small amount of orangish drainage on the dressing. The note described the top portion of the blister as open. The nurse cleaned the area and applied a border dressing for protection. The note indicated they planned to notify the Primary Care Physician (PCP). The Secure Conversations Note dated 1/18/25 at 10:23 PM reflected the following: a. 1/17/25 at 5:31 AM: The facility notified the provider of Resident #24's blister on their right inner heel. The note asked if they could paint the area with skin prep and cover with a gentle border dressing every other day until healed. b. 1/17/25 at 9:47: The facility reported the blister broke open and had a small amount of orangish drainage on the dressing. c. 1/18/25 at 8:10 AM: The provider responded they could proceed with skin prep and cover with a gentle border dressing every other day until healed. A Non Pressure Skin Condition Record dated 1/22/25 documented the right heel measured 4.5 cm x 7 cm and the wound deteriorated. The specialty intervention marked on the form continued as a chair cushion. The progress note on the form documented they couldn't apply the treatment of skin prep due to the wound being open. The note indicated the facility waited for new recommendations from Hospice. A Hospice Form titled Physician Orders dated 1/22/5 included new orders to clean the area on the right heel with soap and water and apply a Mepilex (foam dressing) to the heel 2 times per week and as needed (PRN). A form titled Comprehensive Patient assessment dated [DATE] completed by the Hospice Wound Nurse/CWON (Certified Wound Ostomy Nurse) documented the following assessment on Resident #24's right heel wound: *Etiology: Pressure *Location: Right Heel *Size (LxWxD cm): 4.5 x 7 x 0 *Stage: Unstageable *Edges: Distinct, outline clearly visible, attached, even with wound base *Wound bed: obscured by necrosis *Granulation: No granulation tissue present *Epithelialization: < 25 % wound covered *Necrotic (dead or dying tissue) tissue type: Loosely adherent (still attached to the wound bed) yellow slough (necrotic tissue that builds up on the top of a wound). *Necrotic tissue amount: 75% to 100% wound covered *Drainage type: serosanguineous (thin, watery, pale red/pink) *Drainage amount: small A form titled Recommended Plan of Treatment with a date of service for 1/24/25 documented the Hospice Wound Nurse/CWON completed a virtual follow up by electronic medical record (EMR) review and photo provided by the Hospice nurse on 1/22/25. The note documented Resident #24 had a new wound to the right heel with current treatment dated 1/22/25 to clean the area with soap and water, dry, and apply a Mepilex, then change 2 times per week and as needed. The form documented new recommendations from the wound nurse: a. Right heel unstageable pressure injury: Cleanse wound, dry, apply small amount of Thera honey to wound bed (yellow slough), cover with Vaseline gauze, abdominal (ABD) pad, and secure with kerlix (stretchy gauze used to wrap around an area of a wound). Change 2 times per week and as needed. b. Offload pressure to bilateral heel by using heel lift boots or pillow. The Wound Nurse signed the treatment recommendations on 1/24/25 and the PCP signed the recommendation orders on 1/27/25. The facility nurse noted the orders on 2/4/25. The time stamp on top of the form indicated the provider faxed the form to the facility on [DATE] at 9:42 AM. Resident #24's February 2025 Treatment Administration Records (TAR) reflected the facility didn't implement the new treatment orders signed by the Physician on 1/27/25 until 2/5/25 (10 days after the facility received the orders). In addition, the TAR lacked the order to offload pressure by using heel lift boots or pillows. The Care Plan with a target date of 7/13/25 didn't address offloading the heels using heel lift boots or pillows. In addition, the April 2025 TAR and CNA Kardex didn't address offloading Resident #24 heels with heel lift boots or pillows. On 4/16/225 at 9:35 AM, observed Staff C, RN (Registered Nurse), complete Resident #24's right heel dressing change and measurements. Staff C sanitized her hands and applied gloves. She removed the old dressing off the right heel and cleaned the heel wound with wound cleanser. Observed the wound bed have yellow stringy/adherent slough. Staff C removed her gloves, sanitized her hands, and put on clean gloves. Staff C measured the heel wound and reported the size as 2 cm (length) x 3.3 cm (width). Staff C reported the wound looked better. Staff C described the wound bed as 75% dark red tissue and 25% slough. She reported the wound margins with maceration (softening or breakdown of skin from moisture) and small amount of a callus (thickening of the skin) to the upper side of the wound. Staff C reported she still classified the wound as unstageable due the amount of slough and being unable to see underneath that. Staff C removed her gloves, sanitized her hands, put on new gloves, applied betadine to the heel wound, let the betadine dry, and then covered the wound with a Mepilex dressing. Staff C removed her gloves, sanitized her hands, and put the heel protector boots back on, the she covered Resident #24 up. On 4/17/25 at 9:00 AM, the DON (Director of Nursing) and the Corporate Nurse reported they expected staff to obtain a physician order when applying a skin treatment. The DON reported they used heel lift boots as a standard intervention when a pressure ulcer develops on a heel. The DON verified the fax number on the top of the form titled Recommended Plan of Treatment was the facility's fax number. The DON acknowledged the time stamp as 1/27/25 at 9:42 AM. On 4/17/25 at 12:07 PM, the DON verified the facility didn't complete an incident report for Resident #24's pressure area. She reported she didn't know why they didn't implement the Physician's order on 1/27/25 until 2/5/25. She said the nurse who noted the order on 2/4/25 didn't know either. The DON and Corporate Nurse reported they expected the staff to implement the treatment order immediately and obtain the supplies. The DON verified she couldn't locate documentation regarding the heel lift boots under tasks (Kardex), treatment records, or the Care Plan. The DON reported when a resident developed a new pressure ulcer she expected staff to contact the Physician for a treatment order, complete an incident report, notify the family, and put a skin intervention in place. A facility policy titled Pressure Ulcer Risk Assessment and Documentation revised January 2011 directed staff to assess any new pressure ulcer as soon as discovered and document the following in the interdisciplinary notes: a. location, stage, size, depth, drainage, odor, color, surround skin condition, location and extent of any undermining or tunneling/sinus tract and granulation. b. Once the area has been assessed, notify the resident and or responsible party, physician, and DON. Document notification in the interdisciplinary notes. c. Obtain treatment orders from the Physician and record the treatments either on the MAR (Medication Administration Record) or TAR. d. Notify the Dietary Manager and they have the responsibility to initiate dietary interventions. e. Update the Care Plan to reflect new intervention to aid in the healing process. f. Update CNA assignments to include new interventions.

Based on observation, record review, staff interview, and policy review the facility failed to assess, provide interventions, or notify the physician, the Registered Dietitian (RD), and the family about a resident with a significant weight loss (over 5% in month) for 1 of 2 residents (Resident #14) reviewed. In 1 months, timeframe, Resident #14 lost greater than 5% of their body weight (considered significant weight loss). The facility failed to notify the RD and physician for interventions to prevent further weight loss. The facility reported a census of 30 residents. Findings include: Resident #14's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS included diagnoses of cancer and heart disease. On 4/14/25 at 12:04 PM, observed Resident #14 in the dining room eating lunch. Resident #14's Weight Summary reviewed 4/15/25 identified the following weights: a. 3/9/25: 205.3 pounds (lbs.) b. 4/6/25: 191.4 lbs. The calculated weight loss percentage revealed a weight loss of 6.92% in 1 month (significant considered greater than 5% in 30 days). The Care Plan Focus with target date 7/13/25, documented Resident #14 had a potential/risk for altered nutritional status. The Goal reflected Resident #14 would maintain their weight without significant changes. The Interventions directed the following: a. Monitor weights b. Notify the physician and RD of significant weight changes. Resident #14's clinical record lacked notification to their physician, RD, or their family of their significant weight loss on 4/6/25. Interview on 4/16/25 at 5:37 PM, the Assistant Director of Nursing (ADON), reported the previous weight review procedure as to weigh all residents' Sundays, then the past Director of Nursing (DON) reviewed the weights on Mondays. The RD came to the facility every Thursday. The ADON agreed Resident #8 had a significant weight loss from 3/9/25 - 4/6/25 and didn't know if the RD reviewed Resident #14's weight loss on 4/10/25 when she came to the facility. The ADON added the RD reviewed the residents due for their quarterly and annual MDS. She added the facility didn't have a process in place to ensure the RD reviewed weight losses. The ADON stated the staff should have notified the physician, RD, and family Resident #14's significant weight loss. She expected the staff to notify the physician, RD, and family with any significant weight loss. Interview on 4/17/25 at 9:17 AM, the RD stated she came to the facility every Thursday and completed the dietary assessments for residents due for a quarterly or annual MDS, any significant changes, and residents with any skin issues. The RD stated she pulled a report from the facility's charting system for any significant weight changes, but that the reports are not always accurate. The RD stated the facility let her know if they had any concerns such as residents who didn't eat but the facility didn't report to her any significant weight changes. The RD stated she didn't review Resident #14's weight changes on 4/10/24 while at the facility, and the facility didn't notify her of their significant weight loss. The RD stated it would be nice for the facility to notify her of residents' significant weight loss. The undated facility policy labeled Family and Physician Notification Relating to Accident or Change in Medical Condition instructed the facility to immediately notify the resident's responsible party and physician of a change in the resident's medical condition. The guidelines referenced to determine the urgency of notifying the physician and responsible party of changes in medical condition such as report on next work day of a weight loss of 5% or more within 30 days.

Based on observation, record review, and staff interview the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice by not changing oxygen (O2) tubing for 1 of 1 resident (Resident #8) reviewed. Facility reported a census of 30 residents. Findings include: A Minimum Data Set (MDS) dated [DATE]for Resident #8, included diagnoses of obstructive sleep apnea (frequent episodes of obstructed breathing while sleeping) and heart failure and received O2. A Brief Interview for Mental Status (BIMS) score of 15 indicated no cognitive impairment. Therapy. Observation on 4/15/25 at 9:50AM, in Resident #8's room was an O2 concentrator (machine that supplies O2) with tubing attached to a bipap machine (medical device that provides airway pressure to assist with maintaining breathing). The tubing supplying O2 from the concentrator to the bipap machine was not dated. Interview on 4/15/25 at 3:38 PM, Resident #8 stated she uses her bipap machine nightly with 2 liters (L) of O2. The resident stated the facility does not change the O2 tubing routinely and she does not know the last time the tubing was changed. Review of Resident #8's Clinical Physician Orders as of 4/16/25 at 11:46 AM, lacked an order to change O2 tubing. Interview on 4/16/25 at 11:39 AM, the Corporate Administrator stated the facility did not have a policy for changing oxygen tubing, that the facility protocol was to change the tubing every Sunday on the 2nd shift. Interview on 4/16/25 at 12:11 PM, the Corporate Administrator confirmed Resident #8 did not have an order to change the O2 tubing and her expectation to have an order and the tubing to be changed weekly.

Based on clinical record review, staff interviews, CDC (Centers for Disease Control and Prevention) recommendations and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed (Residents #10 and #133). After Resident #133 received Resident #10's insulin via an insulin pen, the facility failed to discard the insulin pens after the cross contamination occurred. The nurse put the insulin pens back into the medication cart after the medication error occurred and the nursing staff continued to use the insulin pens when administering Resident #10's insulin. The facility reported a census of 30 residents. Citation considered past noncompliance as the facility completed the following interventions prior to surveyor entering the building on 4/14/25: a. Staff B, LPN (Licensed Practical Nurse), received verbal education on 1/3/25. b. The facility provided the nurses education on 1/16/23 that insulin pens are single patient use and shouldn't be shared between residents. The nurse should get a new insulin if any cross contamination occurred for the next administration. Findings include: Resident #133's Progress Note titled Incident Report - Medication Event dated 12/15/24 at 12:46 PM revealed the nurse accidentally gave Resident #133 another resident's insulin medication. An untitled facility document provided by the Administrator during the survey documented on 12/15/24, Staff B, LPN, administered Basaglar 17 units and Fiasp 7 units to Resident #133, instead of Resident #10 in error. Staff B discovered the medication error when she gave Resident #10's noon insulin. At that time, she realized she didn't give this resident insulin for his morning dose. Staff B reported she used the same pen of Fiasp to give Resident #10's noon insulin dose. 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 5, indicating severe cognitive impairment. The MDS listed Resident #10 as independent with bed mobility and transfers. Resident #10 used a walker for ambulation. The MDS included diagnoses of coronary artery disease (impaired heart blood vessels), hypertension (high blood pressure), renal disease, and type 2 diabetes with hyperglycemia (elevated blood sugar). The MDS documented Resident #10 received insulin injections 7 days and took a hypoglycemic medication during the look back period. Resident #10's Progress Note dated 1/3/25 documented the facility contacted Resident #10's primary care physician and received orders to obtain HBV, HCV, HIV, VDRL labs on 1/6/25 due to cross contamination with insulin pens on 12/15/24. Resident #10's wife gave consent for labs to be drawn. Resident #10's Progress Note dated 1/20/25 documented labs results from 1/6/25, HCV, HBV, HIV and VDRL as non reactive. 2. Resident #133's MDS assessment dated [DATE] identified a BIMs score of 3, indicating severe cognitive impairment. The MDS listed Resident #133 as independent with bed mobility and required partial/moderate assistance with transfers and ambulation. The MDS included diagnoses of hypertension (high blood pressure), renal (kidney) disease, and diabetes mellitus. The MDS documented Resident #133 didn't receive insulin injections and didn't take hypoglycemic medication during the lookback period. Resident #133's Progress Note dated 1/3/25 documented the facility contacted the Medical Director and received orders to obtain HBC (Hepatitis B Virus Core Antigen), HCV (Hepatitis C antibody test), HIV (human immunodeficiency virus), VDRL (screen for syphilis) labs on 1/6/25 due to the medication error that occurred on 12/15/24. Resident #133's daughter gave consent to draw the labs. Resident #133's Progress Note dated 1/20/25 documented labs results from 1/6/25, HCV, HBV, HIV and VDRL as non reactive. A facility form titled One on One Inservice Record dated 1/3/25 documented a verbal review via phone call was completed with Staff B, regarding the following topics: a. 6 rights of medication administration b. Inhaler, eye drops and insulin pens are single patient use c. Discard contaminated medications and obtain new ones for the medication cart. A facility form tilted Staff Development Program Attendance Report dated 1/3/25 for Nurses and CMAs included the following education topics: a. 6 Right of Medication Administration b. Med Error Process c. Insulin Administration d. Inhalers and eye drops. The education form documented all the facility nurses completed the education as of 1/16/25. On 4/16/25 at 12:21 PM, Staff B, verified she was the nurse that made the insulin errors with Resident #10 and Resident #133. Staff B described it as literally a freak accident. She reported being new to the facility, worked as an agency nurse, and not 100% familiar with the residents. Staff B reported she abandoned the 6 rights of medication administration and made a very bad mistake. Staff B reported she gave both insulins from an insulin pen. She said she put brand new needles on the insulin pens before she gave the insulin to Resident #133. She reported after she gave the insulin to Resident #133 she disposed of the needles and put the insulin pens back in the drawer in the medication cart. She reported she used the insulin pens to give Resident #10 insulin that day after she gave Resident #133 the insulin. Staff B reported she received a phone call from the DON (Director of Nursing) and a Pharmacist after the medication error occurred. Staff B reported she couldn't recall what day she received the phone call from the DON and Pharmacist. Staff B reported the Pharmacist told her if that ever happened again that it was in the best interest of the patient to discard the insulin pens even if they used a new needle. Staff B reported she didn't know any better at the time. Staff B reported after the medication error occurred she made her own plan to follow the 6 rights of medication administration and complete extra checks to ensure she gave the right medication to the right resident. The CDC recommendations dated 8/7/24 described insulin pens as a pen shaped injector device that contain a reservoir for insulin or an insulin cartridge. Each pen is designed to be safe for just one patient to use multiple times with a new, fresh needle for injection. Pens must never be used for more than one patient because blood may be present in the pen after use. A CDC brochure dated August 2024 documented although visible to the eye, back flow of blood into the insulin pen can happen during an injection. This created a risk for bloodborne and bacterial pathogen transmission to patients if they used a pen for more than one person, even after changing the needle. The CDC recommended if identified of reuse of a pen, the facility should promptly notify patients and offer appropriate follow up including bloodborne pathogen testing. On 4/16/25 at 3:09 PM, the DON (Director of Nursing) reported she expected insulin pens to be single use and discard an insulin pen if cross contamination occurred. The DON verified the staff continued to use Resident #10 insulin pens after cross contamination until the pens were empty. The DON reported she couldn't determine how many doses the insulin pens had left after the cross contamination occurred as they couldn't determine when the staff opened the insulin pens and started to use them. The DON reported when she learned on 1/3/25 that no one discarded the insulin pens after the cross contamination she sent staff education via text message. A facility policy titled Infection Control Manual Exposure Control Plan revised March 2024 documented if a source patient is determined and the HBV, HCV, and HIV antibody status is unknown, obtain patient consent for blood testing. Inform the source person or legally authorized representative of the incident, and obtain informed consent to test the source's blood, in accordance with applicable state and local laws, to determine the presence of HBV, HCV, or HIV. Testing to determine HBV, HCV, and HIV infection status of the exposure source should be performed as soon as possible after the exposure.

Based on resident interviews, staff interviews, and facility records review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility (Residents #4 and #19). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 4/3/24 assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Census tab in the clinical record revealed Resident #4 resided in room [ROOM NUMBER]. On 4/23/23 at 10:30 AM, the Administrator provided Resident #4's call light report from 3/23/24 to 4/23/24. The Administrator verified the column on the report titled In Room Elapsed Time was the duration the call light was on. On 4/23/24 at 1:05 PM, Resident #4 reported her call light can be long at times on all shifts. She stated she tried to be patient with the staff as she knew they were working with other residents. She stated she used the clock on the wall to time the call lights. In a previous interview on 4/22/24 at 1:18 PM, Resident #4 stated she had been incontinent of bowel while waiting for a call light to be answered. Review of Resident #4's call light reports for room [ROOM NUMBER] from 3/23/24 to 4/23/24 revealed the highest room elapsed time was 25 minutes and 4 seconds. The call light report documented Resident #4's call light was on 15 minutes or more on the following dates and times: 3/23 at 7:54 AM= 21 minutes and 27 seconds 3/25 at 5:53 AM= 17 minutes and 26 seconds 3/26 at 1:30 AM= 16 minutes and 13 seconds 3/26 at 8:18 AM = 16 minutes and 35 seconds 3/28 at 7:09 PM= 17 minutes and 26 seconds 4/1 at 8:13 AM= 15 minutes and 29 seconds 4/2 at 8:17 AM= 16 minutes and 2 seconds 4/4 at 7:31 AM= 15 minutes and 58 seconds 4/8 at 7:38 AM= 16 minutes and 49 seconds 4/10 at 3:29 AM= 25 minutes and 4 seconds 4/13 at 8:19 AM= 15 minutes and 32 seconds 4/14 at 11:23 AM= 15 minutes and 35 seconds 4/15 at 1:30 PM= 18 minutes and 29 seconds 4/18 at 8:14 AM= 17 minutes and 37 seconds 4/20 at 8:20 AM= 18 minutes and 57 seconds On 4/24/24 at 10:14 AM, the Director of Nursing (DON) reported her expectation was to answer the call light as soon as possible but within 15 minutes. The DON reported the facility did not have a call light policy. She stated staff learn the call light expectations through their training. 48886 2. The MDS dated [DATE] documented Resident #19 had a BIMS score of 15, indicating intact cognition. The Census tab in the clinical record revealed Resident #19 resided in room [ROOM NUMBER]. During an interview on 4/22/24 at 1:10 PM, Resident #19 reported having to wait for up to a half hour for a response to her call light, stating this has happened more than once and more so on the weekends. Resident #19 stated she used the clock in her room to time the response to call lights. On 4/23/23 at 10:30 AM, the Administrator provided Resident #19's call light report from 3/23/24 to 4/23/24. The Administrator verified the column on the report titled In Room Elapsed Time was the duration the call light was on. Review of Resident #19's call light reports for room [ROOM NUMBER] from 3/23/24 to 4/23/24 revealed the highest room elapsed time was 34 minutes and 21 seconds. The call light report documented Resident #19's call light was on 15 minutes or more on the following dates and times: 3/23 at 10:54 PM = 18 minutes and 5 seconds 3/30 at 10:49 PM = 18 minutes and 59 seconds 4/1 at 8:56 AM = 23 minutes 42 seconds 4/1 at 11:00 AM = 16 minutes and 2 seconds 4/2 at 12:21 PM = 23 minutes and 41 seconds 4/3 at 12:07 PM = 15 minutes and 45 seconds 4/5 at 10:15 AM = 17 minutes and 13 seconds 4/8 at 12:13 PM = 16 minutes and 18 seconds 4/11 at 11:19 AM = 17 minutes and 11 seconds 4/12 at 2:29 PM = 17 minutes and 25 seconds 4/15 at 7:08 AM = 16 minutes and 32 seconds 4/15 at 9:48 AM = 17 minutes and 41 seconds 4/15 at 1:15 PM = 34 minutes and 21 seconds 4/17 at 10:27 AM = 18 minutes and 19 seconds During an interview 4/24/24 at 10:30 AM, Staff B, Certified Nursing Assistant (CNA), stated all staff carry an I-phone that has the call lights on it, it shows which resident has pushed their call light and how long the light has been on, this helps her determine which resident she should go to first. Staff B will look at the call light log on her I-phone to see who has been waiting the longest for a call light response and will go to the resident waiting the longest. Inquired how and when they turn the call light off to show it was responded to, Staff B advised they turn the light off in the room when they go into the resident's room to see why they pulled their call light, and this turns it off on the call light log on the I-phone. Staff B advised they are trained to respond to call lights within 15 minutes and that is their expectation.

Based on clinical record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis and start of new psychotropic medications (Resident #15). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderately impaired cognition. The MDS revealed Resident #15 had diagnoses of psychotic disorder, adjustment disorder with depressed mood and visual hallucinations. The Care Plan for Resident #15 with a target date of 7/11/24 included a focus area for mood/behavior revealed exhibited visual hallucinations. The Care Plan further documented Resident #15 received psychotropic medications for the hallucinations and depression. The Clinical record revealed Resident #15 had the following diagnoses with effective dates: 1. Adjustment disorder with depressed mood-effective 8/1/23 2. Delusional disorder- effective date 7/31/23 3. Visual hallucinations- effective date 1/26/22 The April 2024 Medication Administration Record (MAR) for Resident #15 directed staff to administer the following medications: a. Sertraline HCL (antidepressant) 25 mg (milligrams) one tablet by mouth in the morning related to adjustment disorder with depressed mood. Start date: 8/2/23 b. Risperdal (antipsychotic) 0.25mg one tablet by mouth two times a day for hallucinations/altered mental status. Start date: 5/5/23 A Level 1 PASRR completed on 4/20/22 documented Resident #15 did not have a major mental illness. The PASRR evaluation documented Resident #15 received Ativan (antianxiety) for anxiety disorder. The clinical record revealed no additional PASRR evaluations after 4/20/22. The Clinical record review revealed Resident #15 did not have a Level 2 PASRR evaluation submitted following the new mental health diagnoses with the addition of new medications. (antidepressant and antipsychotic). On 4/23/24 at 12:45 PM, the Director of Nursing (DON) acknowledged and verified Resident 15's PASRR had not been updated. She stated her expectation for the PASRR was to be updated when there was a new diagnosis or a new classifications of medication. The DON reported the facility did not have a PASRR policy.

Based on clinical record review and staff interview, the facility failed to follow a physician's order for 1 of 1 residents reviewed receiving diabetic medication (Resident #14). The facility reported a census of 30 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] documented Resident #14 had a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment. The MDS further documented the resident had diagnoses to include medically complex conditions, renal insufficiency, and diabetes mellitus (DM). The Care Plan for Resident #14, with a target date of 6/25/24, documented under the focus section the resident had diabetes mellitus, with interventions to take routine insulin and a weekly injection to help control blood sugars. Review of records for Resident #14 revealed a Progress Note entry on 2/9/24 at 10:26 AM titled Physician Visit note, documented new orders received and noted from physician visit note to increase resident's Ozempic (Diabetic medication) to 1mg (milligram) once a week. Review of Progress Note entry on 2/13/24 at 10:07 PM, titled Orders-Administration Note, Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous (applied under the skin) Solution Pen-injector 2 MG/3ML, Inject 1 mg subcutaneously (under the skin) one time a day every Tuesday related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA Only 0.5mg dosage available in the pen. No other pen available. Review of the Medication Administration Record (MAR) for Resident #14 for the month of February 2024, revealed documentation on 2/13/24 of 0.5 mg of Ozempic administered. Review of Progress Note entry on 2/16/24 at 12:43 PM titled Secure Conversations, with a message sent 2/14/24 at 1:05 PM by Director of Nursing (DON) to Resident #14's physician indicating resident only received 0.5 mg Ozempic last evening as that is all that was available, new pens (Ozempic) have been ordered from pharmacy. During an interview 4/24/24 at 10:45 AM, the Director of Nursing (DON) stated Resident #14 had an order from the physician on the 9th of February of 2024 for 1 mg of Ozempic, to be given once a week every Tuesday. The DON stated Resident #14 was not given the full 1 mg of Ozempic as prescribed on Tuesday, the 13th of February. During an interview 4/24/24 at 2:38 PM, the DON advised Resident #14's order for Ozempic changed on the 9th of February, 2024, to 1 mg every Tuesday. The pharmacy did not receive the order change until the 13th and did not deliver it to the facility until the 15th of February. The DON read the Progress Note of the resident only receiving half of the prescribed dose on the 13th of February when she arrived at work on the morning of the 14th of February. The DON sent a message to the resident's physician on the 14th advising of the resident only receiving half of the prescribed dose of Ozempic. The physician replied back on the 16th of February with no new orders. The DON stated an expectation that the nurse administering the medication reach out to the physician prior to giving the resident the incorrect dosage of the prescribed medication on the 13th of February. The DON acknowledged the physician's orders were not followed. During an interview 4/25/24 at 9:34 AM, the Administrator advised the facility does not have a policy for following physician orders, they follow professional standards and nurses are expected to follow physician orders.

Based on observation, staff interviews and policy review, the facility failed to prepare food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 30 residents. Findings include: During an observation on 4/24/24 at 10:50 AM, Staff A, Cook, began the puree process for residents on a pureed diet. Wearing gloves, Staff A tore chicken off the bone and placed on a scale, took the gloves off, did not wash hands, and poured the chicken into the robot coupe (machine used to puree food) container. Using bare hands, Staff A touched the handle on a gallon of milk, the lid on the container, the button on the robot coupe, a drawer handle to get a spatula, a spatula, the robot coupe container, a box of tin foil, a marker from her pocket, and the warming oven. Staff A also touched the table top surface. Without washing or sanitizing hands, Staff A obtained a new container and touched tongs and a spatula to place the second food item to be pureed into the robot coupe container, placing the container onto the robot coupe machine. Staff A touched the inside of the robot coupe container that contained food and the blade that would puree the food that went inside the container. The blade did not slide into the container correctly and Staff A continued to touch the top portion of the blade that would blend the food. Staff A did not wash hands throughout the entire pureeing process. During an interview 4/24/24 at 11:10 AM, Staff A stated washed her hands often, however could not say at what times hands should be washed, stating they are washed throughout the day. Staff A acknowledged touching objects that would come in contact with a resident's food with her hands, without washing or sanitizing her hands. During an interview 4/25/24 at 10:13 AM, the Dietary Manager (DM) stated an expectation for staff to wash hands in the kitchen while handling or preparing food, before and after putting on gloves, after handling raw food, and after handling food or touching a surface or equipment that will come in contact with food. The DM acknowledged Staff A did not wash hands after removing gloves and after touching surfaces and then touching the blade in the robot coupe prior to pureeing food. Review of the facility policy Handwashing, Specific to the Dietary Department, dated 5/16/03, documents hands will be washed with either soap and water or alcohol-based hand rubs before and after using disposable gloves, following any contact with infectious materials, and after completion of a dirty task, prior to beginning a clean task.

Based on observation, facility record review, staff and resident interviews, the facility failed to ensure resident ' s environment remained as free as possible from hazards that had the potential to cause injury for 4 out of 4 residents reviewed, by utilizing space heaters in the resident rooms overnight where they slept, (Residents #19, #11, #4, and #9). The facility reported a census of 34 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview For Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. In an interview during initial tour on 2/6/23 at 11:23 AM, Resident #4, room [ROOM NUMBER], reported that she had recently used a space heater in her room because there was something wrong with the facility boiler. She stated that the heater was removed last night or this morning. 2. Resident #9's MDS dated [DATE], indicated a BIMS of 12 which indicated moderate cognitive impairment. In an interview during initial tour on 2/6/23 at 12:45 PM, Resident #9, room [ROOM NUMBER], reported that she was always cold and the facility staff had brought her in a space heater last week. 3. Resident #11's MDS dated [DATE], indicated a BIMS of 15 which indicated intact cognition. In an interview during initial tour on 2/6/23 at 1:44 PM, Resident #11, room [ROOM NUMBER], reported that he and his roommate (Resident #19) had been using a space heater in their room due to a problem with the facility boiler. 4. Resident #19's MDS dated [DATE] indicated a BIMS of 13 which indicated intact cognition. In an interview during initial tour on 2/6/23 at 1:44 PM, Resident #19, room [ROOM NUMBER], reported that he and his roommate (Resident #11) had been using a space heater in their room due to a problem with the facility boiler. On 2/7/23 at 2:00 PM, 10 electric heaters were observed in a spare room near the conference room. The facility document titled Oil Filled Space Heater Checks dated 1/29 & 1/30/23 and 2/4 & 2/5/23, revealed 15 minute checks for the following areas: Northeast Hall Northwest Hall West Hall room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] The facility failed to complete 15 minute checks on the space heaters while they were being utilized in rooms 24, 25, & 27. In an interview on 2/7/23 at 7:55 AM with Staff C Registered Nurse (RN), regarding boiler issues she stated that yes that some heaters were used, but they did checks every few minutes to be sure nothing caught on fire. She stated she did not know what was going on other than that they were using space heaters. In an interview on 2/7/23 at 7:588 AM, with Staff A, Certified Nursing Assistant (CNA) CNA stated that they were having problems with the boiler and that space heaters were put in the hallways and in resident rooms. She stated she did not know how many residents had heaters in their rooms. In an interview on 2/7/23 at 3:22 PM, with the Administrator, she stated problems with the boiler began Sunday morning 1/29/23, and that staff were sending her pictures of the thermostats which she stated ranged from 71-72 degrees. When she was asked if that was as low as the temperature got, she stated she thought she might have seen one that said 68 degrees. She reported that corporate maintenance came into the facility early on Sunday and stated that they would be back on Monday, the 30th, with the part to fix the boiler. [NAME] stated they continued to have problems with the boiler off and on until Thursday the 2nd of February. She acknowledged that space heaters were put in hallways and residents could come out of their rooms in the gathering area to get warmer if they were cold. She stated 3 heaters were zig-zagged down Northeast and Northwest hallways. When asked if any heaters were placed in resident rooms, she stated she thought a couple of them had them, but didn't know which residents. In an interview on 2/8/23 at 9:10AM, the Administrator stated that she was only aware of 2 residents having space heaters in their rooms and they were only used 1/29/23 and 1/30/23. Administrator was informed that it was said that heaters were removed from resident rooms on the morning of 2/6/23. She stated she was not aware of that and that she would have to talk to Staff B, Maintenance about it. In an interview on 2/8/23 at 9:30 AM, Staff B Maintenance man, stated he was called Sunday morning, 1/29/23 between 1:00 and 2:00 AM by staff letting him know that they were without heat. Corporate maintenance was called and he said he met them early Sunday morning around 8:00 AM. He stated there was a part on the boiler that wouldn't allow it to ignite. He stated all space heaters were picked up and put away on Monday morning 1/30/23. Staff B acknowledged that there had been problems off and on all week but he thought by Thursday, 2/2/23 everything had been fixed and things were running smoothly. He reported that he received a call on Sunday from staff saying that a light in a freezer next to the Assistant Director of Nursing's office was out. He instructed staff to look at the breaker box. He said that a space heater had been plugged in and blew the breaker. Staff B denied being asked if space heaters could be used at that time and stated he did not know if the Administrator was aware. He stated on Monday when he came to work he picked up at least 6 space heaters from resident rooms in the west hallway.

Based on clinical record review, observation, staff interviews, and manufacturer ' s instructions the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 2 residents reviewed for administration of an inhaler, (Resident #28). The facility reported a census of 34 residents. Findings include: Resident #28 ' s Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #28 ' s MDS included a diagnosis of asthma. A Physician Order dated 05/16/2022 directed staff to administer Flovent HFA Aerosol 110 MCG inhaler 2 puffs inhaled orally one time a day related to mild intermittent asthma. Review of Resident #28 ' s Electronic Medication Record (EMAR) for February 2023 documented Resident #28 received the Flovent inhaler one time a day. Review of Flovent HFA Instructions for Use (manufacturer ' s instructions) revised August 2021 directed to wait 30 seconds after the administration of the 1st puff and shake the inhaler for 5 seconds before administering the second puff. Observation on 2/8/23 at 8:15 a.m. Staff D, Certified Medication Aide (CMA) administered two puffs of the Flovent inhaler to Resident #28 and did not wait 30 seconds in between each puff. During an interview on 2/8/23 at 8:18 a.m. the CMA reported she waited approximately 5 seconds in between the two puffs. The CMA stated she probably did not wait enough time. The CMA reported she did recall being told how long to wait in between administering the two puffs. The CMA agreed she did not wait 30 seconds in between puffs per the manufacturer ' s instructions. During an interview on 2/8/23 at 10:15 a.m. the Director of Nursing (DON), reported the facility does not have a policy for administration of inhalers. The DON stated the facility follows the manufacturer's instructions. The DON reported the facility does not have any specific education or training for Staff D, CMA regarding administration of inhalers.

Based on clinical record review and staff interview the facility failed to complete a required Significant Change Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed receiving Hospice Services within the required fourteen days (Resident #27). The facility reported a census of 33 residents. Findings include: The MDS dated [DATE] for Resident # 27 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident had cognitively intact skills for daily decision making. The MDS revealed the resident was receiving hospice care. The MDS revealed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 8/25/21 revealed the resident elected hospice services. Review of the Census tab in the electronic chart revealed Resident #27 went hospice on 3/10/21. Review of the MDS tab in the electronic chart revealed no significant change was completed. During interview on 9/21/21 at 8:28 AM the Corporate Nurse stated they would do a significant change in condition if it meets the requirements. The Corporate Nurse stated that hospice is a significant change in condition and that the resident did go on hospice on 3/10/21.

Based on clinical record review and staff interview the facility failed to submit the Minimum Data Set (MDS) assessment for a resident within 14 days of when resident passing for 1 of 1 residents reviewed, (Resident #1). The facility reported a census of 33 during the survey. Findings include: Review of the electronic chart revealed an MDS completed on 5/6/21 for the notification of death for Resident #1. Review of document CMS Submission Report revealed the MDS was transmitted on 9/21/21 at 11:55:13. An interview on 9/21/21 at 9:35 AM revealed the Nurse Consultant would expect transmission of an MDS to be within 14 days.

Based on observation, staff interviews, review of the cleaning schedules and facility policy the facility failed to maintain proper cleaning of equipment. The facility reported a census of 44. Findings include: 1. An observation on 12/9/19 at 11:13 AM, with Staff B, Human Resource (HR), revealed food debris spattered on the wall behind the garbage receptacle, the stove 4 burners noted to have a carbon buildup and the wall behind the oven had splatters of yellowish material. The oven's handles had sticky material on them that scratched off with the tip of a pen and the oven doors had carbon buildup around the three edges inside of the doors. The second oven with glass in the door, noted a buildup of yellowish material on the glass and carbon buildup around the three edges inside of the doors. An electrical outlet on the food prep table had a white substance and food debris that when touched flaked off and onto the prep table. Staff B, HR, followed the surveyor and confirmed the wall splatters, carbon buildup on the burners, ovens and the outlet on the prep table. A review of the daily cleaning schedule for the weeks of 10/21 to 11/24/19 noted routine cleaning of the stove top, oven and garbage initialed as completed. In an interview on 12/11/19 at 9:33 AM, the Corporate Dietician stated they couldn't find any cleaning schedules since 11/25/19. The Corporate Dietician stated last night and today they used chemical on the stove's front burners to clean them and now needed to just chip away at the left over carbon. A review of an undated, Kitchen Sanitation and Cleanliness policy noted: Policy: Food service preparation, storage, and service areas will be maintained in clean and sanitary conditions. A review of an undated, Cleaning Ovens policy noted: 2. Apply an approved oven cleaner or degreaser and let stand if directed. 3. Wipe off loosened grease and carbon with paper towels or an old cloth. repeat process and scrub with a green plastic scrubbing pad to remove any carbon build-up. 7. Apply oven cleaner such as Fast Foam or degreaser to the interior of the oven . Let stand per manufacturer's directions. 8. Wipe off loosened grease and carbon from inside oven and on door(s). 2. Observation on 12/10/19 at 2:10 p.m., with the CDM (Certified Dietary Manager) from another facility, revealed a large amount of carbon remain on the stove top burners, the wall behind the stove top had splatters of a yellow/orange material similar to grease, the hood above the stove had a few splatters of the same yellow/orange material, the oven door had carbon visible on the 3 edges when the door opened and the oven door handle had a sticky material that came off easily with a finger nail. The CDM touched the yellow/orange material above the stove and stated the substance was grease. The Corporate Dietician arrived at 2:15 p.m. and she and the CDM stated they had been unaware of the carbon around the oven door and the sticky material on the oven door handle and both stated the staff continue to work on cleaning the stove area.

Based on observation, record review and staff interviews, the facility failed to follow the therapeutic menu for 2 of 2 residents on a mechanical soft diet for 1 meal observed. The facility reported a census of 44 residents. Findings include: The facility Diet Type Report revealed 2 residents in the facility received a full mechanical soft diet, Residents #12 and #44. 1. The therapeutic diet for the evening meal on Monday, 12/9/19, directed staff to serve residents on a mechanical soft diet 3 ounces of ground fried chicken During observation on 12/9/19 at 4:48 p.m., Staff A, cook, stated she planned to make 2 servings of ground chicken for 2 residents that received ground meat. Staff A stated she planned to use chicken wing dings instead of the fried chicken pieces for the other residents. Staff A stated 4 wing dings equaled a serving, placed 4 wing dings loosely and heaped in a spoodle for each serving, and placed 2 servings in the [NAME]ot Coupe. Staff A ground the chicken, placed the chicken in a stainless steel pan without measuring the total volume, and put the chicken in the oven to reheat. Observation during the evening meal service on 12/9/19 at 6:08 p.m. revealed the 2 residents had been served a #10 scoop of ground meat. During an interview on 12/9/19 at 6:10 p.m., Staff A verified she had served the 2 residents and used #10 scoop of ground chicken. During observation on 12/9/19 at 6:15 p.m., the Corporate Dietician measured the left over ground chicken and stated almost 2 #10 scoops of ground chicken remained in the steam table. The Corporate Dietician stated she had not realized Staff A had only ground 2 servings of chicken and stated she and the Certified Dietary Manager (CDM) from another facility planned to divide the left over ground chicken and serve the remainder to Residents #12 and #44. During an interview on 12/10/19 at 2:15 p.m., the Corporate Dietician stated if she realized Staff A had prepared 2 servings of ground chicken for 2 residents for the evening meal on 12/9/19, she expected Staff A to serve all the chicken. The CDM from another facility present and verified she had observed Staff A measure the chicken wing dings with a spoodle. During an interview on 12/10/19 at 4:30 p.m., the Corporate Dietician presented dietary intake sheets for the 12/9/19 evening meal and stated Resident # 44 had eaten 100% of the meal and Resident #12 ate 25% of the meal.

Based on clinical record review and staff and resident interview the facility failed to ensure assessments were thoroughly completed and documented in the clinical record after one of one resident reviewed who experienced an acute change in condition. (Resident #28) The facility census was 53. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], included [DIAGNOSES REDACTED]. The MDS documented the resident required no assistance for bed mobility or transfer. The care plan initiated 6/27/16, included a [DIAGNOSES REDACTED]. The care plan included no problem related to the residents respiratory status. A progress note dated 11/13/18 at 1:32 p.m., documented communication with physician, resident vital signs as follows: Temperature-97.7, Blood Pressure-161/69 Pulse-60, Oxygen Saturation 98% , Respirations-22 short and shallow. Resident unable to take a deep breath, noted faint crackles to left upper lobes. Resident stated I took a bite of turkey at lunch then a drink of water and everything went south from there. Wet cough producing large amounts of clear froth like sputum even after 45 minutes. Resident states I feel like something is stuck in my chest and I can't get it out! Please advise. A progress not at 2:21p.m., documented resident left facility via facility van to go to emergency room (ER) per Advanced Registered Nurse Practitioner. A progress note at 3:51 p.m., documented communication with physician, communication sheet returned signed bring to ER now! per physician. Resident transported to emergency room via facility van awaiting return. A progress note at 4:02 p.m., documented resident returned form ER visit due to choking [DIAGNOSES REDACTED]. No new orders. Will see physician on 11/15/18. Clinical record review on the day of 11/14/18 at 2:00 p.m., revealed no nursing assessment completed for the three shifts reviewed following the residents transfer to the emergency room , 11/13/18 evening shift, 11/14/18 night shift or 11/14/18 day shift. On 11/14/18 at 2:15 p.m., the facility Director of Nursing (DON) stated the expectation would be for nurses to at least see how the resident is doing after a choking episode. The DON confirmed the resident's record lacked assessments completed after the resident's returned from the emergency room through the current time. At 2:20 p.m., Staff A, Licensed Practical Nurse, LPN stated the standard of care for a resident who experienced a choking episode would be to do follow-up respiratory assessments. Staff A stated the resident had been assessed by the physician in the emergency room and they did not further assess because the residents lungs were clear when left the emergency room . Staff A verified being the residents nurse on second shift when the resident returned from the emergency room after the choking episode. At 6:15 p.m., Staff A, LPN stated they listened to the residents lungs but did no temperature. Staff A stated they observed the resident at meal time and had no concern with the resident's swallowing. Staff A stated they had now made late entries for the assessments they had completed the previous day. When asked why they reported earlier they did not complete assessments. Staff A stated they had forgotten to tell the surveyor. Staff A stated they had completed late entries from notes they kept in their locker. Clinical record review at that time then revealed a progress note dated for the previous day, 11/13/2018 6:40 p.m., created by Staff A on 11/14/2018 at 2:55:13 p.m., Late Entry: resident out in main dining room eating supper meal, upon return for ER for choking at noon meal. Upon assessment no problems with swallowing, no coughing noted. Resident stated I feel better now then I did earlier. Lungs sounds clear throughout all aspects. Record review continued to show no assessment of temperature, respiratory rate, quality or oxygen saturation.

Based on record review, observation, family and staff interview the facility failed to ensure 1 of 5 resident with incontinence received treatment and care related to bladder incontinence (Resident #15). The facility reported a census of 53 residents. Findings include: According to the MDS (Minimum Data Set) assessment dated [DATE] Resident #15 had [DIAGNOSES REDACTED]. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score 15 which indicated no cognitive impairment. The MDS indicated the resident required extensive assistance of staff for toilet use and was frequently incontinent of urine. Review of the resident's care plan with a target date of 12/05/18 revealed the resident had frequent incontinence. The care plan directed staff to the following intervention: a. Remind resident to change incontinence products frequently throughout the day and as needed for incontinence. b. Staff to assist the resident with incontinence and peri care as needed. c. Incontinence briefs alone do not hold the urine and require wearing a disposal pad. Review of the resident's Electronic Health Record (EHR) and clinical chart revealed a form titled Bowel/Bladder Continence Evaluation dated 8/24/18. The form indicated the resident had bladder incontinence for the last 2-5 years and incontinent more than once a day. Review of a form titled UICC Culture; Urine revealed that on 10/29/18 at 9:12 AM there were greater than 100,000 CFU/ml (colony forming units per milliliter) of Escherichia coli. (A bacteria that is normally found in the intestines of humans.) During a resident interview on 11/13/18 at 10:00 AM Resident #15 not able to hear to complete the interview questions. The resident's husband stated his wife had been incontinent and required more help with cares. The resident and husband admitted to the facility (MONTH) (YEAR). During observation on 11/14/18 at 12:22 PM the resident's husband seated in the dining room requested the surveyor check on his wife. Observation revealed his wife in bed incontinent of urine with the bed linens saturated and pants soiled to the knees. Staff B assisted the resident to the bathroom and the resident sat down on the toilet. Staff B assisted the resident with wiping peri area and then changed the resident's incontinent brief and obtained clean pants. Staff B failed to wash the resident's hips, thighs where the soiled pants had touched. During an interview on 11/14/18 at 5:06 PM Staff C reported the resident incontinent at times and that no one has ever talked to her about offering to take resident to the bathroom. Staff C stated she helps the resident get ready for bed and showers on evening shift. During an interview on 11/14/18 at 5:09 PM the Assistant Director of Nursing (ADON) stated that the resident is incontinent fairly frequently. When asked if the facility had tried a toileting program the ADON stated they have not tried a formal toileting schedule, staff make rounds every two hours. The ADON stated the resident needed the supervision from staff at this time. When interviewed on 11/14/18 at 5:54 PM the Director of Nursing (DON) stated it is her expectation that staff toilet this resident frequently, but the resident capable of toileting herself. The DON stated this depends on the resident's pain and mood. The DON stated she would expect staff to walk the resident into the restroom and change soiled clothes. The DON acknowledged no toileting schedule as the resident is fairly independent. The DON confirmed the resident's incontinence and with a history of urinary tract infections. When interviewed on 11/14/18 at 6:03 PM the Care Coordinator/MDS nurse reported the resident toilets on her own with incontinence issues for a long time. Staff help the resident more frequently with this issue. She continued that the resident at times refuses to get up and toilet and then will be soaked after laid down. The Care Coordinator/MDS nurse stated no voiding diaries or toileting plan completed for the resident and would expect staff to assist the resident every couple hours.

Based on observation, record review, staff interview and facility policy review, the facility failed to ensure staff followed infection control practices for 1 of 4 residents reviewed (Resident #20). The facility identified a census of 53 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #20 had [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS) score of 15 indicated no cognitive impairment. The MDS documented the resident required extensive assistance of one with dressing, and transfer, and further documented an open area on the foot. Observation on 11/14/18 at 9:11 a.m., revealed the facility wound nurse entered the resident's room donned gloves and prepared the resident for treatment without washing her hands after entering the room and before donning gloves. She removed the dressing from the right lateral side of the resident's foot and took the glove off her right hand. Without washing her hands she proceeded to cleanse the wound. She then washed her hands and applied the clean dressing and finishing the treatment to the right lateral side of the foot. She then removed the dressing from the back of the heel and removed her glove. The wound nurse cleansed the area to the back of the right heel without washing her hands prior to cleansing the area. During an interview on 11/14/18 at 9:34 a.m. the Director of Nursing stated that she did not see the wound nurse wash her hands before the treatment was completed. The Director of Nursing acknowledged that the wound nurse did not wash her hands before cleansing the wound on resident's foot. During an interview on 11/14/18 at 9:36 a.m. the wound nurse acknowledged that she did not wash her hands after entering the resident's room, after removing the resident's dressings or before cleansing the wounds. The facility Infection Prevention and Control Program Guidelines directed staff to perform hand hygiene before and after changing a dressing.

Based on observation, record review, and interviews with the physician, resident and staff, the facility failed to ensure two of four residents reviewed for falls received adequate supervision from hazards. The facility failed to reassess and implement adequate supervision for Resident #1 and Resident #3 knowing the residents were cognitively impaired and needed assistance. Neither resident consistently used the call light and/or waited for assistance and staff were not consistent as to how often to check Resident #1. Facility census was sixty (60) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of [DATE] assessed Resident #1 with a brief interview for mental status (BIMS) score of "5" (severe cognitive impairment). The resident usually understood others but may miss part or intent of message. The resident required extensive staff assistance (resident involved in activity, staff provide weight bearing support) for bed mobility, transfers, ambulation in and out of room, dressing, toileting and bathing. The MDS also identified the resident's balance during transition and walking as not steady but able to stabilize without human support when moving from seated to standing position, when walking with assistive device, turning around and facing the opposite direction when walking, when moving on and off the toilet and when transfers between surfaces (transfers between bed and chair or wheelchair). The resident used a walker and wheelchair. The resident was frequently incontinent of bladder (7 or more episodes of urinary incontinence) and not on a toileting program. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident's admitted as [DATE]. The resident received anticoagulant medication. The resident and spouse resided in a room furthest from the nurse ' s station and center of facility. Past History Prior to [DATE] nursing home admission: A history and physical dated [DATE] identified the resident fell at home when the walker slid out from under the resident and the resident subsequently fell to the ground. The resident complained of low back pain and landed on the right shoulder. The X-ray of the low back showed significant degenerative changes and the shoulder X-ray appeared negative for fracture. A new resident admission information form, dated [DATE], stated the resident had [DIAGNOSES REDACTED]. The new admission information form directed staff to provide assistance of one staff with bathing, transfers, dressing/grooming, ambulation and toileting. The new resident admission information did not identify a need for monitoring the resident. An area titled "alarms/safety issues" was blank. An admission/readmission fall risk assessment and interventions form, dated [DATE], directed staff to provide the following interventions: encourage call light use, frequent monitoring by staff members, grab bars, hi/low bed, increased activities of resident interest, nonskid slippers/shoes, place items in reach, recliner in room, reorientation, room free of clutter, room modifications specific to resident preference, toilet per schedule/request. The fall risk assessment and interventions form contained the following addendums: [DATE] occupational therapy (OT) and physical therapy, discussed use of alarms with resident and spouse refused alarm placement, educated on importance of not getting up on own with resident and spouse and an addendum dated [DATE] identified the facility placed a note on the resident's walker to use a call light and wait for assistance. A certified nurse aide (CNA) care plan dated [DATE] directed nurse aides to provide one person transfers with gait belt, assist of one to ambulate with gait belt, use of walker and wheelchair to follow. These interventions were discontinued on [DATE]. The nurse aide care plan did not contain a directive for staff to monitor the resident due to nonuse of call light and tendency to get up on own. A care plan dated [DATE] identified the resident at risk for falls due to a fall at home prior to admission and also due to weakness. A therapy alert dated [DATE] directed staff as follows: please ambulate this resident daily for distance with four wheeled walker and minimum assistance of one staff. Physical therapy (PT) notes identified, on [DATE] a Tinetti assessment tool for balance score of "8". A tinetti assessment tool for gait identified the resident with a score of "8". The resident's balance and gait score totaled 16 out of 28. A score of "16" identified a high risk for falls. The resident began PT on [DATE]. PT identified the resident's current status as "able to transfer and ambulate with minimum contact guard assistance with four wheeled walker. On [DATE] the therapist stated they provided many cues for foot placement and also cued to slow down walking pace. PT also educated the resident to use the call light for assistance. The resident reported he/she did not use it and its been fine. On [DATE] PT identified the resident with a very flexed antalgic gait with loss of balance noted. On [DATE] PT identified the resident with a fall. A facsimile (fax) dated [DATE] identified the resident with an INR (blood clotting test for Coumadin therapy) of 4.1 (high). After notifying the physician of the results of the INR, The physician directed staff to not administer the Coumadin. Occupational therapy notes dated [DATE] stated nursing reported a fall that morning and not able to fully arouse patient. Daily skilled notes identified the following: [DATE] 1 p.m. Resident continues to be up, forgetting to call for assistance with bathroom. 5 p.m. Resident moves very poorly when standing or walking. Needs encouragement to do wimple movements with arms and legs. [DATE] 1:35 p.m. Found resident in bathroom two times and spouse confirmed that resident took self to the bathroom. Discussed safety with resident and spouse due to fall history. [DATE] 2:30 p.m. Not using call light when needing to use the rest room. Resident takes self to the bathroom due to short term memory deficit. Cannot remember to turn call light on and wait for assistance. Found in the bathroom twice. A medication administration record (MAR) identified the resident began using Lortab ,[DATE] milligrams (mg.) (narcotic) routinely twice per day for pain. The facility scheduled the medication administration times as 5 a.m. and bedtime. According to www.ehow.com medication information, common side effects of Lortab are dizziness, weakness, abnormally low blood pressure, drowsiness and faint feeling. Review of the resident's medication administration record (MAR) identified the resident received Lortab ,[DATE] milligrams at 5 a.m. on [DATE] (the day of the fall) [DATE] at 8:30 p.m. Resident self transferred to bed without using call light. Reminders given regarding importance of call light use. [DATE] 10:05 a.m. Resident found returning from breakfast without assistance. Reminded resident to wait for help and assist of one back to room. Found again a short time later ambulating without assistance in hallway. Reminded resident again to wait for assistance. An incident report form dated [DATE] at 9:50 a.m. identified a nurse aide called the nurse to Resident #1's room at 8:10 a.m.. Staff found the resident lying on his/her right side on the floor between the bed and bathroom. The resident's spouse stated the resident was going to breakfast and got near the wheelchair in the room and fell . The resident hit his/her head. The resident complained of dizziness. Staff did not observe injury and faxed the physician of the fall. Staff began neurological assessments. Daily skilled nursing notes identified at 12:15 p.m. of the same date, the resident drooled from the side of the mouth and did not respond. The resident's grips were unequal and vital signs changed from his/her baseline. The facility notified the physician who directed staff to send the resident to the hospital. A discharge summary [DIAGNOSES REDACTED]. 1) Subarachnoid and subdural hemorrhages secondary to #2. 2) Fall 3) Significant long standing ataxia 4) Cerebrovascular dementia. The discharge summary revealed the resident would return to the nursing home for hospice care. The resident will receive Atropine as needed for excess secretions, Morphine as needed for pain and Lorazepam as needed for agitation and seizures. It is expected that a terminal event will occur in the near future. A death record identified the resident expired on [DATE] at 2:05 p.m. due to intracranial hemorrhage. On [DATE] at 3:05 p.m. the resident's physician stated the resident was not steady on feet and did not have restrictions so it did not surprise the physician that the resident fell . Staff Interviews: On [DATE] at 1:52 p.m. Staff A (Director of Nursing) stated she never saw the resident up on his/her own but the resident was known to get up without assistance. When asked how often the facility checked on the resident to monitor for self ambulation, Staff A stated the resident's spouse was fairly good about using the call light. The day of the incident staff already went in and dressed the resident. Staff A stated there was no special time frame directives in place for staff to monitor/check on the resident. On [DATE] at 10:45 a.m. Staff C (Resident care coordinator) stated the resident roomed with his/her spouse. The resident was social and liked to visit. The resident needed assistance of one for cares and ambulation but the resident didn't always ask for assistance. Staff C told both Resident #1 and his/her spouse they needed alarms but they refused them. The resident fell at home and then admitted to the nursing home. The resident had poor balance at times and was not safety cautious. If staff caught the resident up on his/her own, the resident would say, he/she did not want to bother the staff. The resident had cognitive deficits. Staff C stated the only place she documented the alarm refusal was on the care plan. On [DATE] at 2:20 p.m., when asked if there was an expectation on how often staff should check/monitor the resident, Staff C stated there was no set time frame on how often. Staff would try to be proactive and predict the resident's needs and get to him to meet needs. Staff C stated there was no specific times to check the resident. On [DATE] at 9:38 a.m. Staff D (licensed practical nurse) stated she was the charge nurse the morning of the incident. At 6:30 a.m. (on [DATE]) she administered a pill to the resident's spouse at 6:30 a.m. and she observed Resident #1 at that time. After she left the room, Staff N (nurse aide) went in and assisted the resident. Staff D estimated the time Staff N assisted the resident as around 7 a.m. Staff D did not see the resident again until Staff N paged her to the room saying Resident #1 fell . This was at 8:10 a.m. The resident complained of feeling dizzy. Staff D did not observe or assess injury and staff assisted the resident to the recliner. The resident ate breakfast in his/her room. Shortly before noon, staff stated the resident did not seem right. Staff D noticed a bruise by the resident's right eye and the resident did not respond normally. She notified the physician and the resident transported to the hospital. Staff D stated prior to the incident, she witnessed the resident up without using the call light or asking for help. She observed the resident ambulating without assistance once in the hallway and twice when leaving the dining room. When asked if there was any special directive in place for staff to check on/monitor the resident, Staff D stated she could not answer that. She thought management was trying to get the resident a room closer to the nurse ' s station. She stated she did not know that for sure but that is what she heard. She confirmed the resident did not use the call light and was not to ambulate by self. The resident's room had 2 call lights and staff would verbally tell the resident to use the call light. On [DATE] at 11:12 a.m. Staff N (nurse aide) stated she went to Resident #1's room alittle after 7 a.m. and observed the resident sitting up on the bed. Staff N helped the resident up and use the bathroom. He/she did not want to go to the dining room yet because his/her spouse was not up yet so Staff N told the resident to sit in the recliner and when he/she was ready to go to the dining room then pull the call light. Around 8 a.m. Staff N came out of another resident's room and the call light was on. The resident was on the floor between the bed and the bathroom door. The resident stated he/she was going to breakfast. Staff N stated she asked the resident's spouse if the resident pulled the call light before getting up and the spouse stated he/she pulled it after the resident fell . Staff N stated she knew what to do for the resident by viewing a yellow sheet in the communication book (New resident admission information form) and that she was told the resident would get up by self and keep a close eye on the resident. When asked what "keeping a close eye" on the resident meant, Staff N stated staff tried to check on the resident hourly if they are a fall risk and stated there was no specific time listed on the new resident admission information sheet. Staff N stated the resident complained of dizziness after the fall but not before the fall. Staff N stated after the fall, the resident ate breakfast from a tray in his/her room and the resident ate and drank everything. The resident talked as usual and stated he/she would rest after breakfast. Around lunch time, the resident laid there with his/ her eyes shut. The resident would not open his/her eyes on command. Staff D checked the resident and called the ambulance. Staff N stated she did not think the resident was safe with the interventions in place. On [DATE] at 11:38 a.m. Staff M (nurse aide) stated she worked the day of the incident and she did not see the resident prior to his/her fall. She stated the day before she caught the resident up walking without assistance (not documented in progress notes). She stated the call light was available. She stated half the time the resident would use the call light and the other half he/she would not use it. She stated therapy attempted to work with the resident and the resident was not waking up and then the resident went to the hospital. Staff M stated once the resident got going walking that he/she was " Ok " ambulating with missteps at times. She stated the resident did not require weight bearing assistance but needed assistance with balance and to keep going in the right direction. Staff M identified the interventions in place to prevent falls as call light and a sign on his/her walker. She stated staff would check on the resident. It varied when staff would check-30 minutes, one hour or two hours-it was at least every two hour checks. The resident would complain of his/her legs feeling stiff when first getting up. She identified staffing that day was normal. Staff working that morning on Resident #1's wing were: Staff M, Staff N and Staff D. On [DATE] at 3:17 p.m. Staff G (Registered Nurse) stated she never saw the resident up by self but knows that nurse aides have caught the resident up without help. She stated the resident's gait was unsteady. When asked how staff supervised the resident to prevent falls, Staff G stated they didn't have problems on the 2 p.m. to 10 p.m. shift as the resident called for assistance often. Every 30 minutes to one hour staff would check in and ask if the resident needed anything. At times the resident appeared so weak and unsteady it was hard for Staff G to see how the resident could get up on own. On [DATE] at 2:24 p.m. Staff H (nurse aide) stated the resident was occasionally unsteady and would get up by self. She stated most of the time the resident pulled the call light on her shift (2 p.m. to 10 p.m.) Staff H stated she would check the resident every half hour if she could. There was no specific time listed to check the resident, just when staff could get there. She stated the resident's spouse would occasionally activate the call light for the resident. On [DATE] at 12:05 p.m. Staff L (licensed practical nurse) stated nurse aides reported the resident was noncompliant with the call light and waiting for help. The resident was not steady and could not walk by self. The resident never got the concept of pulling the call light. The resident's spouse would pull the call light. When asked about "frequent checks" she stated she observed the resident going back and forth to meals and there was no interval time in between for checking on the resident. Staff L thought the only thing that may have prevented the fall was moving the resident closer to the nurse ' s station. On [DATE] at 1:30 p.m. Staff K (nurse aide) stated she saw the resident get up by self. She stated the resident did not pull the call light and staff checked on him/her every two hours. She did not know of staff performing any special checks on the resident. Spouse Interview: A Minimum Data Set (MDS) with assessment reference date of [DATE] assessed Resident #7 with a brief interview for mental status score of "15" (cognitively intact). On [DATE] at 9:50 a.m. the resident stated Resident #1 got up with a four wheeled walker and got ready to leave the room. The spouse stated Resident #1's bed was closest to the door and had a wheelchair at the end of it causing congestion in that area and that is where the resident fell . Resident #7 stated the resident was not supposed to get up by self but the resident had a short term memory problem and he/she would get up a lot on his/her own and go to the bathroom and dress self. The spouse stated the walker tipped and the resident fell and hit his/her head which caused the resident's brain hemorrhage. The resident stated Resident #1 may have been alittle woozy from pain medication. The resident used a pacemaker and wasn't supposed to have anything stronger than Tylenol. When asked about an alarm, the resident stated she didn't think anyone asked him/her about using one. When asked if she would have agreed to one, the resident stated Resident #1's memory was not that bad yet so she doubted she would want one. 2. A Minimum Data Set (MDS) with assessment reference date of [DATE] assessed Resident #3 with a brief interview for mental status score of "9". A score of "9" identified moderate cognitive impairment. The resident usually understood others but may miss part or intent of message. The resident required limited staff assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) for bed mobility, ambulation in and out of room, dressing and toileting. The resident required extensive staff assistance (resident involved in activity, staff provide weight bearing support) for transfers and bathing. The MDS also identified the resident's balance during transition and walking as not steady and only able to stabilize with staff assistance when moving from seated to standing position and when moving on and off the toilet. The resident used a walker. The resident was frequently incontinent of bladder (7 or more episodes of urinary incontinence) and not on a toileting program. The resident had [DIAGNOSES REDACTED]. The MDS identified falls since admission/entry or prior assessment. However the MDS did not identify the number of falls. A [DATE] BIMS identified the resident with a score of "6" (severe cognitive impairment) A care plan dated [DATE] identified a problem with "safety needs" The goal was "I will accept that I need help with transfer and ambulation". The care plan directed staff to "see a fall risk assessment" for interventions. The care plan directed staff to encourage call light use, non-skid shoes or slippers, place items in reach, room free of clutter, room modifications specific to resident preference, non-skid strips in bathroom, grab bar on south wall of bathroom, resident to sit with undressing or have assistance, place night light in room. Interdisciplinary progress (IDP) notes contained the following information: On [DATE] Resident is now to use assistance of one staff with all transfers. On [DATE] at 6:40 p.m. Up in bathroom by self with four wheeled walker Staff reminded the resident to use the call light. The resident stated, "I know but nobody comes and I can't wait". On [DATE] at 10:05 a.m. Found up without assistance looking in closet. Staff encouraged the resident to ask for assistance On [DATE] at 9:15 a.m. Up in bathroom without assistance. Reminded to use call light and wait. The resident stated, "I can ' t always wait". On [DATE] 4:15 a.m. Resident up looking out doorway. On [DATE] at 6:35 a.m. Staff found the resident sitting on the floor by the bed. The resident stated he/she slid off bed. On [DATE] at 12:35 p.m. Resident isn't always compliant with using call light and waiting for help. Staff attempted to remove rocker from room but family and resident did not want the change. Negotiated risk signed. On [DATE] at 6:30 a.m. Staff lowered the resident to the floor with gait belt. The resident's knees gave out. At 9:45 a.m. of the same date the resident transferred self without assistance. The resident "forgot" to use call light. On [DATE] at 8:45 a.m. Staff applied nonskid strips to bottom of rocker to prevent chair from moving during transfers. On [DATE] at 11:15 p.m. Noncompliant with call light and transfers self in room On [DATE] at 5 a.m. Resident activates call light and by the time, staff arrive resident is in the bathroom On [DATE] at 2:30 a.m. Resident lying on floor at bathroom threshold with head in room. The resident complained of head and back pain. The intervention following the incident was reeducate the resident to use brakes on walker when sitting on toilet. The entry did not identify injury. At 10:30 a.m. the facility asked the resident's daughter about a low bed for the resident and seat alarm. The IDP notes dated [DATE] stated the facility implemented a bed/chair alarm. Noncompliant with use of call lights. According to the [DATE] admission/readmission fall risk assessment and intervention form, the facility implemented a toilet schedule on [DATE] (during the investigation). The form identified the facility implemented the alarms on [DATE]. The form did not identify a low bed. On [DATE] at 12:40 p.m. observation showed the resident seated in a chair in his/her room with call light and walker available. The resident stated he/she fell in the bathroom and bruised his/her back and shoulders and back of head. The resident stated he/she still has a bump on the back of the head. She stated staff doesn't let him/her get up by self and there was a staff in the room when the fall occurred. The [DATE] incident report did not identify how the resident got into the toilet room at 2:30 a.m. The surveyor questioned if the resident went by self or if staff left the resident unattended in the bathroom. The Director of Nursing phoned the charge nurse that worked the night of the incident and asked her on [DATE]. On the same date at 12:45 p.m. the Director of Nursing stated the resident activated the call light and when staff answered it, they found the resident on the floor. The resident didn't wait for assistance. On [DATE] at 2:24 p.m. Staff H (nurse aide) stated the resident gets impatient and pulls the call light and wants staff there in 30 seconds. The resident will start getting up on own. Staff H stated she watched the call light go on and she will immediately go to answer it. When she arrives the resident is already trying to get up and states it has taken forever to get help.

Based on observation, record review, and interviews with resident and staff, the facility failed to ensure Resident #7 received adequate supervision from hazards and failed to reassess and implement adequate safety intervention(s). The resident experienced a fall resulting in a fracture of the left humerus. The facility reported a census of fifty eight residents. Findings include: A November 11, 2012 Encounter Report documented the resident admitted to the hospital with [REDACTED]. The resident's Admission Record documented the resident admitted to the facility on [DATE]. The resident's December 17, 2012 Minimum Data Set (MDS) documented the resident had moderate cognitive impairment. A December 19, 2012 physician's orders [REDACTED]. A December 21, 2012 Therapy Alert (Physical Therapy) directed staff to continue transfers with moderate assistance of one staff. On December 23, 2012 at 11:20 p.m. staff documented in the Daily Skilled Nurse's Note the resident transferred him/herself from the recliner into bed after the meal. Staff documented the resident required assistance of two for ambulation short distances. On December 24, 2012 at 11:20 p.m. staff documented in the Daily Skilled Nurse's Note the resident transferred him/herself into bed after supper. Staff documented the resident educated to wait for assistance. On December 30, 2012 staff documented in the Daily Skilled Nurse's Note the resident used the call light to use the bedside commode, but didn't always wait for staff to get to the room. Staff documented the resident had some difficulty moving his/her feet. On December 31, 2012 at 2:30 a.m. staff documented in the Daily Skilled Nurse's Note a commode at the resident's bedside due to self transfers to the wheelchair and calling for help on the previous shift. The resident had threatened to get up to the bathroom alone. On January 1, 2013 at 10:25 p.m. staff documented in the Daily Skilled Nurse's Note the resident educated not to get up unassisted. Staff documented the resident repeated the message and voiced understanding. On January 2, 2013 at 11:00 p.m. staff documented in the Daily Skilled Nurse's Note staff heard someone hollering and found the resident on the floor. The resident stated, "I hurt my shoulder". Staff sent the resident to the hospital where they identified a fracture of the left humeral head. According to the Major Injury Determination Form the resident's physician documented the fracture was a Major Injury. During interview on January 3, 2013 at 2:52 p.m. Staff B, Certified Nursing Assistant (CNA) stated she had been working on January 2, 2013 when the resident fell . She stated she had found the resident up independently before the fall and had told the resident not to get up without assistance. She reported the day shift had also reported finding the resident up unassisted. She stated she didn't know if the resident forgot to wait for assistance or chose to get up without assistance. During interview on January 7, 2013 at 10:44 p.m. Staff A, CNA, stated she had been working on January 2, 2013 when the resident fell . She stated this occurred between 10:00 p.m. and 10:10 p.m. the resident had stated he/she had been going to the bathroom. She stated she had seen the resident get up independently before and had told the resident to use the call light. She stated at the time of the fall the resident's call light had not been on. The resident's Care Plan lacked any additions or changes after staff became aware of the resident's independent transfers/ambulation until the resident fell and experienced the fractured humerus. On January 3, 2013. During interview on January 3, 2013 at 11:06 a.m. the resident sat in a chair in his/her room with the left arm in a sling. The resident stated when he/she put on the call light, "they never come". At 1:03 p.m. the resident stated at the time of the fall he/she knew they weren't supposed to get up alone. The resident stated, "Yes, I knew. I was just stupid. But it takes so long for them to come." According to call light response records provided by the facility on January 2, 2013, the night of the fall, at 8:53 p.m. it took 99 minutes and 59 seconds for staff to answer the resident's call light. Review of the call light records revealed the following: On December 19, 2012 at 6:31 p.m. it took 54 minutes for staff to answer the resident's call light. On December 20, 2012 at 6:00 p.m. it took 48 minutes for staff to answer the resident's call light. At 8:59 p.m. it took staff 89 minutes to answer the resident's call light. On December 22, 2012 at 11:31 a.m. it took 38 minutes for staff to answer the resident's call light. At 4:40 p.m. it took 38 minutes for staff to answer the resident's call light. On December 23, 2012 at 6:52 p.m. it took staff 24 minutes to answer the resident's call light. At 7:28 p.m. it took 38 minutes to answer the call light. At 10:21 p.m. it took 43 minutes to answer the resident's call light. On December 24, 2012 at 6:16 p.m. it took the staff 29 minutes to answer the resident's call light. On December 25, 2012 at 6:11 a.m. it took staff 59 minutes to answer the resident's call light. At 5:30 p.m. it took staff 19 minutes to answer the call light. On December 28, 2012 at 2:48 a.m. it took staff 23 minutes to answer the resident's call light. On December 29, 2012 at 12:11 a.m. it took staff 65 minutes to answer the resident's call light. At 7:07 a.m. it took staff 33 minutes to answer the resident's call light. On December 30, 2012 at 11:11 a.m. it took staff 92 minutes to answer the resident's call light. At 11:03 p.m. it took staff 28 minutes to answer the call light. On December 31, 2012 at 8:55 a.m. it took staff 32 minutes to answer the resident's call light. At 7:36 p.m. it took 55 minutes to answer the call light. On January 2, 2013 at 9:06 a.m. it took staff 21 minutes to answer the resident's call light. At 6:39 p.m. it took staff 34 minutes to answer the call light. At 8:53 p.m., as previously stated, it took 99 minutes for staff to answer the call light. According to the resident's December 2012 Medication Administration Records the resident took Tylenol #3 for pain in the left leg only nine times between December 4, 2012 and January 2, 2013. After the humeral fracture the resident required the pain medication sixteen times between January 3 and January 7, 2013. The resident described the pain as severe eight times. Three times the resident rated the pain as 9 of a possible ten with ten being the worst. A January 2, 2013 Physical Therapy - Therapy Alert directed staff the resident could be assisted by one staff and directed staff to encourage ambulation to and from the bathroom with a wheeled walker and assistance of one during the daytime. The next day, January 3, 2013 after the fall and humeral fracture Physical Therapy staff directed the resident could still be assisted by one staff with transfers, but directed no more ambulation at this time.

Based on observation, record review and interviews, the facility failed to ensure three of four residents reviewed for falls (Residents #7, #6 and 4) received adequate supervision from hazards and failed to ensure the necessary services and or care plan provisions for safety were implemented. The facility census was fifty-six (56) residents. Findings include: 1. A Minimum Data Set (MDS), with assessment reference date of 4/26/11, assessed Resident #7 with a brief interview for mental status score of "7" (severe impairment). The MDS identified the resident ' s vision as severely impaired (no vision or sees only light, color of shapes, eyes do not appear to follow objects.)The resident required extensive staff assistance (resident involved in activity, staff provide weight bearing support) for bed mobility, transfers, dressing, toileting, personal hygiene, bathing and for locomotion on and off the unit. The MDs identified the resident walked in his/her room with limited assistance (with staff providing guided maneuvering of limbs or other non-weight bearing assistance). The MDS also identified the resident ' s balance during transition and walking as not steady but able to stabilize without human support when moving from seated to standing position, when walking, when moving on and off the toilet and when transfers between surfaces (transfers between bed and chair or wheelchair). The resident had functional limitation in range of motion of both lower extremities. The resident was occasionally incontinent of bladder (less than 7 episodes of incontinence) and not on a toileting program. The resident had [DIAGNOSES REDACTED]. The resident received antipsychotic and anti-anxiety medication. An evaluation of resident functional status dated 4/20-26/11 asked the question "Is the resident steady?" of each shift for those 7 days. The 10 p.m. to 6 a.m. shift answered "no" all 7 days, identifying the resident as unsteady on that shift (and for all seven days per each shift, the staff documented the resident was unsteady 78% of the time; and staff had to steady the resident 76 % of the time). The staff charted the amount of physical assistance provided to the resident when walking in his/her room, and documented the resident required one staff assistance 100% of the time for seven days, per each shift (6-2 shift, 2-10 shift and 10-6 shift). A therapy alert dated 8/18/10 directed staff as follows: recommend staff supervision with ambulation/transfers as she allows due to poor vision and lower extremity instability. The physical therapy (PT) plan of treatment identified the resident's knees as subluxed and unstable. The resident ' s Problem/Goal Review Listing dated 5/4/11 documented the resident was able to walk with walker short distance, ex(example) bed to bathroom; resident ' s knees are loose in the socket from surgery, and he/she may need then to lock when standing up. The document identified the resident was afraid of falling and had been asking staff to assist him/her. Interdisciplinary progress notes, dated 4/30/11 at 9/10 a.m. documented the resident wanted staff to hold on until his/her legs are straight when getting off bed and to the wheelchair. Review of care plans identified the facility did carry the supervision d directive over to the care plan. The care plan, dated 5/4/11 identified the resident as "up ad lib" in room. By the time the investigation commenced, the care plan directive for "up ad lib" had a line drawn through it. The line was not dated. On 6/29/11 at 10:22 a.m., the Director of Nursing stated the facility discontinued the "up ad lib" directive when the resident returned from the hospital because the resident was non-weight bearing after that. Interdisciplinary progress notes, dated 6/5/11 at 1:50 a.m. stated staff found the resident yelling. Staff entered the room and found the resident laying on back on floor beside bed. Three staff assisted the resident off of the floor with as gait belt. Assessment showed the resident's left ankle appeared displaced and swollen at 30 degree outward angle. Staff transferred the resident to the hospital for evaluation. The resident's four wheeled walker found sideways on floor next to resident with bed controller and cord on floor also. The resident identified a need for the bathroom when asked what happened. On the same date at 2:30 a.m., the resident returned to the facility with a [DIAGNOSES REDACTED]. An emergency room note, dated 6/5/11 identified the resident got up on own out of bed and fell injuring the left ankle. Because of deformity to the ankle, the ambulance was summoned. X-rays showed a bimalleolar left ankle fracture. The physician explained to the resident's son that the injury could be a life threatening injury due to the resident's age (101). A facility summary report stated the physician identified the injury as a major injury and the facility reported the incident to the Department of Inspections and Appeals (DIA). Staff Interviews: On 6/29/11 at 9:51 a.m., Staff A stated 75% of the time, the resident would use the call light more the resident would call out. Staff A stated the resident stated she forgot about using the call light at times. Staff A stated the resident had a steady gait and would say he/she could not see and had bad knees. On 6/29/11 at 3:10 p.m., Staff U identified the resident as needing standby assistance with ambulation. Staff U stated the "up ad lib" portion of the care plan was crossed out before the fall. When asked to find the standby assistance directive, Staff U could not locate a standby assistance directive. Staff U identified the resident as using the toilet frequently. Staff U stated antispasmodic medication was tried to see if it assisted with the resident's frequent urination issue, but it did not help. On 6/28/11 at 2:26 p.m., Staff B stated the resident's normal routine was to get up by self to the toilet. If the resident felt his/her knees were weak then the resident would holler for help. The resident rarely used the call light. The resident called out for help if needed. On 6/27/11 at 6 11:10 p.m. Staff C identified the resident's normal routine as pulling the call light once in awhile or would holler for help. The resident would use the toilet frequently and would sometimes get up on own. Staff C stated she worked the night of the incident and the resident's call light was available and not on when staff found the resident on the floor. On 6/29/11 at 4:30 p.m., Staff D stated she provided the resident standby assistance because she thought the resident needed it due to poor vision and the resident's age. She stated the resident used the toilet every 30 minutes and the resident would yell or pull the call light. Sometimes the resident would just go by self. Staff did not assist the resident unless the resident yelled or pulled the call light. On 6/28/11 at 3:22 p.m., Staff I stated some days the resident would demand help and other days he/she would not allow help. Some days the resident would get up without help. The resident would turn to sit down and ask if he/she was close enough to sit. The resident used a walker in the room and wheelchair out of the room. On 6/29/11 at 4:05 p.m., Staff L stated the resident used the call light 50% of the time. Staff L thought the resident did well on his/her own. She stated staff waited for the resident to call for help. 2. A Minimum Data Set (MDS) with assessment reference date of 5/18/11 assessed Resident #6 as unable to complete the brief interview for mental status (BIMS). The resident had impaired short term memory and modified independence with daily decision making. The resident required supervision with ambulation in room, transfers and extensive assistance with bathing. The section "balance during transitions and walking" identified the resident as unsteady and able to stabilize without human assistance while walking and turning around to face the opposite direction while walking. The resident was continent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The MDS identified two or more falls with injury since the last assessment. A previous MDS dated [DATE] documented the resident required supervision with ambulation in room, transfers and extensive assistance with bathing. The section "balance during transitions and walking" identified the resident as unsteady and able to stabilize without human assistance while walking and turning around to face the opposite direction while walking. A care plan run date 2/27/11 indicated the the resident walked on his/her own. The care plan also indicated the resident had a history of [REDACTED]. A care plan run dated 3/16/11 contained an addendum on 5/13/11 that stated, "When I am not feeling well, I require staff assistance of one. I do not remember to ask staff for help". The care plan indicated the resident ambulated without assistance and uses a walker but needed reminders to use it. A hand written amended approaches dated 3/16/11 revealed the resident had attempted to sit in his/her chair and missed and sat on the arm when the chair tipped over. The intervention directed the resident would be screened for transfers by PT (physical therapy). The hand written amended also contained an entry for 4/16/11 which indicated the resident slid out of his/her chair while applying his/her pants. The facility replaced the chair with a normal recliner. The amended documented on 5/5/11 the resident ' s spouse had taken his/her cane home and he/she need to use his/her walker for ambulation. On 5/11/11 the amended approach indicated the medications list had been sent to the physician for review of PT screening. Falls: A physician ' s communication sheet dated 3/16/11 indicated staff found the resident on the floor. The resident attempted to get out of the chair and sat back down on the arm of the chair. the chair tipped over and the resident fell on another chair in room and causing pain and redness to the right upper rib area. At that time, staff requested an order for [REDACTED]. Following this a physical therapy screen dated 3/24/11 recommended a PT evaluation to determine safest assistive device and identified that the "patient's cognition limits safety". The record lacked evidence the facility obtained physical therapy evaluation for the resident. Interdisciplinary progress notes dated 5/5/11 at 2 p.m., identified the resident laying beside the bed on the floor on the resident's right side. The resident identified hitting head on foot board of bed as resident attempted to move electric lift chair. Knees gave out and the resident missed the chair when he/she attempted to sit in the chair. Following the fall, staff removed the recliner and replaced it with a straight back chair. A nonpressure skin condition report dated 5/5/11 identified the following injury from the fall: a red raised area with red area measuring 4.5 centimeters (cm.) by 6.4 cm. with raised area measuring 3 cm. by 4 cm. to the right posterior head. Interdisciplinary progress notes dated 5/11/11 stated staff found the resident, at 12:15 p.m. sitting on the floor facing the toilet with one leg on each side of the toilet. The resident stated he/she lost balance and fell to floor. Assessment showed a 2 centimeter (cm.) by 1 cm. dark purple bruise to the right upper buttock. The facility placed antiskid strips to the bathroom floor. On 5/12/11 the physician reduced the resident's Metoprolol from 25 milligrams (mg.) to 12.5 mg. in response to the falls. On 5/16/11 a physician communication sheet indicated therapy screened the resident and felt the resident could benefit from a physical therapy evaluation and treatment due to recent falls. The physician replied "OK" to the request. Interdisciplinary progress notes dated 5/17/11 at 2:05 p.m. indicated the resident had an appointment scheduled on 5/20/11 in Mason City for headache. Interdisciplinary progress notes, dated 5/18/11 at 1:20 a.m., identified Resident #6's roommate notifying staff Resident #6 fell . Staff found the resident sitting on the bathroom floor with legs straight out in front of resident with back against wall. The resident complained of pain in the neck, forehead and left hand. Staff notified the physician. The physician directed staff to transport the resident to the emergency room for evaluation. Prior to transfer, staff assessed the following injuries: large red swollen area to forehead approximately 10 centimeters (cm.) by 6 cm., one cm. indentation on bridge of nose and significant purple bruising under the left eye. Three bluish colored bruises on the palm of the left hand approximately one cm. in diameter., an abrasion to the left knee approximately 2 cm. in diameter. According to the emergency room Note dated 5/18/11, the resident had apparently used his/her walker in the bathroom, slipped and fell . The report documented the resident hit the bride of his/her nose and his/her left periorbital area. The report revealed the resident complained of some posterior neck pain and some mid back pain. The CT of the C- spine showed some mild prevertebral soft tissue swelling of the cervical spine. Interdisciplinary progress notes, dated 5/18/11 at 9:15 a.m. stated the physician phoned the facility and informed staff the resident transported to Mason City hospital for further evaluation. A hospital discharge summary identified the resident discharged from the hospital on [DATE]. The primary [DIAGNOSES REDACTED]. The summary revealed the resident developed some dysphagia, probably secondary to the prevertebral hematoma. The summary documented the resident ' s pain was controlled with morphine (as needed). The resident received physical therapy while in the hospital. Staff Interviews: On 6/29/11 at 9:51 a.m., Staff A stated the resident chose not to use the call light for help. On 6/28/11 at 2:26 p.m., Staff B stated the resident would ambulate independently until staff decided he/she needed one assist and a walker. In the night the resident would go in the toilet and fall asleep on the toilet and regarding the 5/18/11 fall they assumed the resident went into the toilet and fell asleep. On 6/30/11 at 9:48 a.m., Staff F stated the resident was noncompliant with call light use. It was hit and miss so if staff went by the resident's room and saw the resident up, staff would go in and assist the resident. The resident would fall asleep on the toilet and needed frequent reminders. Observation showed, on 6/28/11 at 3:10 p.m., the resident transferred with one staff and a gait belt from bed to chair. The resident ambulated with one staff and wheeled walker. 3. A Minimum Data Set (MDS) with assessment reference date of 5/2/11 assessed Resident #4 with a brief interview for mental status(BIMS) score of "11" (moderate cognitive impairment. The resident required limited assistance with transfers, ambulation, dressing and supervision with toileting and personal hygiene. A "balance during transitions and walking" section of the MDS identified the resident as unsteady but able to stabilize without human assistance with the following: moving from seated to standing position, walking, turning a round and facing the opposite direction while walking, moving on and off the toilet and transfers between bed and chair or wheelchair. Falls: An incident report form, dated 2/3/11 at 6:40 p.m., stated the resident slid from the recliner when reaching for the call light. In a summary prepared by the facility, the intervention following the 2/3/11 fall as anti skid strips in front of the recliner. On 4/29/11 the facility educated the resident to slow his/her pace and take deep breaths with ambulation. Interdisciplinary progress notes dated 5/27/11 at 12:30 a.m., stated staff found the resident lying flat on his/her back at bedside. The resident stated he/she lost balance when returning from bathroom and crawled to bedside to reach call light. Resident unable to recall what caused the fall. The resident sustained [REDACTED].) skin tear to the left elbow. Following this fall, the entry identified 15 to 30 minute checks for the remainder of the shift. Following this fall, staff rearranged items in room to make a clear path to the toilet. The resident started physical therapy (PT) for safety. A therapy alert at the conclusion of PT therapy dated 6/16/11 stated the resident remains noncompliant with proper use of hemiwalker (carrying it at times). Recommend resident remain standby assistance with ambulation/transfer second to decreased safety awareness. The care plan, dated 5/11/11 did not identify a change in interventions after the physical therapy screen identified the need for standby assistance, other than identification of a negotiated risk written on 6/17/11. Interdisciplinary progress notes dated 6/20/11 at 11:30 p.m., staff heard the resident yelling for help. Observation showed the resident lying on the left side at the foot of the bed with legs slightly bent. The resident complained of rib pain. The resident refused the offer of staff to call the ambulance. The facility started 30 minute checks. At 2:05 p.m., the resident complained of severe pain in the right upper quadrant and continued to refuse medical care. At 4:30 a.m., the resident stated he/she suffered enough and agreed to go to the hospital. On 6/21/11 at 7:30 a.m., the hospital called and stated the resident had fractured ribs and was admitted to the hospital. The resident's son signed the negotiated risk on 6/21/11. The final agreement stated the resident would be up ad lib in room regardless of patient education and the risks that injury may result since resident does not want staff assist resident will continue to get bruises to right hand and arm due to refusal of sling. Staff P care plan nurse confirmed on 6/29/11 at 1:20 p.m. that the facility implemented the negotiated risk and no other interventions. The resident returned to the facility on [DATE] to a room closer to the nurses station. The resident also received physical and occupational therapy upon return. An emergency room note dated 6/21/11 stated the resident was up in room and lost balance, fell on to right side and developed some right sided rib pain throughout the evening. X-rays showed three anterior lateral rib fractures of ribs 9, 10, 11. Once hospital personnel identified rib fractures, the resident admitted to the hospital for pain control. On 6/30/11 at 5:22 p.m., the physician stated the resident does not want anything extra done for him/her and the resident even delayed his/her own care by not allowing staff to send the resident to the hospital. The physician stated the resident is alert at times and able to control his/her own care and then other times, the resident can hardly be aroused. Observation showed, on 6/28/11 at 2:15 p.m., 2 staff transfer the resident from the bed to the recliner via EZ lift. When asked about the fall, the resident stated, "I fell . I don't remember much. It took four people to get me back up". On 6/29/11 at 4:20 p.m., Staff K stated prior to the 5/27/11 fall the resident was up ad lib in room. Staff did not provide any special monitoring or checks on the resident. On 6/29/11 at 4:05 p.m., Staff L stated prior to the 5/27/11 fall, the resident did not require a lot of care. Staff would go in and get the resident's supper order. The resident would "do their own thing" in the room. The resident did not pull the call light very often and spent most of his/her time in the recliner. On 6/29/11 at 9:51 a.m., Staff A stated a long time ago therapy cleared the resident to be up ad lib in room with hemiwalker. The resident did not take it with him/her. On 6/27/11 at 11:10 p.m., Staff C stated she worked the night of the 5/27/11 fall. As Staff C got water pitchers she heard the resident call for "help". She walked in and saw the resident on the floor. The resident wanted to get up. Staff J then assessed the resident. Staff C stated before the fall, the resident got up on the other side of the bed and came around the bed to get the walker. The resident then fell . The resident did not have slippers on. She stated sometimes the resident would turn the call light on and other times the resident would get up. The resident would put the call light on around 11 p.m. or 12 a.m. to sit in recliner and use the toilet. Staff C stated when the incident occurred, the resident did not have the call light on and got up on own and fell . On 6/29/11 at 4:30 p.m., Staff D stated she thought the resident could do a lot by self and was up on own in the room. Staff checked the resident every two hours or at the most hourly.