Every finding on record at Rehabilitation Center of Des Moines

Based on clinical record review, policy, and staff interview, the facility failed to notify the Long term Care (LTC) Ombudsman for 3 of 4 residents who transferred to the hospital (Resident #1, #43, and #66). The facility reported a census of 72 residents. Findings include: 1. Resident #1'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 included diagnoses of chronic respiratory failure and acute pulmonary edema. Resident #1's Hospital Summary date 3/12/26 documented he was admitted to the hospital on [DATE] and discharged back to the nursing facility on 3/12/26. Resident #1's Census tab revealed the following: 3/6/26 admitted to hospital 3/12/26 readmitted to facility The facility record titled Notice of Transfer Form to Long Term Care Ombudsman for March 2026 lacked documentation of Resident #1's transfer to the hospital. On 8/25/2026 at 1:36 PM Staff E, Social Services Director reported she does the ombudsman reports monthly. She reported she pulled the admission/ discharge report in Point Click Care (PCC) the Electronic Health Record (EHR) program to get her information on who to put on the ombudsman report. She reported the residents were missed because the report did not show it for her because it was a hospital discharge. She reported the residents should have been on the report for hospitalizations. The facility policy title Transfer and Discharge revised 10/2024 documented all facility transfers will be communicated to the appropriate ombudsman monthly. 2. Resident #43's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included a diagnosis of heart failure and renal failure. Resident #43's Hospital Summary date 4/21/26 documented she was admitted to the hospital on [DATE] and discharged back to the nursing facility on 4/21/26. Resident #43's Post Acute Report dated 7/16/26 documented she was admitted to the hospital on [DATE] and discharged back to the nursing facility on 7/16/26. Resident #43's Census tab revealed the following: 4/15/26 admitted to hospital 4/21/26 readmitted to facility 7/8/26 admitted to hospital 7/16/26 readmitted to facility The facility record titled Notice of Transfer Form to Long Term Care Ombudsman for April and July 2026 lacked documentation of Resident #43's transfer to the hospital. 3. Resident #66's MDS assessment dated [DATE] documented no discernible consciousness. The active diagnoses include traumatic brain injury and quadriplegia. Resident #66's Hospital Discharge Summary, date 5/22/26, documented they were admitted to the hospital on [DATE] and discharged back to the nursing facility on 5/22/26.Resident #66's Census tab revealed on 5/12/26 they were admitted to hospital. They were then readmitted to the facility on [DATE]. The Notice of Transfer Form to Long Term Care Ombudsman for May'26 did not include Resident #66. In an interview on 8/27/26 at 3:30 PM, Staff F, Social Services Director, acknowledged Resident #66 was missing from May's monthly report when they should have been listed.

Based on clinical record review, observation, staff interview, and policy review, the facility failed to follow the physician's order and flush a gastrostomy tube (g-tube) with the ordered amount of water for one of two residents observed for g-tube medication administration (Resident #61). The facility also failed to administer nasal spray as directed for one of one residents observed during medication administration (Resident #28). Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had diagnosis of malnutrition. The MDS indicated the resident had a feeding tube. The Care Plan initiated 4/17/26 revealed the resident required a tube feeding related to dysphagia (difficulty swallowing). The resident was dependent for tube feeding and water flushes. The Order Summary revealed the following orders: a. May crush medications and administer medications via feeding tubeb. Administer liquid protein two times a day for wound healing and malnutrition (30 milliliters) (ml) and flush with 100 ml water after (had an order date 5/22/26). The Order Summary lacked an order for water flushes between the medications.The Medication Administration Record revealed the following medications administered via PEG tube for the PM 15 dose by Staff B, Licensed Practical Nurse (LPN) on 8/24/26: a. 1 tablet of risperidone 1 mgb. 3 tablets of carbidopa/levodopa 25-100 mgc. 8 ml of Gabapentin 250 mg/5ml d. 10 ml of Senna syrup 8.8 mg/5ml e. 30 ml of Liquid Protein for wound healing and malnutrition. Flush with 100 ml water after. During observation on 8/24/26 at 3:14 PM, Staff B, LPN, prepared medications for Resident #61. Staff B crushed carbidopa-levodopa and risperidone medications and added the crushed contents to the liquid medications gabapentin (8 ml), senna syrup (10 ml) and liquid protein (30 ml) in a plastic cup. At 3:19 PM, Staff B, removed Resident #61's plug on the g-tube, attached a syringe to the g-tube, flushed the g-tube with 30 ml of water, drew the medications up in the syringe and administered all of the medications through the g-tube, then administered 35 ml of water and removed the syringe from the g-tube. Staff B, LPN failed to flush with 100 ml water after the liquid protein per physicians order.In an interview on 8/24/26 at 3:35 PM, Staff B, LPN, confirmed he gave a total of 30 ml water prior to administering the medications through g-tube and another 30 ml after he gave all of the medications through the g-tube. In an interview on 8/25/26 at 3:10 PM, the Director of Nursing (DON) reported there was an order to flush the g-tube with 30 ml of water before and after each medication administered. Medications should also be diluted with 10 ml water. The water flush amount depended upon the physician's order and what the dietician recommended for fluid intakes. The DON stated the reason for flushing a g-tube was to maintain patency of the tube and prevent the tube from clogging. The DON reported she expected staff to follow the doctor's order for water flushes. A Gastrostomy Tube Care and Management policy revised 4/2025 revealed to flush the feeding tube per the physician's orders before and after giving any medication by tube. Routine flushing of the tube with water remains the best method to prevent tube clogging. Always flush with lukewarm water before and after each medication administration and whenever the feeding is interrupted to reduce the risk of tube clogs. The amount of water used for flushing the tube depended on the physician's orders. 2. During observation on 8/24/26 at 3:25 PM, Staff C, certified medication aide (CMA) administered to Resident #46 azelastine hydrochloride 0.1 % nasal spray one spray to both nares. Resident #46's Order Summary Report revealed azelastine two sprays to both nostrils twice a day for rhinitis (inflammation and swelling of the mucous membranes inside the nose) started 2/28/25. The PM 15 dose on 8/24/26 was documented as administered by Staff C. In an interview on 8/25/26 at 3:10 PM, the Director of Nursing reported she expected staff to follow the doctor's order for medication administration. The facility policy with subject Physician Orders with revised date10/2024 directed staff as follows; It is the policy of this facility that all physician orders will be followed through with upon the written order by a personnel licensed to write orders and/or take verbal orders from provider

Based on clinical record review, observation, resident interview, staff interviews, nurse practitioner interview, and facility policy. The facility failed to follow up on progress notes from the nurse practitioner with orders for premarin vaginal cream (a prescription medication that contains estrogen used to treat certain types of urinary incontinence) 1 of 3 residents. (Resident#1). The facility reported a census of 70. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact for Resident#1 (R1). The Care Plan initiated 12/10/25 instructed staff that R1 had incontinence and to check as required for incontinence. Change clothing as needed after incontinence episodes. The Progress Note dated 4/29/26 by the Nurse Practitioner documented R1 was seen for complaints of urinary incontinence. Urinary frequency has been ongoing for the last few months and started to feel mild burning with urination. Urinary symptoms overall are getting worse. Recheck UA to r/o infection. Start premarin cream, vaginally at night for two weeks, then two times a week.The Progress Note dated 5/12/26 signed by the Nurse Practitioner ([NAME] Payne) documented Resident #1 was seen for a follow up visit. The Resident was reporting dysuria last month, with orders for UA recheck but does not appear was completed. Was also ordered to start premarin vaginal cream but does not appear this has been put in yet either. Continues to have urinary incontinence, poor bladder control, with evident skin breakdown today. Continue with good pericare, frequent toileting. Start premarin cream, vaginally at night for two weeks, then two times a week. Observation on 6/1/26 at 12:57 PM, revealed Resident #1 had her call light on. Certified Nursing Assistant (CNA) answered her call light. The resident requested to be changed as she was incontinent of urine. The CNA assisted with change of incontinent brief, perineal cleansing, and change of a bath blanket on the resident's recliner. The blanket was saturated with urine but was not soaked through the blanket as her recliner was still dry. The resident's room smelled odorous, like urine. On 6/1/26 at 1:05 PM the resident indicated she had been incontinent for 4-6 months and didn't know if it was because of her hysterectomy with laser therapy, or because she had 8 bladder infections after the surgery. I don't know what they are doing for the incontinence. They were supposed to put me on a cream and do another urine test but that hasn't happened yet. They didn't do any urine tests or put me on a cream. On 6/1/26 at 1:50 PM with Staff, B RN indicated the nurses working put in the new orders after the doctors round on the residents. The doctors wrote the orders on sheets or on lab sheets. The nurses placed orders to the pharmacy and then complete assessments each shift. She was not aware if the NP wrote orders for premarin cream. On 6/1/26 at 3:30 PM, the Director of Nursing, (DON). Confirmed the progress notes from the NP documented orders to start premarin cream and obtain another UA to rule out infection. Also confirmed the progress notes from the NP which documented the premarin and UA were not started.On 6/1/26 at 3:41 PM Administrator acknowledged and indicated that he would expect if a NP placed an order it should be completed. Also indicated that they were not able to find any hard copies of the orders.The Progress Note dated 6/2/26 at 2:42 PM, the Director of Nursing (DON) documented the doctor reviewed the Nurse Practitioners progress notes related to premarin cream. Received new orders to administer premarin cream 2 grams vaginally at bedtime x 14 days. The pharmacy was notified. The Care Plan initiated on 6/2/26 documented the resident has intermittent cream for bladder strengthening and incontinence. The Treatment Administration Record for June 2026 documented premarin vaginal cream 0.625 mg/gm, insert 2 gram vaginally at bedtime for 14 days related to disorder of the urinary system. Order date 6/2/26 with a start date of 6/3/26.In an interview on 6/3/26 at 11:35 AM the doctor stated that he saw Resident #1 yesterday, reviewed the Nurse Practitioners notes, and acknowledged that she indeed needed the premarin cream treatment as the urinalysis was negative. In an interview on 6/4/26 at 12:20 PM, the Nurse Practitioner (NP) acknowledged that she had seen Resident #1 on 4/29/26 and 5/12/26. The NP reported she wrote orders and gave them to the charge nurses working those days. The NP was unsure what nurses were that she gave them to. She also indicated that she did not order another urinalysis on 5/12/26 because the resident was no longer having the burning with urination. However she was still experiencing frequent incontinence. The Facility Policy and Procedure for Medication Administration dated 7/25 instructed the following:1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medication administration. 2. Medications must be given in accordance with the resident's plan of care. 3. Medications must be administered in accordance with the written orders of the attending physician. 4. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR). 5. Topical medications used in treatments should be recorded on the resident's medication administration record (MAR). 6. Identification of the resident must be made prior to administering medication to the resident. 7. Unless otherwise specified by the resident's attending physician, routine medications will be administered per the facility time ranges. This is to promote the continuance of a home like environment for our residents. 8. The nurse or medication technician administering the medication must record such information on the resident's MAR before administering the next resident's medication. 9. When PRN medications are administered, the nurse or medication technician must record the date and time administered, and later the results achieved from the PRN medication as appropriate. 10. Prior to administering the resident's medication, the nurse or medication technician should compare the drug and dosage schedule don the resident's MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse or med tech should check the physician's orders.

Based on clinical record review, observation, resident interview, staff interviews, and review of the facility policy. The facility failed to administer Levothyroxine and Acyclovir per physicians orders for (Resident #7) 1 of 3 Residents reviewed. The facility reported a census of 70. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The physician signed a written order for Acyclovir (an antiviral medicine used to manage and treat viral infections like cold sores, genital herpes, shingles, and chickenpox) 800 mg 1 tablet 5 times daily by mouth for 7 days on 6/1/26. On 6/2/26 at 7:25 AM, Resident #7 indicated she was having some pain and had something that was like chicken pox. An observation on 6/2/26 at 7:30 AM revealed that Staff A, Certified Medication Aide (CMA) administered Levothyroxine. Staff A, CMA gave Resident #7. Resident #7 asked Staff A, CMA what the medication was after she swallowed the Levothyroxine. Staff A, CMA told her that it was her thyroid medication that she was supposed to get early in the morning. The resident received pain medication for complaints of pain related to shingles. The June 2026 Medication Administration Record (MAR) revealed the Levothyroxine was scheduled to be given at 5:00 AM and nursing staff failed to chart administration for 6/1/26 and 6/2/26. The June MAR also revealed staff had failed to chart administration of Acyclovir on 6/1/26 at 9:00 PM, 6/2/26 at 5:00 AM, and 6/2/26 at 9:00 AM. On 6/2/26 at 9:15 AM Staff A, CMA reported he could not administer the resident's Acyclovir because they have not received the supply from the pharmacy yet. On 6/2/26 at 9:15 AM Staff C, Registered Nurse (RN) indicated he called the pharmacy to see why they haven't sent in the supply yet. Also indicated when they receive an order in the evenings after the pharmacy is closed, we don't always get the supply right away. On 6/2/26 at 9:39 AM Staff C, RN indicated he called the pharmacy, they said they delivered the medication and this mornings dose was at the facility and she has now received her first dose this morning. Also informed he would revise the order to start today to assure she receives the full course of antibiotics. He provided written warning to Staff A, for not calling the pharmacy to locate the medication. Per policy CMA's are supposed to notify the nurse or call the pharmacy to locate the medication. Also informed the Acyclovir was found in the medication cart but in a different area. On 6/2/26 at 11:52 AM the Director of Nursing acknowledged the nurse had to place a new order for Acyclovir as the order was not given on 6/1/26 or early this morning. Also indicated she would have expected the Resident received her first as ordered on 6/1/26.The Facility Policy and Procedure for Medication Administration dated 7/25 instructed the following:1. Only licensed medical and nursing personnel or other lawful authorized staff members may prepare, administer, and record medication administration. 2. Medications must be given in accordance with the resident's plan of care. 3. Medications must be administered in accordance with the written orders of the attending physician. 4. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR). 5. Topical medications used in treatments should be recorded on the resident's medication administration record (MAR). 6. Identification of the resident must be made prior to administering medication to the resident. 7. Unless otherwise specified by the resident's attending physician, routine medications will be administered per the facility time ranges. This is to promote the continuance of a home like environment for our residents. 8. The nurse or medication technician administering the medication must record such information on the resident's MAR before administering the next resident's medication. 9. When PRN medications are administered, the nurse or medication technician must record the date and time administered, and later the results achieved from the PRN medication as appropriate. 10. Prior to administering the resident's medication, the nurse or medication technician should compare the drug and dosage schedule don the resident's MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse or med tech should check the physician's orders.

Based on electronic record review (EHR), staff interviews, policy review, and guidance from the 2024 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual the facility failed to accurately complete the Minimum Data Set (MDS) Assessment for 5 of 18 resident. Residents #1, #3, #6, and #13 were not coded correctly regarding pneumococcal vaccinations and Resident #3 and #13 were not coded correctly regarding the use a Code Alert (wander guard) bracelet. The facility reported a census of 72. Findings include: 1.The MDS Assessment completed on 7/10/25 revealed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #1's pneumococcal vaccination was not up to date and it was offered and declined. Physician's Order dated 9/9/23 directed staff to administer pneumonia vaccination with informed consent. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24. Resident #1 signed the document and consented to received the pneumococcal vaccine according the Centers for Disease Control and Prevention (CDC) recommended schedule. The EHR Progress Notes lacked documentation Resident #1 received a pneumococcal vaccine. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #1 was eligible to receive the PCV20, PCV21, or the PCV15 followed by the PPSV23 at least one (1) year later. 2.The MDS Assessment completed on 8/1/25 revealed Resident #3 with a BIMS score of 5 indicating severely impaired cognition. Diagnoses on the MDS include non-Alzheimer's dementia, post traumatic stress disorder, and a psychotic disorder (other than schizophrenia). Resident #3 noted to be independent with use of a manual wheelchair and without use of a wander/elopement alarm. The MDS indicated Resident #3's pneumococcal vaccination was not up to date and it was offered and declined. Physician Order Summary Report, obtained on 9/11/25, listed the following orders: Check Code Alert for proper functioning every shift; Start Date 9/8/24.Check Code Alert placement every shift; Start Date 9/8/24.Code Alert expires 12/2026. Change Alert on or before expiration date; Order Date 9/8/24.Administer pneumonia vaccination with obtained consent; Start date 6/19/24. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/9/24. Resident #3's Power of Attorney (POA) provided verbal consent for the resident to receive the pneumococcal vaccine according the Centers for Disease Control and Prevention (CDC) recommended schedule. The EHR Progress Notes lacked documentation Resident #3 received a pneumococcal vaccine. The Care Plan, last updated 8/15/25, included a Focus Area related to wandering/elopement risk. Interventions include to monitor wander guard placement (right wrist). During an observation on 9/11/25 at 11:15 AM, Resident #3 seen with a Code Alert bracelet on their right ankle. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #1 was eligible to receive the PCV20, PCV21, or the PCV15 followed by the PPSV23 at least one (1) year later. 3.The MDS Assessment completed on 6/13/25 revealed Resident #6 with a BIMS score of 4 indicating severely impaired cognition. The MDS indicated Resident #6's pneumococcal vaccination was up to date. Physician's Order dated 9/25/23 directed staff to administer pneumonia vaccination with informed consent. The EHR Clinical Immunizations tab indicated Resident #6 received the Prevnar13 (PCV13) pneumococcal vaccination on 4/25/22 and no further pneumococcal vaccinations. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24. Resident #6's POA provided verbal consent for the resident to receive the pneumococcal vaccine according the Centers for Disease Control and Prevention (CDC) recommended schedule. The EHR Progress Notes lacked documentation Resident #6 received an updated pneumococcal vaccine. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #6 was eligible to receive the PCV20 or PCV21 pneumococcal vaccine as of 4/25/23 to be considered up to date. 4.The MDS assessment dated [DATE] revealed Resident #8 with a BIMS of 13 indicating intact cognition. The MDS indicated Resident #8's pneumococcal vaccination was up to date. Physician Order dated 1/24/24 directed staff to administer pneumonia vaccination with informed consent. The EHR Clinical Immunizations tab indicated Resident #8 received PPSV23 (pneumococcal polysaccharide vaccine) on 8/26/20 and no further pneumococcal vaccinations. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24. Resident #8's POA provided verbal consent for the resident to receive the pneumococcal vaccine according the Centers for Disease Control and Prevention (CDC) recommended schedule. The EHR Progress Notes lacked documentation Resident #8 received an updated pneumococcal vaccine. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #8 was eligible to receive the PCV20, PCV21, or the PCV15 pneumococcal vaccine as of 8/26/21 to be considered up to date. 5.The MDS assessment dated [DATE] revealed Resident #13 with a BIMS score of 12 indicating moderately impaired cognition. Diagnoses include anxiety disorder, schizophrenia, and traumatic brain injury. Resident #13 noted to be independent with use of a manual wheelchair and without use of a wander/elopement alarm. MDS indicated Resident #13's pneumococcal vaccination was not up to date and it was offered and declined. Physician Order Summary Report, obtained on 9/11/25, listed the following orders: Administer pneumonia vaccination with obtained consent.Check Code Alert for proper functioning every shift; Start Date 5/28/24.Check Code Alert placement every shift; Start Date 5/28/24. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24. Resident #13 signed the document and consented to receive the pneumococcal vaccine according the Centers for Disease Control and Prevention (CDC) recommended schedule. The EHR Progress Notes lacked documentation Resident #1 received a pneumococcal vaccine. The Care Plan, last updated 8/22/25, included a Focus Area related to wandering/elopement risk. Interventions include to monitor wander guard placement (right wrist). During an observation on 9/10/25 at 2:30 PM, Resident #13 seen with a Code Alert bracelet on their right wrist. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #13 was eligible to receive the PCV20, PCV21, or the PCV15 followed by the PPSV23 at least one (1) year later. During an interview on 9/9/25 at 4:45 PM, the Facility Administrator stated pneumococcal vaccinations were not offered as part of the October 2024 vaccination clinic. During an interview on 9/15/25 at 12:45 PM, the MDS Coordinator acknowledged the lack of coding for the Code Alert bracelets for Residents #3 & #13. They believed the bracelets were considered a restraint and therefore not coded. The RAI Manual coding instructions documented the following after determining if the resident up to date on pneumococcal vaccinations: Question O0300ACode 0, no, if the vaccination is not up to date or cannot not be determined. Proceed to item O0300B, if pneumococcal vaccine not received, state reason. Code 1, yes, if the vaccination is up to date. Question O0300BCode 1, not eligible, if the resident is not eligible due to medical contraindications.Code 2, offered and declined if the resident or responsible part/legal guarding had been informed of what is being offered and chooses not to accept.Code 3, not offered, if the resident not offered the vaccination. After determining whether or not an item listed in P0200 (alarms), which included a wander/elopement alarm, was used during the 7-day look-back period, code the frequency of use:Code 0, not used, if the device was not used during the 7-day look-back period.Code 1, used less than daily, if the device was used less than daily.Code 2, used daily, if the device was used on a daily basis during the look-back period. The definition per the RAI of a wander/elopement alarm: Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings.

Based on record review, staff interview and policy review the facility failed to vaccinate an eligible resident with the pneumococcal vaccine for 5 of 5 resident reviewed, (Residents #1, #3, #6, #8 and #13). The facility reported a census of 72 residents.Findings include: 1.The Minimum Data Set (MDS) assessment for Resident #1 dated 8/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anemia, coronary artery disease (CAD - arteries that supply blood to the heart muscles), diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia, and chronic obstructive pulmonary disease (COPD). It indicated the resident had not received a pneumococcal vaccination. The resident's most recent MDS, dated [DATE], additionally documented the resident to be not up to date on pneumococcal vaccination. It coded the vaccine was offered and declined. Physicians Orders dated 9/9/23 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The Electronic Health Record (EHR) included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident consented to receive the pneumococcal vaccination. The Progress Notes did not include any documentation the resident received a pneumococcal vaccination. On 1/13/25, an X-Ray result indicated the resident had midlung consolidation for pneumonia. The Care Plan dated 1/13/25 and resolved 2/26/25 indicated the resident had pneumonia. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #1 was eligible to receive the PCV20, PCV21, or the PCV15 followed by the PPSV23 at least one (1) year later. 2. The MDS assessment for Resident #3 dated 9/03/24 revealed a BIMS score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, CAD, kidney failure, non-Alzheimer's dementia, and COPD. It indicated the resident had not received a pneumococcal vaccination. The most recent MDS of Resident #3, dated 8/1/25, additionally documented the resident to be not up to date on pneumococcal vaccination. It coded the vaccine was offered and declined. Physicians Orders dated 6/19/24 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident's Power of Attorney (POA) consented to the resident receiving the pneumococcal vaccination. The Clinical Immunizations tab lacked a documented pneumococcal vaccination. The Progress Notes did not include any documentation the resident received a pneumococcal vaccination. The Care Plan revised 10/14/24 included a resolved intervention to ensure all immunizations were up to date. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #1 was eligible to receive the PCV20, PCV21, or the PCV15 followed by the PPSV23 at least one (1) year later. 3. The MDS assessment for Resident #6 dated 9/28/24 revealed a BIMS score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, CAD, heart failure, diabetes mellitus, non-Alzheimer's dementia, and morbid obesity. It indicated the resident's pneumococcal vaccination was not up to date. The most recent MDS of Resident #6, dated 6/13/25, coded the resident was up to date on pneumococcal vaccination, although an updated vaccination had not been administered. Physicians Orders dated 9/25/23 directed staff to administer influenza vaccination every year during flu season if no allergy to eggs or egg products and administer pneumococcal vaccine -PPSV 23 per CDC guidelines if indicated and consented. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident's POA consented to the resident receiving the pneumococcal vaccination. The Clinical Immunizations tab indicated the resident received the Prevnar13 (PCV13) pneumococcal vaccination on 4/25/22 and no further pneumococcal vaccinations. The Progress Notes did not include any documentation the resident received a pneumococcal vaccination. The Care Plan did not include any documented vaccinations. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #6 was eligible to receive the PCV20 or PCV21 pneumococcal vaccine as of 4/25/23. 4. The MDS of Resident #8 dated 8/01/24 revealed a BIMS score of 05 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, seizure disorder, and schizophrenia. It indicated the resident was offered and declined a pneumococcal vaccination. The most recent MDS of Resident #8, dated 6/25/25, coded the resident was up to date on pneumococcal vaccination, although an updated vaccination had not been administered. Physicians Orders dated 1/24/24 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The Clinical Immunizations tab indicated the resident received the PPSV23 (pneumococcal polysaccharide vaccine) on 8/26/20. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident's POA consented to the resident receiving the pneumococcal vaccination. There were no pneumococcal vaccination declination forms in the EHR. The Clinical Immunizations tab indicated the resident received the PPSV23 (pneumococcal polysaccharide vaccine) on 8/26/20. The Progress Notes did not include any documentation the resident received a pneumococcal vaccination. The Care Plan did not include any documented vaccinations. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #8 was eligible to receive the PCV20, PCV21, or the PCV15 pneumococcal vaccine as of 8/26/21. 5. The MDS assessment for Resident #13 dated 8/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anemia, schizophrenia, and traumatic brain injury (TBI). It indicated the resident had not received a pneumococcal vaccination. The most recent MDS of Resident #13, dated 8/29/25 documented the resident remained out of date for pneumococcal vaccination. Physicians Orders dated 2/21/24 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident consented to receive the pneumococcal vaccination. The Clinical Immunizations tab lacked a documented pneumococcal vaccination. The Progress Notes did not include any documentation the resident received a pneumococcal vaccination. The Care Plan did not include any documented vaccinations. A CDC document titled Pneumococcal Vaccine Timing for Adults dated 3/2025 indicated Resident #1 was eligible to receive the PCV20, PCV21, or the PCV15 followed by the PPSV23 at least one (1) year later. On 9/9/25 at 4:45 pm the Administrator stated she had verified the Covid and Pneumonia vaccines had not been administered, only flu shots. She stated the facility had a vaccine clinic scheduled to get the residents up to date on other vaccines as well. The facility policy Immunizations - Residents, review date 7/2023, documented the following: Policy: It is the policy of this facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine(s) and obtaining consent. Eligibility to receive the vaccines may include, but is not limited to current vaccine status, season/time of year, medical contraindications, or resident preference/choice.Procedure:1. Residents will be screened at the time of admission to determine vaccine status and eligibility, using current CDC/ACIP guidelines, to receive the influenza, pneumococcal, and/or COVID-19 vaccine(s). 2. Before offering any vaccine and to ensure a resident's right to choose, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization.3. Each eligible resident is offered a seasonal influenza immunization unless the immunization is medically contraindicated or the resident has already been immunized. 4. Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized.5. Each resident is offered a COVID-19 immunization unless the immunization is medically contraindicated or the resident has already been immunized. 6. The resident or the resident's representative has the opportunity to decline any or all immunization(s). 7. Information related to education provided regarding the benefits and risks of each immunization and the administration or refusal of or medical contraindications to the vaccines will be documented in the resident's medical record.a. Document that the resident either received the influenza and/or pneumococcal and/or COVID-19 immunization or did not receive the influenza and/or pneumococcal and/or COVID-19 immunization due to medical contraindications or declination. b. Documentation will also include any adverse effects experienced by the resident related to vaccination(s). (Electronic health record/immunization tab/progress notes)

Based on clinical record review, resident and staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents for 5 of 5 resident reviewed for vaccines (#1, #3, #6, #8, and #13). The facility reported a census of 72 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 8/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anemia, coronary artery disease (CAD - arteries that supply blood to the heart muscles), diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia, and chronic obstructive pulmonary disease (COPD). It did not indicate the resident received a COVID-19 vaccination. The resident's most recent MDS, dated [DATE], coded the resident remained out of date for COVID-19 vaccinations. Physician's Orders dated 9/08/23 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The resident's chart failed to reveal an order for administering COVID-19 vaccinations. The Electronic Health Record (EHR) included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident consented to receive the COVID-19 vaccination.The Clinical Immunizations tab lacked documentation of a COVID-19 vaccination after 10/31/23. The Progress Notes failed to reveal any documentation that the resident received a COVID-19 vaccination. The Care Plan did not include any documented vaccinations. 2. The MDS assessment of Resident #3 dated 9/03/24 revealed a BIMS score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, CAD, kidney failure, non- Alzheimer's dementia, and COPD. It did not indicate the resident received a COVID-19 vaccination. The most recent MDS of Resident #3, dated 8/1/25, coded the resident remained out of date for COVID-19 vaccinations. Physician's Orders dated 6/19/24 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The resident's chart failed to reveal an order for administering COVID-19 vaccinations. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident's Power of Attorney (POA) consented to the resident receiving the COVID-19 vaccination. The Clinical Immunizations tab lacked a documented COVID-19 vaccination after 9/23/21. The Progress Notes failed to reveal any documentation the resident received a COVID-19 vaccination. The Care Plan revised 10/14/24 included a resolved intervention to ensure all immunizations were up to date. 3. The MDS assessment for Resident #6 dated 9/28/24 revealed a BIMS score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, CAD, heart failure, diabetes mellitus, non-Alzheimer's dementia, and morbid obesity. It did not indicate the resident received a COVID-19 vaccination. The resident's most recent MDS, dated [DATE], coded the resident remained out of date for COVID-19 vaccinations. Physician's Orders dated 9/5/23 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The resident's chart failed to reveal an order for administering COVID-19 vaccinations. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident's POA consented to the resident receiving the COVID-19 vaccination. The Clinical Immunizations tab lacked a documented COVID-19 vaccination after 10/19/23. The Progress Notes failed to reveal any documentation the resident received a COVID-19 vaccination. The Care Plan did not include any documented vaccinations. 4. The MDS assessment for Resident #8 dated 8/01/24 revealed a BIMS score of 05 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, seizure disorder, and schizophrenia. It did not indicate the resident received a COVID-19 vaccination. The resident's most recent MDS, dated [DATE], coded the resident remained out of date for COVID-19 vaccinations. Physician's Orders dated 1/24/24 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The resident's chart failed to reveal an order for administering COVID-19 vaccinations. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident's POA consented to the resident receiving the COVID-19 vaccination. The Clinical Immunizations tab lacked a documented COVID-19 vaccination after 11/15/21. The Progress Notes indicated the resident was evaluated on 8/31/24 for confirmed COVID-19 diagnosis. However, notes failed to reveal any documentation that the resident received a COVID-19 vaccination after 3-months post-recovery. The Care Plan did not include any documented vaccinations. 5. The Minimum Data Set (MDS) assessment for Resident #13 dated 8/29/24 revealed a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anemia, schizophrenia, and traumatic brain injury (TBI). It did not indicate the resident received a COVID-19 vaccination. The resident's most recent MDS, dated [DATE], coded the resident remained out of date for COVID-19 vaccinations. Physician's Orders dated 2/21/24 directed staff to administer influenza vaccination annually with obtained consent and administer pneumonia vaccination with obtained consent. The resident's chart failed to reveal an order for administering COVID-19 vaccinations. The EHR included a document titled Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 10/09/24 indicated the resident consented to receive the COVID-19 vaccination. The Clinical Immunizations tab lacked a documented COVID-19 vaccination. The Progress Notes indicted the resident tested negative for COVID-19 infection. It also did not include any documentation the resident received a COVID-19 vaccination. The Care Plan did not include any documented vaccinations. On 9/9/25 at 4:45 pm the Administrator stated she had verified the Covid and Pneumonia vaccines had not been administered, only flu shots. She stated the facility had a vaccine clinic scheduled to get the residents up to date on other vaccines as well. A CDC document titled Recommended Adult Immunization Schedule 2025 indicated adults age [AGE] years and older who received a COVID-19 vaccination prior to the 2024-2025 vaccine period should receive two (2) COVID-19 vaccines 2 to 6 months apart for the 2024-2025 vaccination season. The facility policy Immunizations - Residents, review date 7/2023, documented the following: Policy: It is the policy of this facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine(s) and obtaining consent. Eligibility to receive the vaccines may include, but is not limited to current vaccine status, season/time of year, medical contraindications, or resident preference/choice.Procedure:1. Residents will be screened at the time of admission to determine vaccine status and eligibility, using current CDC/ACIP guidelines, to receive the influenza, pneumococcal, and/or COVID-19 vaccine(s). 2. Before offering any vaccine and to ensure a resident's right to choose, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization.3. Each eligible resident is offered a seasonal influenza immunization unless the immunization is medically contraindicated or the resident has already been immunized. 4. Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized.5. Each resident is offered a COVID-19 immunization unless the immunization is medically contraindicated or the resident has already been immunized. 6. The resident or the resident's representative has the opportunity to decline any or all immunization(s). 7. Information related to education provided regarding the benefits and risks of each immunization and the administration or refusal of or medical contraindications to the vaccines will be documented in the resident's medical record.a. Document that the resident either received the influenza and/or pneumococcal and/or COVID-19 immunization or did not receive the influenza and/or pneumococcal and/or COVID-19 immunization due to medical contraindications or declination. b. Documentation will also include any adverse effects experienced by the resident related to vaccination(s). (Electronic health record/immunization tab/progress notes)

Based on electronic health record review (EHR), staff interviews, and policy review, the facility failed to complete and document resident neurological exams (neurochecks) as scheduled for 2 of 2 residents reviewed for falls (Residents #3 and #8.) The facility reported a census of 72. Findings include: 1. Minimal Data Set (MDS) Assessment completed on 8/1/25 revealed Resident #3 with a Brief Interview for Mental Status (BIMS) score of 5 indicating severely impaired cognition with continuous disorganized thinking and inattentive. Diagnoses on the MDS include non-Alzheimer's dementia, post-traumatic stress disorder, and a psychotic disorder (other than schizophrenia). Resident #3 required staff supervision for transfers and noted independent with use of a manual wheelchair. The MDS documented a resident fall with injury (skin tears/abrasions, lacerations, bruises, hematomas, sprains) since the last assessment. The Care Plan, last updated on 8/15/25, included Focus Areas related to fall risk and impaired cognitive function. The Progress Note dated 6/10/25 at 1:33 AM documented an unwitnessed fall with left knee injury for Resident #3. The Progress Noted dated 8/5/25 at 1:38 AM documented an unwitnessed fall with no visible injuries for Resident #3. The EHR lacked documentation neurochecks were initiated and/or completed for the duration of the scheduled timeframe for Resident #8 after the unwitnessed falls on 6/10/25 and 8/5/25. 2. The Minimum Data Set (MDS) Assessment completed 6/25/25 revealed Resident #8 with a BIMS of 13 indicating intact cognition. Diagnoses include anxiety disorder, depression, malnutrition, non-Alzheimer's dementia, dysphasia (swallowing difficulty), seizure disorder/epilepsy, and schizophrenia. Resident #8 requires maximum staff assistance for transfers. Resident #8 utilizes a manual wheelchair and noted to be independent for short distances (at least 50 feet) but dependent on staff for longer distances (at least 150 feet). The MDS documented a resident fall with no injury since last assessment. The Care Plan, last updated 3/26/25 included Focus Areas related to fall risk and impaired cognitive function. The Progress Note dated 12/15/24 at 7:50 AM documented a fall with Resident #8 hitting the back of their head on the floor. No visible injuries. The Progress Note dated 12/16/24 at 11:00 AM documented Resident #8 was transported to the emergency room. This was related to continued swelling and pain to the left wrist. The Progress Note dated 12/17/24 at 12:44 AM documented Resident #8's return to the facility from the emergency room with a diagnosis of fractures to the left distal radius and ulna. The Progress Note dated 12/19/24 at 5:37 PM indicated the fall with fracture occurred on 12/16/24. The Progress Note dated 4/28/25 at 2:15 PM documented an unwitnessed fall with no visible injuries. The document Neurological Evaluation was initiated for Resident #8 on 12/16/24 at 5:00 AM. The scheduled neurochecks for the first hour after the fall lacks documentation for the final 15-minute check. Neurochecks were not resumed upon Resident #8's return from the emergency room on [DATE] at approximately 12:45 AM. The neurocheck form lacked documentation for all of 12/17/25. Neurocheck documentation resumed on 12/18/24 and noted with an incomplete assessment noted for 2nd shift scheduled check (no level of consciousness, pupil size, pupil response, hand grasp documented). The last scheduled neurocheck on 12/19/24 for 2nd shift lacked documentation. The document Neurological Evaluation was initiated for Resident #8 on 4/28/25 at 2:15 PM. The scheduled neurochecks for every 2 hours for 8 hours had 1 documented assessment out of 4. The scheduled neurochecks for every 4 hours for 12 hours had 1 documented assessment out of 3. The scheduled neurochecks for every shift for 48 hours lacked documentation. During an interview on 9/16/25 at 8:45 AM, Staff I, Registered Nurse (RN), recalled events of Resident #3's unwitnessed fall on 8/5/25. Staff I explained neurochecks were initiated and completed as scheduled for the remainder of their shift. Assessments were documented on the neurocheck form. Once their shift was over the form documenting the checks was handed off to the day shift. During an interview on 9/16/25 at 9:15 AM, Staff J, RN, was unable to recall events of Resident #3's unwitnessed fall on 6/10/25, Staff J acknowledged neurochecks are initiated with head injuries and unwitnessed falls. Staff J explained neurochecks are documented on paper and then on the computer. During an interview on 9/15/25 at 4:30 PM the Facility Administrator reviewed neurocheck forms and acknowledged the lack of documentation for Resident #3 and the inconsistent documentation for Resident #8. The Administrator would expect staff to complete neurochecks as scheduled. Neurochecks should have been resumed after Resident #8 returned from the hospital unless further testing had been completed to rule out a brain bleed. On 9/16/25 at 835 AM the Facility Administrator confirmed Resident #8 did not have any additional testing at the hospital to rule out a brain bleed. The policy Neuro Policy revised 4/2022 outlined the following:Complete full neuro assessments with any unwitnessed fall or fall with resident hitting their head.Licensed nurse will complete an initial neuro assessment at time of the incident and in the assigned increments of time: Q15 minutes x1 hour, Q30 minutes x1 hour, Q hour x2 hours, Q4 hours x12 hours, and Q shift x48 hours or as instructed by the provider.

Based on electronic health record review (EHR), staff interviews, and policy review, the facility failed to coordinate nutritional care with the dialysis unit for 1 of 2 residents reviewed for dialysis (Resident #2). The facility reported a census of 72.Findings include: The Minimum Data Set (MDS) Assessment completed on 6/16/25 revealed Resident #2 with a Brief Interview for Metal Status score of 15 indicating intact cognition. Diagnoses include end stage renal disease (receiving dialysis), diabetes, heart failure, hyperkalemia (high blood potassium levels), and respiratory failure. The MDS did not indicate a therapeutic diet (such as low sodium diabetic) was in place. The Care Plan, last revised 6/26/25 included a Focus Area related to nutrition due to end stage renal disease, hyperkalemia (high blood potassium), and fluid overload. Interventions include a liberalized regular textured diet with thin liquids and to honor resident rights to make personal dietary choices. Physician Order Summary report, obtained on 9/11/25, listed the diet order as liberalized regular textured diet with thin liquids. The EHR included Nursing Dialysis Communication Records from May 2025 to September 2025. On 13 different occasions, dialysis staff documented on the communication sheet to offer a low potassium or renal diet due to high potassium levels. The EHR lacked documentation regarding communication between the facility's Registered Dietitian (RD) and the dialysis center's RD. During an interview on 9/15/25 at 10:15 AM the Certified Dietary Manger (CDM) reported they have not received any communication (written or verbal) for the dialysis center or the facility regarding diet. The CDM has not received any directive to offer a low potassium diet from facility staff or the RD. During an interview on 9/15/25 at 10:45 AM, the RD reported they had reviewed the Nursing Dialysis Communication Records and aware of the low potassium/renal diet request. However Resident #2 is resistant to change and feels a renal diet is too restrictive. The RD explained they have not reached out to dialysis staff, including the dialysis RD, to update that the resident declines dietary restrictions. The RD noted they do not have dialysis RD contact information. If needed, the RD reported the facility could provide a low potassium diet if Resident #2 agreed. During an interview on 9/15/25 at 11:45 AM the dialysis RD acknowledged Resident #2's high potassium levels and the requests for a low potassium/renal diet. Monthly lab work is faxed over the facility with contact information attached. The dialysis RD explained calling the facility on July 30, 2025. Facility staff answering the phone confirmed Resident #2 was on a renal diet. As far the dialysis RD knows, a renal diet was in place. information. During an interview on 9/15/25 at 1:00 PM, the Administrator acknowledged Resident #2's high potassium levels. They were not aware of any specific labs or faxes from the dialysis unit has they are faxed to the floors directly. The Administrator noted Resident #2 has moved floors since facility admission in May 2025. When discussing the dialysis RD call on July 30th, the Administrator noted the person who they were talking with may have been a resident. The name the dialysis RD provided does not match up with any staff member but with a resident. Any diet specific items should be addressed by the facility RD. The Administrator believed the current RD would be reaching out to the dialysis center as per past facility RDs. The policy Dialysis (Renal), Pre and Post Care, revised 4/2025, noted the following:Staff to participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.Notify Registered Dietitian of any dietary concerns.

Based on electronic health record review (EHR), observations, staff interview, and policy review, the facility failed to provided oxygen (O2) therapy as ordered by the physician for 1 of 1 residents reviewed for respiratory care (Resident #2). The facility reported a census of 72. Findings include: The Minimum Data Set (MDS) Assessment completed on 6/16/25 revealed Resident #2 with a Brief Interview for Metal Status score of 15 indicating intact cognition. Diagnoses include end stage renal disease (receiving dialysis), diabetes, heart failure, respiratory failure and seizure disorder. The Order Summary Report, obtained on 9/11/25, noted an order for continuous O2 at 2L/min via nasal cannula to keep O2 saturation (amount of oxygen in the blood) above 90% every shift; Start date 7/11/25. The Medication Administration Record for September 2025 showed O2 saturation (sats) levels are monitor three times per day. The EHR clinical O2 Sats summary tab lacked consistent documentation of the O2 setting when O2 sats obtained when the use of O2 via nasal cannula noted. No O2 settings were documented in August or September with 2 settings documented in July after the order initiated. These were documented at 3L (liters). During an observation on 9/8/25 at 1:40 PM, Resident #2's O2 concentrator was set at 4L. The EHR lacked documentation regarding the increased O2 setting. During an observation on 9/11/25 at 3:20 PM, the O2 concentrator was turned off. Resident #2 turned it on and the setting was noted at 4L. The EHR lacked documentation regarding the increased O2 setting or why the O2 concentrator was off. During an observation on 9/15/25 at 8:15 AM, Resident #2's O2 concentrator was set at 3L. The EHR lacked documentation regarding the increased O2 setting. During an interview on 9/11/25 at 3:20 PM, Resident #2 voiced the need for O2 therapy especially when sleeping. Resident #2 acknowledged they may remove and/or adjust the O2 settings as needed but would not set it above 3L. During an interview on 9/11/25 at 3:50 PM, Staff F, Certified Medication Aide (CMA), explained CMAs cannot adjust a resident's O2 setting. Only nurse may do so. Staff F noted they may not routinely look at O2 settings when taking vitals, which include O2 sats. Staff F explained the 3rd floor nursing needs currently split between the 2nd and 4th floor nursing. During an interview on 9/11/25at 4:00 PM, Staff G, Registered Nurse, acknowledged Resident #2 use of O2 and believed settings were ordered at either at 2L or 3L; Was unsure without referring to EHR. Staff G aware of Resident #2 adjusting levels on their own but had not seen it set higher than 3L. Staff G confirmed they are scheduled to cover the 2nd floor as well as half of the 3rd floor at this time. During an interview on 9/15/25 at 8:20 AM Staff H, Licensed Practical Nurse, voiced being familiar with Resident #2. They were unsure of Resident #2's O2 setting order without referring to the EHR. Staff H explained vitals obtained either by nursing staff or the aides. They may not routinely chart O2 setting when obtaining O2 sats. Should the resident need an increase in O2 (above what is ordered), Staff H explained a physician order would be needed. Staff H confirmed they are scheduled to cover the 2nd floor as well as half of the 3rd floor at this time. During an interview on 9/15/25 at 1:00 PM, the Administrator confirmed Resident #2's current O2 order at 2L. Staff should be documenting O2 settings in the EHR. The Administrator noted Resident #2 does take off their O2 when going to smoke, as required. The policy Oxygen Administration, revised 12/2017, noted the following the resident's clinical record will include:That oxygen is to be administered.When and how often oxygen is to be administered.The type of oxygen device to use (i.e., mask, nasal).Charting and documentation related oxygen use.

Based on record review, observation, staff interview, policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement infection control practices to prevent cross contamination by staff failing to perform appropriate hand hygiene during medication administration for 1 of 4 residents reviewed for medication administration (Resident #2). The facility reported a census of 72 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] indicated that Resident #2 had a diagnosis of chronic pain syndrome. The Care Plan initiated on 5/6/25 revealed that Resident #2 is on pain medication for chronic pain syndrome. During an observation on 9/10/2025 at 8:56 AM Staff A, CMA gave Resident #2 her oral medications. Staff A, CMA did not perform hand hygiene after giving the oral medications. Resident #2 then asked for her pain patches to her back. Staff A, CMA told her to go to her room and he would be down to apply the patches. At 9:01 AM, Staff A, CMA documented the oral medications and took the patches out of the medication cart. Gloves were donned and Staff A, CMA applied the patches to Resident #2's back. He then doffed his gloves and charted the medications. He did not perform hand hygiene before donning or doffing of his gloves. Medication observation was competed for Resident #2. At the conclusion of the observation of Resident #2, Staff A, CMA continued to be observed preparing medications and entering another Resident's room with them. Hand hygiene was not completed between Resident #2 and the next resident. In an interview on 9/11/2025 at 10:00 AM Staff B, RN stated hand hygiene should be performed when removing gloves, after touching a resident and between residents. In a document titled Hand Hygiene, it stated to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: 1. Before and after direct contact with residents. 2. Before preparing or handling medications. 3. After removing gloves. According to the CDC document Clean Hands dated 2/27/24, hand hygiene should be performed immediately before touching a patient, immediately after glove removal, before exiting a patient room and if moving from care on one patient to another patient. This document can be found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.htm

Based on observations, interviews, and record review, the facility failed to provide privacy and dignity while providing care to 1 out of 3 residents reviewed (Resident #5). Staff provided care to Resident #5 while she was lying in bed. During the provision of care both upper and lower areas of Resident #5 were exposed to include her breasts, buttocks and genitals. The blinds on this resident's window were left open with a parking lot just outside of her window. The facility reported a census of 72 residents. Findings include: A Quarterly Minimum Data Set, dated dated dated [DATE], documented diagnoses for Resident #5 included bipolar disorder, muscle weakness and need for assistance with personal care. A Brief Interview for Mental Status documented a score of 15 out of 15, which indicated intact cognitive functioning. Resident #5 was dependent on 2 or more staff for toileting hygiene, showering/bathing, upper and lower body dressing and personal hygiene. On 5/5/25 at 12:26 p.m., Resident #5 stated that when staff do her cares they often leave the blinds to her window open, so anyone that is out there could see. On 5/5/25 at 1:15 p.m., Staff D, Certified Nurse Aide (CNA) and Staff E, CNA, went into Resident #5's room. They started providing cares to this resident. The window blinds were open. A car parked in an empty spot approximately 4 spaces away from this resident's window. A person got out of the car and walked away from, not toward the window. Directly following this observation, Staff D, when asked about the blinds being left open while they provided care, stated she should have shut them. When told a car pulled up, a person got out but that person didn't walk toward the window, Staff D nodded and repeated she should have shut them. On 5/6/25 at 3:35 p.m., the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), acknowledged the concern regarding the blinds not being drawn while cares were given. They acknowledged this was a dignity/resident rights issue. A Resident Rights Policy with the subject of Dignity and Privacy revised on 10/2024, directed the following: POLICY: It is the policy of this facility that all residents be treated with dignity, respect, and privacy. PROCEDURES: 1. The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings. 2. Schedules of daily activities allow maximum flexibility for residents to exercise choices about what they will do and when they will do it. Residents' individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainment are elicited and respected by the facility. 3. Residents will be appropriately dressed in clean clothes arranged comfortably on their persons, and be well groomed per their preference. 4. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by. People not involved in the care of the Resident shall not be present without the resident's consent while they are being examined or treated. 5. Privacy of a Resident's body shall be maintained during toileting, bathing and other activities of personal hygiene, except when staff assistance is needed for the Resident's safety. 6. Violations of the Resident's right to dignity and respect should be promptly reported to the Director of Nursing Services and/or the Administrator. HIGHLIGHTS: Dignity and respect, daily activity schedules, privacy, care and treatments, reporting violations and grievances

Based on observations, interviews and record review, the facility failed to have clear direction for their staff regarding code status for 1 of 1 resident reviewed (Resident #2). The facility had a doctor's order for a full code which directed that in the event Resident #2's heart and respirations should stop, CPR (Cardiopulmonary Resuscitation)(Chest Percussions and rescue breathing) (Full Code) was to be performed. The IPOST (Iowa Physician's Orders for Scope of Treatment) for this resident directed that this resident was to be a DNR (Do Not Resuscitate) in the event Resident #2's heart and respirations should stop this resident was not to have chest percussions nor was he to have rescue breathing given to him. The facility reported a census of 72 residents. Findings include: A Care Plan for Resident #2 had a focus area initiated on [DATE], directed that Resident #2 desired to be a DNR per IPOST. The Goal was that Advanced Directives will be honored by staff. The intervention directed that the IPOST document would be reviewed with each care conference and updated as needed. An IPOST dated [DATE], directed that resident was a DNR/Do Not Attempt Resuscitation. A Physician's Order dated [DATE], directed that Resident #2 was to have CPR/Full Code. On [DATE] at 11:47 a.m., Staff A, Certified Medication Aide (CMA), stated that on [DATE] Resident #2's eyes didn't look right and his respirations were high. Staff A asked 2 other staff to lay Resident #2 down. Staff A stated that the staff reported when they were laying this resident down, this resident started to turn blue. Staff A stated he called for a code blue overhead and everyone came down. Staff A stated he knew they (the nurses) were trying to work with the oxygen and they were trying to find out code status for Resident #2. Staff A stated that the papers they were going to send with the ambulance directed that Resident #2 was a DNR, but Resident #2 was listed as a Full Code in the facility's system. On [DATE] at 12:56 p.m., Staff B, Registered Nurse (RN), 2nd floor Unit Manager, stated that Staff A shouted down the hall to Staff B that they needed her. She stated that they called on the overhead speaker for assistance on the 2nd floor. She stated the overhead call was for a code. Staff B stated a code was not initiated as Resident #2 had a pulse and was breathing. He was pale in color. She stated then the EMS (Emergency Medical Services) arrived. Staff B stated that this resident was a DNR. She stated his IPOST directed that he was a DNR. Staff A stated she knew that in his chart there was a doctor's order for a full code. She stated the DNR/IPOST was signed around December (2024) and the doctor's order was written as a full code when Resident #2 returned around [DATE] from his prior hospitalization last month. Staff B stated she did not feel the team at this facility could have done anything differently then what they did, other than being sure the code status was aligned. On [DATE] at 11:36 p.m., Staff C, Nurse Practitioner, stated that she usually goes over code status when residents return from the hospital and Staff C wanted to talk with his son. Staff C stated that the hospital likely changed Resident #2 to a full code in order for them to perform a wound debridement procedure. Staff C stated that she thought Resident #2's son made Resident #2 a DNR when this resident was very first admitted to the facility. On [DATE] at 3:35 p.m., the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) , acknowledged the above concern regarding differing code status for Resident #2. They stated they became aware of this situation on the day it happened and have started to look further into this situation, including doing audits on the other residents. A Care and Treatment Policy with the subject Advance Directives revised on ,d+[DATE], directed the following: POLICY: It is the policy of this facility that a resident's choice about advance directives will be respected. PROCEDURES: 1. The care plan team will ask residents, and/or their family members, about the existence of any advance directives. 2. Should the resident indicate that he or she has issued advance directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record. 3. The facility will work with the resident and their responsible party in completing an advanced directive if they choose and an IPOST to clarify their wishes to be documented for physician signature. 4. The facility has defined advanced directives as preferences regarding treatment options and are included, but not limited to: a. Living Will - A document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis; b. Do Not Resuscitate -- Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health-care proxy, or representative (sponsor) have directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used; c. Do Not Hospitalize - Indicates that the resident is not to be hospitalized , even if he/she has a medical condition that would usually require hospitalization ; d. Feeding Restrictions - Indicates that the resident, legal guardian, health-care proxy, or representative (sponsor) does not wish for the resident to be fed by artificial means (e.g., tube, intravenous nutrition, etc.) if he/she is not able to be nourished by oral means; e. Medication Restrictions - Indicates that the resident, legal guardian, health-care proxy, or representative (sponsor) does not wish for the resident to receive life-sustaining medications (e.g., antibiotics, chemotherapy, etc.); and f. Other Treatment Restrictions - Indicates that the resident, legal guardian, health-care proxy, or representative (sponsor) does not wish for the resident to receive certain medical treatments. Examples include, but are not limited to, blood transfusions, tracheotomy, respiratory incubation, etc. 5. If advance directive documents or IPOST are not available or signed by the resident (responsible party) and the physician, the facility will consider the resident a full code until clarification is obtained. 6. If advance directive documents were developed in another state, the resident must have such documents reviewed and revised by legal counsel in this state before the facility may honor such directives. 7. The care plan team will review periodically, at least quarterly, annually with the resident his/her advance directives to ensure that they are still the wishes of the resident. Such reviews will be made during the assessment process and recorded on the resident assessment instrument (MDS). 8. Changes or revocations of a directive must be submitted to the facility, in writing. The facility may require new documents if changes are extensive. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. 9. The facility will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical records and plan of care. 10. Inquiries concerning advance directives should be referred to social services, and/or to the director of nursing services.

Based on observation, interviews, and record and policy review, the facility failed to ensure safety risks were minimized for 1 of 1 resident observed (Resident #8). Resident #8 was observed being pushed in her wheelchair (w/c) by Staff F, Certified Nurse Aide (CNA) without her feet on w/c pedals. It was noted that the bottom of Resident #8's feet were skimming the floor while Staff F was pushing her. The facility reported a census of 72 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #8 included carpal tunnel syndrome bilateral upper limbs, repeated falls, and weakness. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognitive functioning. Resident #8 could wheel herself once seated in a manual wheelchair at least 50 feet and make 2 turns. It documented that this resident used a manual wheel chair and once seated she had the ability to wheel at least 150 feet in a corridor or similar space. Observation on 5/6/25 at 3:30 p.m., revealed Resident #8 was being pushed in her w/c by Staff F, CNA. There were no w/c pedals on the chair. This resident stated she asked Staff F to push her down the hall. Staff F said she knows to use w/c pedals when pushing residents. Staff F said this resident had asked Staff F to push her in her w/c. This resident said she did ask Staff F to push her down the hall in her w/c. When asked about her feet touching the floor, this resident lifted her feet way up. Staff F stated that Resident #8 normally wheels herself all over the place or walks behind the w/c. Staff H, Certified Nurse Aide (CMA) was standing at the medication cart. She said she didn't see this incident. Staff H said she was new to the facility. Staff H asked Staff F if most residents have bags on their w/cs to place w/c pedals. Staff F said she didn't know if Resident #8 even had any w/c pedals. Staff G, MDS Coordinator/nurse, stated understanding of this observation. Staff G acknowledged that no resident should be pushed in a w/c by staff without having the legs and w/c pedals on the wheelchair with the resident's feet on the pedals. When Staff F was asked if she knew why there was a concern with this situation, she stated yes, they could break their ankles. On 5/6/25 at 3:35 p.m., the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), when told about this observation, stated understanding of the concern and acknowledged it was a concern. The DON stated usually Resident #8 uses her feet to go all over the facility in her w/c. On 5/7/26 at 11:36 a.m., Staff C, Nurse Practitioner, stated that Resident #8 is alert and oriented times 3 (oriented to person, place, and time). Staff C stated that Resident #8 should not have been pushed with her feet skimming on the ground. A Quality of Life policy with a subject of Safety, Resident was reviewed on 10/2024. It directed the following: POLICY: It is the policy of this facility to create a safe environment for wheelchair mobility. PROCEDURES: 1. Assist resident to wheelchair as resident needs arise per resident's care plan. 2. Make sure the person is comfortable. 3. Position the patient's feet on the footrests of the wheelchair when needed per resident needs. 4. When transporting a resident in a wheelchair unlock the wheelchair brakes and transport the individual forward through an open doorway after checking for traffic. 5. When transporting the individual up to a closed door, open the door and back the wheelchair through the doorway. 6. Take the individual to their destination and ensure they are safe

Based on observation, clinical record review, staff interview and family interview, and policy review, the facility failed to maintain infection control standards due to not wearing Personal E(PPE) of gown and gloves while providing high contact care activity for a resident required to be on Enhanced Barrier Precautions (EBP) (an infection control intervention requiring staff to wear designated PPE to reduce transmission of organisms for designated residents) for 3 (Resident #49, #119, and #219) of 3 residents reviewed and not completing proper hand hygiene with cares for 1 (Resident #52) of 1 reviewed. The facility reported a census of 66 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #119, dated 8/9/24, included diagnoses of osteomyelitis (bone infection) of vertebra, Stage 4 (full thickness of skin wound) pressure ulcer of right buttock, and septicemia (infection in blood) and documented the resident had a Foley catheter (tube to empty urine from the bladder) and colostomy (opening in the abdominal wall from the colon to the outside of the body). Observation on 10/15/24 at 3:00 PM, Staff E, Certified Nurse Aide (CNA) and Staff F, CNA entered Resident #119's room and applied gloves. Staff E and Staff F transferred the resident from the bed to a wheelchair with a full body mechanical lift, holding the catheter tubing while transferring. Staff E and Staff F removed their gloves and exited the resident's room without completing hand hygiene. No EBP signage on resident's door and no PPE supplies available at doorway. Interview on 10/14/24 at 2:09 PM, a resident's wife stated she visited daily. The wife stated the staff always wear gloves, but do not wear a gown, when providing care for her husband who had a tracheostomy (surgical opening in neck) and gastrostomy tube (surgical opening into stomach to provide nutrition). Observation and interview on 10/14/24 at 3:04 PM, no EBP signs on ant residents' doors in the 200 hall. Staff J, CNA stated did have EBP signs on the residents' doors back in July and August but have not had for a while. Staff J stated his understanding of EBP was to wear a gown and gloves with cares with residents with wounds or lots of tubes and he stated staff do not to that consistently. Staff J confirmed there were no EBP signs on the residents' doors in the 200 hall. Staff J stated PPE supplies are available at the nurse's station and not outside doors or inside rooms. Observation on 10/15/24 at 10:AM, EBP signs on 9 residents' doors in the 200 hall. Facility policy for Standard and Transmission-Based Precautions revised 3/2024 directed EBP used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use include: dressing, transferring, providing hygiene, device care (indwelling catheters, feeding tube, tracheostomy). 46513 2. The Quarterly MDS dated [DATE] for Resident #52 documented diagnoses including, wound infection, pneumonia, schizophrenia and bipolar disorder. Skin conditions included surgical wound and open lesions. Resident #52 required surgical wound care, application of ointments and medications. The Care Plan focus dated 9/30/24 indicated resident had infection to the right knee that required intravenous antibiotics. Also indicated impairment to skin integrity on left ankle and directed to maintain standard precautions when providing resident care. The Treatment Administration Record, October 2024 for Resident #52 directed treatments as follows: a. cleanse right knee with normal saline and cover with (absorbent dressing to treat large wounds, or wounds that require a lot of absorption) ABD pad secure with any tape of choices, one time a day for surgical area b. Cleanse wounds on the left lateral leg with normal saline and gauze, cover wound bed with triad then cover with 4 inch x 4 inch Mepilex border (dressing). Perform wound cares every other day and as needed for saturation of dressing. in the morning, Tuesday, Thursday, Saturday. During an observation on 10/14/24 at 8:27 AM, Registered Nurse (RN) Staff #B entered resident #52's room. Staff B set up supplies needed for dressing change on a barrier, gowned and gloved appropriately for the procedure. Staff B removed the right knee dressing, cleansed the wound and covered with a dressing. Staff B took off the gloves and put on new gloves, did not sanitize hands after removing gloves and proceeded on to complete the left leg wound care. In an interview on 10/16/24 at 8:51 AM followed dressing change, RN Staff B acknowledged he did not complete hand hygiene after removing gloves and putting on new gloves as continued on for wound care to resident's other leg. On 10/16/24 at 5:30 PM the Director of Nursing (DON) acknowledged hand hygiene should be performed after removing gloves and new gloves for infection control. DON also, acknowledged Enhanced Barrier Precautions (EBP) needed improvements for compliance, had struggled with EBP process since this is resident's home and felt EBP conflicted with resident dignity by wearing gowns for some procedures. In an interview with 10/16/24 02:00 PM with Registered nurse, Staff K, acknowledge EBP signs were posted on resident doors earlier this week and reported work needed to be done to ensure compliance. Staff K reported not receiving education about the EBP and would look into this. 50500 3. The Admission Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #49 could not complete the Brief Interview for Mental Status. Diagnoses on the MDS included: renal insufficiency/renal failure/or end stage renal disease, neurogenic bladder, Multidrug-Resistant Organism (MDRO), diabetes, aphasia, stroke, hemiplegia/hemiparesis, and respiratory failure. The MDS revealed the presence of a feeding tube and receiving tracheostomy care. The Care Plan initiated on 6/24/24 revealed Resident #49 with self-care performance deficit due to impaired mobility. The Care Plan noted the need for a tracheostomy related to impaired breathing mechanics. A jejunostomy tube present for daily tube feedings due to dysphagia. A gastric tube present for drainage with the drainage bag emptied daily. During observation on 10/16/24 at 9:00 AM, Staff E, Certified Nursing Assistant, and Staff H, Registered Nurse, completed hand hygiene & donned a pair of gloves upon room entry. Both staff members completed pericares with hand hygiene and glove changes completed throughout. Once pericares were completed, Staff H washed hands and initiated tracheostomy cares. All Supplies laid out on a bedside table with a barrier. A new pair of gloves obtained from the tracheostomy suction kit. Suctioning completed. Staff H transitioned to changing out the tracheostomy annual. Hand hygiene completed with a new pair of gloves obtained from the cannula kit. The cannula changed out with Staff H completing hand hygiene and glove change afterwards. Staff H did not wear a gown during tracheostomy cares. An enhanced barrier protection sign present on the door with supplies available in the hallway. 4. The Care Plan initiated on 10/3/24 revealed Resident #219 admitted to the facility with two stage three pressure Injuries to bilateral hips requiring daily dressing changes. The Care Plan documented that Resident #219 had and infection to the buttocks that required antibiotic therapy. During wound care observation on 10/15/24 at 3:25 PM, Staff H, Registered Nurse completed hand hygiene and donned a pair of gloves upon room entry. Wound supplies laid out on bedside table with a barrier. Staff H explained Resident #219 had a shower earlier where the left hip wound dressing was removed. Wound cleansed with gauze pre-soaked with normal saline and then pat dry. Staff H completed hand hygiene and changed gloves. Triad paste and dressing applied. Staff H completed hand hygiene and changed gloves to initiate wound cares to the right hip. After the old dressing removed, hand hygiene completed and gloves changed. Wound cleansed with gauze pre-soaked with normal saline and then pat dry. Staff H completed hand hygiene and changed gloves. Triad paste and dressing applied. Hand hygiene complete after all cares were finished. Staff H did not wear a gown during wound cares. An enhanced barrier protection sign present on the door with supplies available in the hallway.

Based on observation, staff interview and policy review, the facility failed to ensure dignity was provided, resident pulled to shower room backwards down the hall covered with only a blanket for 1 of 3 residents reviewed for dignity (Resident #51). The facility reported a census of 66 residents. Findings include: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. The MDS further documented the resident had diagnoses included traumatic brain injury, schizophrenia and bilateral lower leg amputation. The resident required substantial/maximal assistance with bathing. The Care Plan dated initiated 2/21/24 revealed a focus area for Resident #51 Activity of Daily Living (ADL) self-care performance deficits related to traumatic brain injury and double below knee amputation. Interventions included substantial/maximum assistance with bathing/showering 2 times a week and as necessary, dependent on staff to dress lower body. In an observation on 10/14/24 at 12:21 PM Certified Nursing Aide (CNA) Staff A pulled resident in a wheeled shower chair through the hall while resident sat with back to staff A. Resident observed covered with a blanket, head uncovered, lower legs partially covered displayed both legs were amputated. In an Interview on 10/16/24 at 5:30 PM The Director of Nurses (DON) acknowledged concerns regarding Resident #51 dignity, relayed ongoing work is in process to ensure resident dignity is maintained. Facility policy titled Dignity and Privacy Revised May 2007 documented all residents be treated with dignity, respect and privacy. Residents shall be examined and treated in a manner that maintains the privacy of their bodies.

Based on clinical record review, observations, staff interview, and policy review, the facility failed to revise and update a comprehensive person-centered care plan for 2 of 21 residents reviewed (Residents #27 and #61). The facility reported a census of 66 residents. Findings include: 1. The Minimal Data Set (MDS) assessment dated [DATE] recorded Resident #27 had diagnoses including cancer, anemia, coronary artery disease, hypertension, renal insufficiency, obstructive uropathy, history of urinary tract infections, and diabetes. Other diagnoses verified by the primary care provider include chronic osteomyelitis (unspecified site), difficulty walking (not elsewhere classified), type 2 diabetes with diabetic polyneuropathy, and acquired absence of left leg below the knee amputation (BKA). The MDS documented Resident #27 does not have any type of a urinary catheter. Resident #27's Care Plan, with target completion date of 11/1/24, revealed inconsistent amputation sites and presence of a urinary catheter with the following Focus area statements: a. Activities of Daily Living (ADL) self-care performance deficit related to recent myocardial infarction, left BKA, adult failure to thrive b. Has a risk for urinary retention related to benign prostatic hyperplasia (BPH) with obstruction. I know have a Foley catheter c. Has indwelling catheter related to BPH d. At risk for falls related to confusion and recent amputation of right foot e. Potential fluid deficit related to history of infection to amputated left BKA f. Has acute/chronic pain related to right foot amputation The Change in Condition progress notes completed by nursing staff revealed the following: On 7/16/2024 at 5:39 PM, Symptoms or signs noted of Condition change: Other change in condition Blood in urine. foley catheter d/c. Voiding trial. Notifications: Reported to primary care clinician: Date and time of clinician notification: 07/16/2024 3:00 PM On 7/16/24 at 5:48 PM, Blood in urine. Foley d/c. Voiding trial initiated. Current Conditions: Resident noted with blood in his urine and also blood from his penis. Resident denials pain/discomfort. Respiration even, unlabored. No s/s of acute distress noted. VSS. Nurse Practitioner on unit and she made aware. Order received for labs. BMP, CBC, UA/C&S. CBC and BMP labs obtained. Pending results. Order also received to keep foley catheter out after it dislodge. Check VS every shift. Voiding trial initiated. Resident voids large amount of urine mixes with blood. Care plan ongoing. On 7/17/24 at 8:15 AM, Change in Condition: Symptoms or signs noted of Condition change: Falls Other change in condition Ok to send to the hospital to eval/treat d/t hematuria, lethargic and generalized weakness. Notifications: Reported to primary care clinician. On 10/14/24 at 10:00 AM. Resident #27 observed sitting at the edge of his bed wearing a short-sleeved shirt and an incontinent brief (no shorts or pants). No urinary catheter visualized. On 10/16/24 at 11:25 AM. Resident #27 verbalized and confirmed an amputation to his left leg due to an infection. The resident's right foot visualized and did not show signs of an amputation. No urinary catheter tubing or bag visualized. During an interview on 10/17/24 at 8:15 AM, Staff H, Registered Nurse, confirmed Resident #27 returned without a urinary catheter when hospitalized in July. Resident #27 remains without urinary catheter. 2. The Quarterly MDS assessment dated [DATE] revealed the Brief Interview for Mental Status could not be completed on Resident #61. Diagnoses on the MDS included stroke, aphasia, hemiplegia or hemiparesis, depression, and dysphagia. The MDS indicated Resident #61 experienced one fall since admission or prior assessment. The MDS indicated the use of an antidepressant. Resident #61's Care Plan, with target completion date of 9/26/24, indicated a fall with an intervention to utilize a fall mat (date initiated 7/18/24). Room observations completed on 10/15/24, 10/16/24, and 10/17/24. Resident #61 found sleeping during each visit with no fall mat present visualized next to the bed. During an interview on 10/17/24 at 8:15 AM, Staff H voiced Resident #61 did not have any specific fall preventions in place. Staff H denied current use of or need for a fall mat. Staff H explained Resident #61 brought out to the nurse's station after meals and encouraged to remain upright for 30 minutes. This additional oversight indicated due to history of Resident #61 scooting himself down to laying position. Staff H also explained his room door is kept open most of the time for increased resident visualization. The Care Plan failed to indicate the above fall interventions and contained an intervention not being utilized. The Order summary Report documented Sertraline HCl 100 milligrams by mouth in the morning for depression with the start date of 7/30/24. Clinical record review indicated Resident #61 receiving counseling services thru Flowstate Health for treatment of his depression. The Social Services Summary progress note from 9/27/24 at 11:28 AM states, [NAME] is a resident at a Long Term Care Facility (LTC) which remains appropriate for his LOC needs as he is dependent for most ADLs. He is cognitively impaired and has some signs and moderate symptoms of depression. BIMS 9 PHQ 15. Agreeable to continue individual therapy sessions. Family would like to see him move to a facility closer to their home, but he has not been accepted elsewhere. The clinic record showed scanned counseling session notes from the Flowstate Health therapist During an interview on 10/17/24 at 8:50 AM, Staff L, Social Services, confirmed Resident #61 received counseling. Services began 6/7/24 with Flowstate Health. Staff L indicated social services personnel would update resident care plans to reflect mental health services. During an interview on 10/16/24 at 3:30 PM, the Director of Nursing (DON) explained unit managers were responsible for care plan updates up until August of this year. The DON or the MDS coordinator are primarily responsible to update care plan. The policy Care Planning, with a review date of November 2022, revealed the following: a. The comprehensive care plan will be developed by the Interdisciplinary Team (IDT) within seven days of the completion of the resident's MDS> and will include needs identified in the comprehensive assessment, any specialized services, resident goals/outcomes, and preferences for future discharge plans b. The comprehensive care plan will be reviewed and/or revised by the IDT after each assessment and updated as appropriate c. The care plan will be reviewed as needed for order changes or resident changes in condition and interventions will be implemented as appropriate.

Based on clinical record review and staff interviews the facility failed to obtain follow-up blood work in the timeframe ordered by the Primary Care Provider (PCP) laboratory (Resident #49) and the resident was eventually hospitalized with 1 of 3 residents reviewed. The facility reported a census of 66 residents. Findings include: 1. The Admission Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #49 could not complete the Brief Interview for Mental Status. Diagnoses on the MDS included: renal insufficiency/renal failure/or end stage renal disease, diabetes, aphasia, stroke, hemiplegia/hemiparesis, and respiratory failure. The MDS revealed the presence of a feeding tube and the resident received tracheostomy care. Laboratory blood work obtained on 8/6/24, revealed a low potassium level of 3.1 mEq/L (reference range 3.4-5.0mEq/L) and a sodium level of 142 (refence range of 135-15mEq/L). On 8/8/24, the PCP ordered a potassium supplement and to recheck labs in one week (8/13/24). The order was noted by the facility's registered nurse on 8/8/24 and placed on the laboratory treatment administration sheet for 8/15/24. The clinical record revealed the follow-up blood draw was not completed until 8/20/24, five days after it was initially scheduled. There is no indication in the clinical record that staff notified the PCP of the missed and delayed lab work. On 8/22/24, the PCP notified of results which included a potassium level of 3.8mEq/L (within acceptable parameter) and an elevated sodium level of 154mEq/L. Orders to increase free water flushes and to recheck labs next week noted by the facility's registered nurse on 8/22/24. The Progress Note dated 8/27/24 11:43 AM documented a critical sodium 161mEq/L with Resident #49 tired and lethargic. Per orders from the PCP, Resident #49 transported to the emergency room and was subsequently admitted for hypernatremia (elevated sodium level). During an interview on 10/17/24 at 8:15 AM, Staff H, Registered Nurse explained routine, non-emergent blood work completed on Tuesdays. Those labs which are considered emergent are obtained per timeframe ordered by the PCP. Facility staff will contact the PCP if labs were not obtained, as ordered, for any reason. During an interview on 10/17/24 at 12:30 PM, the Director of Nursing (DON), voiced the expectation of staff obtaining Resident #49's blood work on 8/15/24, as ordered by the PCP. The DON acknowledged lab work was missed and lacked documentation which indicated the PCP was notified. The DON explained labs were obtained as soon as the oversight noticed, which was on 8/20/24. During an interview on 10/17/24 at 1:55 PM, Staff I, Advanced Registered Nurse Practitioner, unable to recall if the facility staff notified of the missed lab work from 8/15/24. Staff I unable to determine if the delay in obtaining the lab work on 8/15/24 would have prevented the hospitalization for hypernatremia.

Based on resident interview, staff interview, clinical record review and facility policy the facility failed to ensure specialist referral for 1 of 3 residents reviewed for referrals. Resident #38 complained of worsening vision. The facility reported a census of 66 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognition. The MDS included resident diagnoses, heart and respiratory disease, non-Alzheimer's dementia, anxiety, depression, post-traumatic stress and depression. The Care Plan dated 4/2/22 identified Resident #38 medications included the following types psychoactive drugs, antidepressants, antipsychotics and antianxiety medications and directed to observe for side effects which included blurred vision. A Progress Note dated 6/27/23 from the Nurse Practitioner, Staff C documented, detailed exam included for vision, seen today as a new patient, Resident #38 has blurry vision in his left eye that isn't new onset. A Progress note dated 11/2/2023 revealed Resident #38 reported that he has a hard time seeing out of his left eye and that its been getting worse over the last month or so, this nurse spoke with resident and social services and an appointment will be made for the optometrist, reported Nurse Practitioner, Staff C notified as well. In an interview on 10/15/24 08:59 AM Resident #38 relayed needs to see an eye doctor, could not see out of left eye, had told staff and continued to worsen since February 2024. In an interview on 10/16/24 at 5:17 PM Director of Nurses, DON relayed was not aware of Resident #38 had eye trouble, would check into further. In an interview on 10/17/24 09:16 AM Social Services, Staff B relayed several options for vision care nearby without regard to funding source. Relayed was not aware until this week that resident expressed change in vision, reported Resident #38 now has an appointment for tomorrow. In an Interview on 10/17/24 at 1:39 PM with the DON reported the expectation if a resident complained of vision changes, the resident would be referred to the optometrist. In a telephone interview on 10/17/24 at 01:15 PM Nurse Practitioner Staff C relayed did not recall resident complaining of blurred vision and If a resident complained would write an order, patient needs to be seen by an optometrist, also would alert the facility nurses. Relayed is no longer contracted to work at this facility, cannot access notes and could not recall Resident #38 complaining of any vision complains. Discussed note in resident electronic recorded by this NP dated 6/27/23 documented, Resident #38 has blurry vision in left eye that isn't new onset, Staff C relayed had just begun working at the facility at that time likely one of the first notes and could not recall. The facility policy titled, Procedure Referrals dated May 2022 documented, If the facility does not employ a qualified professional to furnish a specific service ordered by the physician, the facility will make necessary arrangements for services to be furnished to the resident by a person or agency outside the facility.

Based on observation, clinical record review, and staff interview the facility failed to ensure an emergency tracheostomy kit was at the resident's bedside for 1 of 3 residents reviewed (Resident #57). The facility reported a census of 66 residents. Findings include: The Annual Minimum Data Set (MDS) for Resident #57, dated 7/19/24, included diagnoses of anoxic brain damage (due lack of oxygen) and respiratory failure. The MDS documented resident was totally dependent on staff for all cares, had a tracheostomy (surgical opening in neck to provide for obstruction of breathing) and required oxygen. Observation on 10/14/24 at 11:54 AM, resident in room reclined in a wheelchair with a tracheostomy, with an oxygen (O2) mask over the tracheostomy, and O2 at 4.5 liters. No emergency tracheostomy kit available at the resident's bedside. Resident's Care Plan initiated 6/30/23, documented resident had a tracheostomy related to impaired breathing mechanics and intervention to keep a tracheostomy tube and obturator (medical device to hold tracheostomy tube in place) at bedside. Interview on 10/15/24 at 1:50 PM, Staff D Registered Nurse confirmed she was unable to find an emergency tracheostomy kit in the resident's room. Interview on 10/15/24 at 3:02 PM, the Director of Nursing confirmed no emergency tracheostomy kit in the resident's room and stated her expectation of an emergency tracheostomy kit should be at the bedside for any resident with a tracheostomy.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure 1 of 1 residents reviewed for vehicle safety(Resident #8) was secured in a van during transport, causing the resident to fall out of her seat. The facility reported a census of 65 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 10/11/23, listed diagnoses which included diabetes, non-Alzheimer's dementia, and anxiety disorder and listed her Brief Interview for Mental Status(BIMS)score as 15 out of 15 indicating intact cognition. The facility policy Fleet Safety Program, revised 4/14/21, stated the driver and all occupants were required to wear safety belts at all times and the driver was responsible for ensuring all passengers were properly secured in the vehicle at all times. A 12/9/23 untitled incident report stated the resident was transported and was not properly fastened in the seat belt. The driver attempted to leave the parking lot and the resident's flew forward and landed on her stomach on the front of the vehicle. The resident was not properly fastened in the car seat which caused her to fall forward when the vehicle started moving. The resident was sore all over her body but had no visible bruising and could move all extremities without difficulty. A 12/9/23 11:30 a.m. Nursing Note stated the resident transferred to the ER due to fall. A 12/9/23 3:06 p.m. Nursing Note stated the resident returned to the facility and had no pain or discomfort at the time. A 12/11/23 provider Encounter Note stated the resident hit the right side of her head when she flew between the driver and passenger seat during a van trip. The resident went to the ER for evaluation and stated her head still hurt some, and her chronic shoulder and knee pains were worse. A 12/11/23 Nursing Note stated the resident's was sore but her pain medications helped. On 6/6/24 at 1:40 p.m., the Director of Nursing(DON) stated that residents should be strapped into vehicles securely. She stated the resident did not sustain a fracture but was assessed at the hospital.

Based on observations, clinical record and policy review, and staff and resident interviews, the facility failed to provide adequate nursing supervision and assistance devices to mitigate risk for elopement for 2 of 9 residents reviewed (Residents #32 and #23). Elopement is defined as a resident leaving the facility without staff knowledge or permission. The facility door alarm system only sounded on the first floor where there were times when there were no staff present on that floor to monitor the alarm. On other floors, a light displayed on a screen at the nurse's station that also showed which residents had pressed their call light for assistance. However, there was no sound to alert staff that the door alarm had been activated on the first floor. 1. On 8/1/22 at approximately 6:50 AM, a cognitively impaired resident (Resident #32) exited the building (eloped) via the west door and later at approximately 7:00 AM. Staff were alerted by another resident that saw Resident #32 leaving the building. When staff investigated, they found Resident #32 outside on the southeast corner of the building by the road. 2. Resident #23, who prior to admission had a history of leaving a homeless shelter, getting intoxicated, and forgetting to return to the shelter, was admitted to the facility on [DATE], after being declared mentally incompetent by a court. The facility determined the resident was not at risk for elopement and took no action to supervise the resident. On 02/04/2022, the day after admission, at approximately 1:30 to 1:45 PM, Resident #23 left the facility during a resident smoke break. Staff saw the resident go out the door, but believed the resident was a visitor. The facility did not identify Resident #23 was missing until 3:30 PM, approximately two hours later. Resident #23 was located at a local hospital at 4:00 PM and was transported back to the facility with no injuries. This situation was identified as an Immediate Jeopardy to resident health and safety. The facility reported a census of 72 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #32 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired decision making and had wandering behavior presence of 1 to 3 days during the look back period. The MDS reported him to be independent with activities of daily living and needed set up only for eating, dressing and personal hygiene. The MDS reported diagnoses of hypertension, Alzheimer's disease, non-Alzheimer's Dementia, unsteadiness on feet and generalized muscle weakness and he took an anticoagulant, diuretic and opioid 7 out of 7 days during the look back period. Resident #32's Care Plan dated 5/18/18 included the risk for impaired cognitive function related to dementia and Alzheimer's disease. The care plan included interventions as follows: a. Communicate with family/caregivers regarding my capabilities and needs. b. Engage me in simple, structured activities that avoid overly demanding tasks. c. Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. d. Needs supervision/assistance with all decision making. e. Provide me with a program of activities that accommodates abilities. The Care Plan dated 5/18/18 also included He is at risk for an ADL Self Care Performance deficit related to dementia. He wanders around and ask lots of questions due to diagnosis of dementia and included interventions as follows: a. Independent with transferring without the use of an assistive device, updated 3/5/20. b. Elopement risk related to Impaired safety awareness, diagnosis of dementia, updated 8/13/19. c. On 8/1/22 staff trained on where to find high risk resident binder at each nurse's station, staff educated to monitor call light board for elopement notification, updated 8/15/22. d. If I am wandering, please document my behavior and attempted diversional interventions, initiated 8/13/22. e. If wandering reoccurs, identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, initiated 8/13/19. f. Monitor Wander Guard placement on left wrist, initiated 8/3/22. The Elopement Policy and Assessment revised on 2/2022 included the following: It is the policy of this facility to provide a safe environment for all residents. The facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Wandering is defined as movement about the area without a fixed goal, and elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of staff. Assessment and Identification of Wandering Residents a. The facility will attempt to obtain history of behaviors, including wandering prior to admission This can be accomplished during the pre- admission inquiry from the family, hospital records, or physician's history. b. Upon admission an elopement evaluation will be completed. Resident identified to be at risk for elopement will have and individualized care plan and intervention implemented. c. Change in environment can stimulate wandering behavior in resident with no prior history. Observed behaviors will be documented in the medical record and a new elopement evaluation will be completed. d. Each resident will be reassessed quarterly and after a significant change in condition, the care plan modified as necessary. Residents Identified at Risk for Elopement Residents whose assessment identified wandering behavior shall also be considered at risk for elopement. If a resident is identified at risk for elopement. If a resident is identified at risk for elopement, the following steps will be taken and or verified that completed by the individual completing the assessment: a. An alarm bracelet may be placed on the resident to audible alert staff for attempts by the resident to exit. In the facilities with this capability. b. The resident's care plan shall address behaviors using resident specific goals and /or approaches as assessed by the interdisciplinary team. c. A current picture of the resident will be maintained in the facility. d. Facility staff will insure that all exit alarms are responded to immediately. Elopement Risk Protocol/ Known Resident Eloper Residents with an elopement incident form the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement. These residents will have the following precautionary measures implemented to prevent repeat incidents of elopement. a. Resident will wear an alarm bracelet (in all facilities with this monitoring capability) to alert staff if he/she is trying to leave the facility. The bracelet will be checked daily to assure that it is functional. And checks will be logged. b. Staff will encourage activities which the resident enjoys in order to occupy the resident; c. An Elopement book identifying risk for elopement will be placed at the nurse's stations so that staff is aware of residents to be closely monitored and will be available for law enforcement in the event of an elopement. d. In the unlikely event the residents missing from the facility, the elopement policy will be initiate. When a Door Alarm Sounds When any door alarm sounds the facility staff shall: a. Check the alarm panel to determine which door has been opened. DO NOT ASSUME someone else has already done this. b. Check that exit floor for any exiting resident by means of a visual check. c. Visual check means observing the area around the exit, and may require leaving the building. d. If a resident discovered outside the facility inappropriately, staff will assist him/her back into the facility. e. Reset the door alarm after it is determined by visual check that no residents has exited the facility inappropriately, or is returned to the facility. f. If for any reason door alarms are turned off, the staff will continually visually monitor the door/doors. g. If an alarm is discovered de-activated, staff will prefer an immediate head count to ensure all resident are accounted for. Elopement Policy When an alarm is activated, and it is determined a resident is missing, the following will occur: a. Call CODE PINK on intercom system. Alert the unit nurse and all shift personnel to search the facility. If staff cannot locate the resident, institute a grounds search. b. If the resident is still unaccounted for after a thorough search of the building and grounds, immediately notify the Administrator/Director of Nursing (DON), Family and or legal representative, Attending physician, police. c. A complete description of the resident will be given to police along with a current photo of the resident. When the resident is located, the following procedures will be followed: a. The charge nurse or designee will utilize the intercom system to call CODE PINK ALL CLEAR b. An assessment of the resident will be completed to determine if medical attention is required. c. After assessment is completed, the attending physician will be notified and results of assessment reported. d. The resident's family. Legal representative shall be notified of the resident's condition. The resident's condition will be monitored every shift for forty-eight (48) hours. A detailed incident report will be completed and submitted to Administration. The incident will be logged in the Elopement Incident Log. Incident for the month shall be reviewed at the monthly Safety Committee meeting and again at each quarter with the Quality Assurance Committee. The facility will notify the appropriate State Agency a. Any incident or accident which has, or likely to have a significant effect of the health, safety or welfare of a resident or residents. b. Any incident or incident requiring the services of a physician, hospital, police department fire department, coroner or other service provided on an emergency basis. Notification of the appropriate State Agency will be made: a. Within twenty-four (24) hours of the serious accident/incident. b. A narrative summary of each incident/accident will be forwarded to the appropriate State Agency within 5 days. The document tilled Elopement/Wandering Evaluation dated 4/20/22 included the following: a. Predisposing Diseases - Alzheimer's Disease. b. Ambulation - Ambulates independently or with supervision. c. Mental Status - Disoriented. d. History of elopement in last 6 months - no history. e. Resident makes statements about a desire to leave the facility, etc. - Yes. f. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? - Yes, wandering is aimless with the potential to go outside, active exit seeking behavior. g. Does the wandering significantly intrude on the privacy or activities of others? - Yes, wandering is aimless with potential to intrude on others, active exit seeking behavior that could intrude on others. h. How does the resident's wandering behavior compare to prior evaluation or 90 days if new admission? - Improved i. Score Ranges: Low Risk: 0-9 -- High Risk: 10-55, Score 11. Form completed by DON. Resident #32's Medication Review Report included the following: a. Check code alert monitoring system every shift for monitoring, with a start date of 7/13/22. b. Check code alert placement every shift for monitoring, with a start date of 7/13/22. c. Code alert expires 10/2024 change alert on or before date expiration date, with a date of 4/28/22. An untitled document provided by the facility of the screen alert on all floors for the date and time of Resident #32's elopement included the following: a. On 8/1/22 at 7:00 AM, the Emergency East Exit Door alarm sounded. Staff responded in 11 seconds. b. On 8/1/22 at 7:00 AM, an elopement was identified at the East Door when the Wanderguard alarm sounded. Staff responded in 4 minutes and 9 seconds after being paged again one time. c. On 8/1/22 at 6:50 AM, an elopement was identified at the West Door. Staff responded in 5 minutes and 42 seconds after being paged again one time. d. On 8/1/22 at 6:50 AM, an elopement was identified at the West Door when the Wanderguard alarm sounded. Staff responded in 14 minutes after being paged again four times. e. The document showed none of the alerts were acknowledged. According to the incident report dated 8/1/22 at 6:50 AM, Resident #32 seen leaving the building. The resident pushed the door until it opened and then exited on foot. The wander guard system alerted at the door and on the call light monitor. Staff activated Code Pink and the resident was found near the east door. Resident stated I was stuck outside. Resident #32's August Medication Administration Audit Report directed staff to: a. Check code alert for proper functions every shift, Schedule dated 8/1/22 at 6:00 AM, Administration time 8/1/22 at 7:07 AM by Staff H, Certified Medication Aide (CMA). b. Check code alert placement every shift for monitoring, Schedule date 8/1/22 at 6:00 AM, Administration time 8/1/22 at 7:07 AM by Staff H, CMA. During an observation on 9/26/22 at 11:17 AM Resident #32 sat by the nurse's station on the 3rd Floor wearing a Wanderguard on his left wrist. At 11:48 AM, the resident walked from the Nurse's Station to his room without difficulty. Closer observation showed no staff around with an awareness of his whereabouts. During an observation on 9/27/22 at 1:25 PM Resident #32 entered the 3rd floor elevator wearing a Wanderguard on his wrist. The elevator dinged, the door opened, and the elevator did not move. He tried it again and the door shut, dinged, and immediately opened again. Resident #32 made several more attempts until staff approached, entered the elevator code, and rode the elevator down with him. Resident wanted to wait to go smoke and knew he needed a code to make the elevator descend. On 9/27/22 at 8:56 AM Staff H CMA stated he observed Resident #32 walking up and down the hallway in the morning of 8/1/22 around 6:45 AM after he came to work. He stated he checked the Wanderguard before the incident and it turned green to show it had worked. Staff H stated Resident could just go outside if he followed a resident that knew the code. Resident # 8 alerted Staff L housekeeper that a resident went outside. Staff L called up to the floor to let him know. On 9/27/22 at 9:12 AM Staff L, Housekeeper explained another resident alerted her that Resident #32 went outside, so she went to the door, looked, and did not see the resident. Staff L reported she walked around the building and found him on the west side of the building. Staff L continued that she called the floor with her cell phone, and just then 2 nurses arrived and assisted the resident back into the building. On 9/27/22 at 12:15 PM, the Administrator provided the work order for Alliance Monitoring Technologies. He reported when Resident #32 left, the screen on each floor showed the Wanderguard had been activated but did not audibly alarm. The facility placed the walkie talkies in a box at each of the nurse's station so alarms would sound at the nurse's station when it shows on the screen. Now it sounds both at the board and on the walkie, so that way they had a backup for the alarm. The Administrator and the DON added that the morning Resident #32 went outside it registered on the screen, but did not sound. They then provided the call light log to verify an alert showed on the screen. An interview on 9/27/22 at 1:18 PM with Staff B, Registered Nurse (RN) revealed she was on her way to work on the morning of 8/1/22 and recognized Resident #32 (outside). Staff B explained she turned onto the side street off Pennsylvania Ave and pulled her car to the side of the road and ran down the street to the resident. At that time, he did not resist going with her as she explained to him who she was and resident agreed to go with her. Staff B acknowledged Resident at the south east corner of the building heading to the street. Staff B further explained as the two of them walked around the building to the side door and a staff member came out the door since the facility called a (CODE PINK) alert that a resident out of the building. Resident went back into the building without incident. On 9/27/22 at 1:20 PM, Resident #8 (BIMS of 11) reported he lived in room 305, just down the hall from Resident #32's room (301). He stated Resident #32 he did not follow any one, he just walked out the door, just left. He added the alarm did not sound until Resident #32 went out the door. Resident #8 reported he then told a staff member what he had witnessed. On 9/28/22 at 3:26 PM, Staff H CMA explained the day that Resident #32 left out east door the box was not hooked up so is did not sound ([NAME] Notification) sounds off and the shows the location of the door. The paper goes off with the call lights and wander guard (all call) system. The system does go to all floors so that if call lights going off other floors could come and help out. The only place the alarms sound is at the nurse's station. The pager is in a locked plastic box. Staff H stated they use to have pagers but not used anymore. Observation at the same time 2 residents that smoke and wear wander guards were at the west elevator waiting to go smoke. Once they got on the elevator the all call symptom showed on the screen the west elevator for elopement and sounded an alarm. The alarm stopped when a Staff Member entered the elevator and entered the code. The elevator did not work until code entered. This system is new since Resident #32 eloped. An interview on 9/29/22 at 9:44 AM with Maintenance Supervisor stated the wander guard system not completely hooked up at the time Resident #32 eloped. He will provide the information to show the date they started hooking up the wander guard. He further explained on 8/1/22 the time Resident #32 eloped the door alarmed down on the first floor (no staff on the first floor). It only showed up on the screen with no alarm going off, it showed up on screen on all floors elopement for the west door. An interview on 9/29.22 at 3:40 PM per DON she went right away on 8/1/22 and bought clear plastic boxes to place pager in. The DON acknowledged they had problems with batteries for the [NAME] Notification system and believe someone unplugged the system to quiet it down. The DON explained if the battery is low it sounds off as low battery. The Administrator stated he did not know we needed to list it as a regular maintenance check item but it is now. DON stated she was not worried about the battery issue since they are checked now. The DON added that is why we put the clear boxes on the wall at each nurse's station as a backup in case the system did not sound when activated. The Administrator provided a work order dated 9/12/22 that verified the alarm system was complete and functioning. 2. A review of the facility's policy titled, Elopement-Policy and Assessment, revised February 2022 revealed, It is the policy of this facility to provide a safe environment for all residents. The facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Wandering is defined as movement about the area without a fixed goal, and elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff. A review of the facility's Wander System Monitoring Program policy/procedure dated February 2022 revealed, It is the policy of this facility that all new residents will be evaluated with initial assessment process as to whether he or she presents an elopement risk. Any residents previously identified as a wandering risk will be reassessed quarterly and with changes in behavior. All residents identified to be at risk for elopement will have a wander-monitoring bracelet. An elopement/wandering binder will be kept at each nurse's station identifying all residents currently using the wander monitoring system. The policy/procedure indicated 1. An Initial Wandering assessment will be completed on all new residents on admission. 3. One wander-monitoring bracelet will be placed on either the resident's wrist or approved alternate location, i.e., ankle or back of resident's wheelchair. A review of Resident #23's hospital Chief Complaint & History of Present Illness dated 02/02/2022, revealed the resident presented to the Emergency Department (ED) with a Department for Human Services (DHS) Social Worker. The resident had a history of [CONDITION(S)], was recently diagnosed with dementia, and presented to the ED for diarrhea. Resident #23 had been residing at a homeless shelter and had been leaving the shelter to buy alcohol, forgetting to return to the shelter, and passes out on snow. The DHS social worker reported the homeless shelter was unable to keep the resident safe. A court order was obtained declaring the resident was not competent to make decisions and DHS was seeking nursing home placement. A review of Resident #23's Admission Record revealed the facility admitted the resident on 02/03/2022 with diagnoses which included dementia, lack of coordination, and alcohol dependence. A review of Resident #23's Initial Admission Record, initiated on 02/03/2022 and completed on 02/04/2022, revealed the resident was admitted due to alcohol dependence, homelessness, and chronic pain. The resident was oriented to the facility. According to the Initial Admission Record the facility answered not applicable to a question about whether the resident was ambulatory or self-mobile in wheelchair. The record indicated if the facility answered yes, an elopement/wandering evaluation would trigger. Further review of the Initial Admission Record revealed the resident smoked, which indicated a smoking evaluation would be triggered. The resident was alert; oriented to time, place, person; and was able to follow simple commands. A review of an Elopement/Wandering Evaluation, dated 02/03/2022, for Resident #23 revealed even though the assessment was not triggered from the Initial Admission Record, the facility completed an evaluation. In addition, even though Resident #23 had a history of leaving the homeless shelter and forgetting to return, and had been declared incompetent to make decisions, the facility assessed the resident as low risk for elopement with a score of 8. The scoring was based on the following information: The resident had dementia, ambulated independently or with supervision, was disoriented, did not have an elopement history, made statements about a desire to leave the facility but had no history or current behaviors of wandering. A review of Resident #23's Smoking Evaluation, effective 02/03/2022 at 4:45 PM, revealed the resident had cognitive loss, smoked a pack of cigarettes a day during the morning, afternoon, evening, and at night. The evaluation indicated staff was unable to determine if the resident was able to light their own cigarette. According to the evaluation, the plan of care was not used to assure Resident #23 was safe while smoking; however, the resident needed staff supervision while smoking. A review of Resident #23's Care Plan, initiated on 02/03/2022, indicated the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to a diagnosis of dementia without behavioral disturbance and a diagnosis of [CONDITION(S)]. The care plan revealed the department of human services was supporting the resident due to cognitive impairments and homelessness. The care plan interventions included supervising/assisting the resident with all decision making. A review of Resident #23's Progress Notes dated 02/04/2022 at 3:35 PM revealed the resident was at the facility entrance door at approximately 1:30 PM to 1:45 PM when the resident smoking group was coming in from a supervised smoke break. An activity staff member was holding the door open for the resident smoking group to come inside when Resident #23 went out the door. At the time, the activity staff member was unsure but thought that Resident #23 was a visitor. At approximately 3:30 PM, therapy staff alerted the nurse that Resident #23 was not in his/her room and a building search was conducted. The note revealed Resident #23 could not be located inside the facility or on the facility grounds. Subsequently, police and local hospitals were contacted. Further review of the Progress Notes revealed the resident was located at approximately 4:00 PM at a hospital emergency department, which was a short walking distance from the facility. Hospital staff stated that they were unsure how long the resident had been in the waiting area of the hospital. The facility transported the resident back to the facility without incident. According to the Progress Notes, Resident #23 was wearing socks, shoes, a maroon-colored puffer winter jacket, a stocking hat with a baseball cap over it, and blue colored pants. The note indicated the temperature outside was 18 degrees. Further review of Progress Notes for Resident #23 dated 02/04/2022 at 4:45 PM, revealed the resident's temperature was 97 degrees Fahrenheit (average is 98.6 degrees Fahrenheit), blood pressure was 151/84 (normal is 90/60 to 140/80), pulse was 64 (normal is 60-100), and oxygen saturation was 99 percent (normal is 95-100). The resident was alert and oriented, denied pain/discomfort, and had no signs/symptoms of acute distress. According to Progress Notes dated 02/04/2022, at 7:37 PM, a wander guard bracelet was placed on Resident #23's right wrist upon return to the facility and the resident's care plan was updated. An interview with Resident #23 on 09/30/2022 at 10:05 AM, revealed the resident left the faciity on [DATE], went to a convenient store, and ended up at the hospital. Resident #23 stated he/she wanted to take a walk and then someone called the store to take the resident to the hospital. The resident stated someone took the resident to the hospital because the resident was wearing blue clothes, like the ones from the hospital. Resident #23 stated staff picked the resident up from the hospital in the van. Resident #23 stated he/she was gone from the facility for approximately one and one-half hours. The resident stated that was why they put this on me and pointed to a Wanderguard bracelet. Resident #23 stated the bracelet let staff know where the resident was located. During a phone interview on 10/03/2022 at 8:19 AM, Staff BB, the former Activity Director, stated Resident #23 was admitted to the facility on [DATE], and did not have a Wanderguard bracelet. She stated the hospital made it known the resident was at risk of wandering and the resident should have been wearing a Wanderguard bracelet. She stated the Director of Nursing (DON) employed at the time agreed that Resident #23 should have been wearing a Wanderguard bracelet. She stated the resident went out the door with other residents during the 3:30 PM smoke break. Staff BB stated she and the Activity Director thought Resident #23 was a visitor and did not know otherwise until staff told them after the resident eloped. Staff BB stated that at the time, there was no way to identify a resident and no way to identify whether the resident was at risk for elopement or required supervision with smoking. She stated once the facility identified the resident was missing, staff went to look for the resident. She said she left her telephone number with the hospital, who called within approximately 30 minutes and reported the resident had walked into the hospital. Staff BB stated she thought the resident got the two buildings confused. At the time, the resident was able to recall what happened and realized he/she should have told someone he/she was leaving. Staff BB stated the resident reported he/she went to a convenient store to purchase cigarettes. During a phone interview on 09/30/2022 at 11:36 AM, the Activity Director stated that on 02/04/2022 when Resident #23 left the facility, staff was letting residents in and out of the patio door for a smoke break. She stated it was a traffic jam at the door during smoke break times and Resident #23 slipped out the door. She stated she, Staff BB (the former Activity Director), and a former housekeeper were monitoring that day. She said there were a lot of residents in the area, and some were being pushed in and out and Resident #23 slipped by them. The Activity Director stated she did not know she had to keep an eye on the resident to make sure the resident was at the facility. She stated she spoke with Resident #23 after the incident, and the resident reported he/she did not know residents were supposed to ask staff to purchase cigarettes for them, and the resident went to the convenient store. The resident told staff that he/she could not remember which building to return to, so the resident went to the hospital. The Activity Director stated the hospital notified the facility that the resident was safe, and staff picked the resident up in the facility van. The Activity Director stated prior to Resident #23's elopement, the facility did not have elopement books in place. The Activity Director stated the residents the facility identified as high risk for elopement had Wanderguard bracelets and the doors alarmed when the resident got near them. During a phone interview on 10/01/2022 at 11:26 AM, Corporate Nurse #1 stated she was not in the facility when Resident #23 was admitted nor when the resident eloped. She said she received a call from the former MDS coordinator/DON that the resident left the building. She stated the activity staff thought the resident was a visitor and let the resident out the door. She stated staff searched the building and grounds and contacted the police. Corporate Nurse #1 stated the resident was located at the hospital. She stated she spoke with Resident #23, who told her he/she went to the hospital to get warm when homeless. The resident stated he/she just needed cigarettes and would not go out again. During a phone interview on 10/03/2022 at 11:56 AM, Staff CC, the Medical Director, stated Resident #31 managed to get out of the facility without facility knowledge, and ended up at the hospital emergency department. He stated the facility reported the resident was admitted the day before. Staff CC stated he did not know how the resident got out of the facility. He stated it was possible the resident got out because staff thought the resident was a visitor. Staff CC stated staff should recognize a new resident. Staff CC did not think there was anything in place to ensure staff were familiar with new residents, which was a concern because some residents were admitted on night shift and the facility utilized agency staff who were not familiar with residents. He stated the facility had Wanderguard bracelets for those who needed them and was told residents were not able to move from floor to floor if they had a Wanderguard. Staff CC stated the facility needed to monitor residents and visitors to reduce the risk of harm. During a phone interview on 10/04/2022 at 12:12 PM, Staff GG, the former Administrator, stated she left early and was not at the facility when Resident #23 eloped. She stated the resident was newly admitted and staff had not seen the resident; subsequently, activity staff thought the resident was a visitor. She stated later the staff discovered Resident #23 was not a visitor. She stated a staff person notified her of the elopement. Staff GG stated she returned to the facility and drove around the area looking for the resident. She stated the activity staff were also looking for the resident. She stated the resident was at the hospital. The resident did not realize he/she could not leave to get cigarettes and when the re [TRUNCATED]

Based on record review, staff interviews and facility policy review, the facility failed to ensure staff maintained a safe and secure environment for 1 of 7 residents reviewed. Resident #30's care plan directed staff to transfer the resident with 2 staff and Hoyer lift. On 8/7/20 2 staff transferred the resident without a Hoyer lift or gait belt. When the resident bore weight on her only remaining leg, staff heard a crack and lowered the resident to the ground. The resident immediately complained of pain and x-rays showed a nondisplaced oblique fracture involving the distal right tibia. The facility identified a census of 72 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 with [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), weighed 250 pounds (#), required extensive assistance of two (2) staff with transfers, non-ambulatory and with no falls in the past 3 months. A Care Plan with a focus area dated 10/30/18 indicated the resident as at risk for falls related to left [MEDICAL CONDITION] with new prosthesis, obesity, potential side effects of medications received to manage multiple health conditions and the resident required assistance to complete activities of daily living (ADL's) due to decreased mobility following a left [MEDICAL CONDITION] with a new prosthesis, weakness and obesity. The approaches included the following: a. Transferred with the assistance of 2 staff members with an mechanical lift device. Date initiated 11/27/18 A Fall Risk Evaluation form dated 8/7/20 at 6:31 p.m. identified the resident at high risk for falls with [DIAGNOSES REDACTED]. Review of the facilities Progress Notes revealed staff documented the resident experienced no pain on the following dates and times: a. 8/7/20 at 1:47 p.m. b. 8/6/20 at 1:47 p.m. c. 8/5/20 at 1:47 p.m. d. 8/4/20 at 1:47 p.m. An Incident Report form dated 8/7/20 at 6:31 p.m. documented the following: A Certified Nursing Assistant (CNA) got this Registered Nurse (RN) and oncoming Licensed Practical Nurse (LPN) to assist the resident. Upon entrance to the room observation showed the resident leaned with her back against the bed with her right lower extremity (RLE) bent at the knee and resting below the knee amputated left lower extremity (LLE). The resident complained of pain to her ankle of the LLE. The resident's vital signs (VS) registered within normal limits (WNL), fall witnessed and assistance given by 2 CNA's. Staff heard a loud pop when the resident stood with the assistance of 2 staff and transferred from the wheel chair to bed. The resident then stated she had intense pain and could not complete the transfer process. Staff assisted the resident to the floor. No injury noted to the head. Resident safely assisted by four (4) staff into a mechanical lift pad then transferred via the mechanical lift device to bed. The resident yelled out when staff palpated her ankle/lower leg however she minimally wiggled her toes. The resident stated I heard a loud pop and fell . A typed statement from an unknown source documented the following information: On 8/7/20 report received that Resident #30 had an assisted fall. Two staff members transferred the resident from her bed to her wheel chair when they heard a pop and the resident sat straight down on the floor. Staff T, Certified Nursing Assistant (CNA) stated she and Staff E, CNA completed a 2 person transfer from the bed to the wheel chair positioned at a 90 degree angle. As the resident stood on her right leg they heard a pop so the resident had been unable to stand on her right leg and they lowered her to the floor. Staff E stayed with the resident and Staff T went and notified the RN and LPN who came on shift. After the nurse assessed the resident they transferred her per a mechanical lift device onto her bed. Staff E stated that she and Staff T, CNA completed a 2 person transfer from the bed to the wheel chair positioned right next to the bed. When the resident stood up she yelled out in pain and quit bearing weight at all to her leg. They lowered her straight down to the floor at that time and obtained nurse assistance. They used a mechanical lift device and transferred the resident to bed. Staff S, RN on duty and assessed the resident with complaints of RLE pain at about the ankle area after an assisted fall to the floor. Staff S noted she entered the room and observed the resident sitting on the floor with back leaning against the bed. The RLE appeared bent at the knee and resident below the amputated LLE. The resident c/o (complained of) pain to ankle of LLE. Resident VS (vital signs) WNL (within normal limits). Call placed to physician and updated the Nurse Practitioner (NP) the resident previously reported increased pain to the RLE and the 2 view x-ray completed on 8/2/20 with the following findings: Degraded by position and 2 views. Generalized soft tissue swelling. No gross fractures identified. Vascular calcifications. Short-term follow up 3 view radiographs may be helpful if symptoms persist. New order obtained for a 3 view right ankle x-ray at this time. Bio Tech X-ray notified and came that same night for an x-ray. On 8/31/20 at 4:35 p.m. Staff S identified herself as the charge nurse working on 8/7/20 when the resident fell . She stated Staff T came to her and told her the resident fell to the floor around 6 p.m. When Staff S walked into the room she observed the resident sitting on the floor complaining of right ankle pain. Staff S performed a full assessment of all extremities with no abnormalities or obvious fractures identified. The resident's vital signs (VS) registered as stable. Within the last couple of weeks the resident's transfer status changed from stand by assistance (SBA) to 2 staff assistance. The staff member could not recall if the staff used a walker with the transfer but she knew staff failed to utilize a gait belt device. On 8/31/20 at 4:54 p.m. Staff T stated the resident fell on [DATE] around suppertime. Staff T identified herself and Staff E as in a hurry because they had a staff called in that evening and they needed to get the resident up in her wheel chair for supper so they could get supper trays passed. Both of the staff members realized they both had regular sized gait belts and the resident required an extra large gait belt which was usually in the resident room however they could not find the device at that time. Since they were in a a hurry, Staff T tried to use her regular sized gait belt on the resident as she placed it under both of the residents arm pit areas but decided that was not safe either so they removed the gait belt and transferred the resident without a gait belt. Staff T stood on the resident's left side as Staff E stood on the residents right side and faced the resident. They stood her up at bed side and heard a loud crack as the resident leaned towards the right side due to her having been an [MEDICAL CONDITION] on the left leg. She then she fell towards Staff T so the staff lowered her to the floor. Staff T stayed with the resident as Staff E reported the incident to the nurse who assessed the resident. When Staff T spoke to the Director of Nursing (DON) the following day she identified the fall as totally her fault since they did not utilize a gait belt device during the transfer process. Staff T stated she knew after the fall the resident told people they used a gait belt with the transfer but Staff T told the resident they failed to use a gait belt a the time of the fall and the resident knew that. The staff member again confirmed she had been at fault. A Pain Management Review 8/7/20 at 6:31 p.m. indicated the resident received scheduled [MEDICATION NAME]. Despite receipt of the pain medication, the resident continued to have RLE pain. Treatments in place and ineffective so added [MEDICATION NAME] (non-steroidal anti-[MEDICAL CONDITION] drug) as needed (PRN). The form indicated the resident had pain rated at an 8, almost constant pain the past 5 days on her RLE described as burning, pressure and throbbing with her pain moderately managed the past 3 months. A 2 view Radiology Results Report form dated 8/2/20 at 4:53 p.m. documented a view as taken of the resident's right ankle due to extreme pain and difficulty with transfers. The findings/impression described generalized soft tissue swelling especially dorsally with no gross fractures identified, vascular calcifications and cortical thickening about the third metatarsal shaft consistent with a chronic process. A 3 view Radiology Results Report form dated 8/7/20 at 8:47 p.m. documented a view as taken of the resident's right ankle post fall and pain. The findings/impression described a non-displaced oblique fracture that involved the distal right tibia not visible on the prior study. No distal fibular fracture, normal joint alignment, joint spaces well maintained, no ankle joint effusion and prominent [MEDICAL CONDITION] observed in the soft tissues of the right leg and ankle. The facility reported the 8/7/20 completed X-ray result to the NP with new orders received by Staff KK, LPN for a no weight bearing (NWB) status to the RLE and follow up with Orthopedics. Orthopedics appointment scheduled for 8/12/20. On 9/2/20 at 11:38 a.m. the resident's NP stated, without review of the records she could not know if there had been another reason for the fall but stated she knew if the staff used the gait belt the fall could have been prevented. An Orthopedics Physician order [REDACTED]. On 9/2/20 at 9:30 a.m. Staff LL, Occupational Therapist (OT) confirmed prior to the resident's fracture she required staff assistance with transfers but self transferred at times. The OT confirmed they always recommend the use of a gait belt device with any residents who require staff assistance with transfers. On 9/2/20 at 10:22 a.m., Staff PP, certified nursing assistant (CNA) confirmed anytime a resident requires assistance staff is required to use a gait belt with transfers. On 9/2/20 at 10:32 a.m., Staff DD, CNA confirmed anytime a resident requires assistance with transfers that gait belts are required. On 9/2/20 at 10:47 a.m. ,Staff MM, CNA confirmed she observed staff transfer residents without using a gait belt. The staff member indicated she knew of facility policy for using gait belts and she would use a gait belt with any resident who requires the assistance of 1 or 2 staff. On 9/2/20 at 11:01 a.m., Staff NN, CNA confirmed anytime a resident requires assistance with transfers that gait belts are required. On 9/2/20 at 11:44 a.m., Staff OO, CNA confirmed she observed staff as they transferred residents without using a gait belt. The staff member confirmed gait belts are required with any resident who requires the assistance of 1 or 2 staff assistance. A Policy/Procedure - Nursing Clinical form for gait belt/transfers described the policy as follows: a. Provided safety for the unsteady and/or confused resident. b. Aided in the transfer of the dependent resident. c. Prevented injuries to employees and residents. d. Allowed the resident and aid to have felt more secure during a transfer.

Based on clinical record review, observation, and staff interviews, the facility failed to prevent the development of a stage III pressure ulcer for one of two residents reviewed (Resident #47). The facility did not demonstrate the development of the pressure sore was unaviodable due to failure to provide adequate pressure reduction after the resident was bedfast (MONTH) 2019 following a stroke. The facility reported a census of 64 residents. Findings include: The Significant Change Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. According to the MDS the resident scored a two out of fifteen on the Brief Interview for Mental Status (BIMS) indicating severe cognitive deficit. The MDS revealed the resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident had impairment on both sides for functional limitation in range of motion for both upper and lower extremities. According to the MDS the resident always incontinent of both bowel and bladder. The MDS indicated the resident had a feeding tube and required tube feeding. According to the MDS the resident was at risk for pressure ulcer/injuries. The Quarterly MDS dated [DATE], revealed [DIAGNOSES REDACTED]. According to the MDS the resident scored a zero out of fifteen on the BIMS indicating severe cognitive deficit. The MDS revealed the resident required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use. The MDS indicated the resident had impairment on both sides for functional limitation in range of motion for both upper and lower extremities. The MDS identified the resident as always incontinent of bowel and bladder. The MDS indicated the resident had a feeding tube and required tube feedings and at risk for pressure ulcer/injuries. The care plan dated 12/1/18 identified a focus area of actual impairment to skin integrity related to stage III pressure ulcer secondary to previous stroke with [MEDICAL CONDITION], recent hospitalization related to a [MEDICAL CONDITION] dysphagia and new [DEVICE] placement, decreased mobility, and new need for mechanical lift transfers. On 6/6/19 at 8 a.m., Staff B verified the date of initiation should be 6/4/19 not 12/1/18. Interventions include cleanse stage III pressure ulcer to coccyx with cleanser of choice, apply collagen pad (moisten with saline) and cover with silicone foam boarder dressing initiated 6/4/19. The wound care specialist was consulted to assess and follow wound, monitor/document location, size and treatment of [REDACTED]. Reposition resident frequently and at times the resident is resistant to being re-positioned per recommendations and continue to encourage him to reposition. The resident has an air mattress to protect his skin while in bed with a date initiated of 12/1/18 but Staff B verified the air mattress was placed on 5/13/19 after the wound developed. The care plan dated 12/9/18 revealed the resident has bowel and bladder incontinence related to impaired mobility, recent significant stroke resulting in communication deficit and decline in health status. Observation on 6/4/19 at 1:54 p.m., Staff A, Licensed Practical Nurse (LPN) entered Resident #47's room. Supplies noted on the bedside table. A Certified Nurses Aid (CNA) assisted Staff A with turning the resident to perform wound care. An area was noted on the resident's coccyx approximately a quarter in size with depth to the wound and beefy red wound bed with surrounding skin intact. A collagen dressing was applied to the wound and a duoderm dressing was placed over the collagen dressing. The Braden Score for Predicting Pressure Sore Risk dated 4/3/19 revealed a score of nine indicating very high risk for developing a pressure ulcer. The Braden Score for Predicting Pressure Sore Risk dated 5/2/19, revealed a score of 10 indicating high risk for developing a pressure ulcer. A Skin Evaluation - PRN (as needed)/ Weekly assessment dated [DATE] revealed no skin concerns at this time, skin clean, dry and intact. A Skin Evaluation - PRN/ Weekly assessment dated [DATE], revealed Buttock open sore 2.5 centimeters (cm) x 2.3 cm. The facility skin nurse notified, changed resident position to sides and treatment in place. Will continue to monitor and reposition every two hours. A Skin Evaluation- PRN/Weekly assessment dated [DATE], revealed buttock open sore 2 x 2.3 cm. The resident positioned to sides, treatment in place and continuing to monitor and reposition every two hours. A Skin Evaluation- PRN/Weekly assessment dated [DATE], revealed coccyx pressure sore has been treated. The resident repositioned and peri-care provided every two hours. No other concerns at this time. A Skin Evaluation- PRN/Weekly assessment dated [DATE], revealed coccyx pressure sore has a new treatment in place. Apply one packet of collagen powder and mix with A&D ointment place in wound twice a day. No other concerns. A Skin Pressure Ulcer Weekly assessment dated [DATE], revealed a Stage III pressure ulcer to the Coccyx measuring 3.7 x 2.4 x 0.3 cm. with serosanguinous exudate noted with moderate amounts, wound bed with granulation tissue and defined edges. Additional documentation revealed wound presents as pressure on 6/4/19. New orders were obtained, nutrition managed by enteral feedings and reviewed by the facility dietitian. The wound specialist consulted for the morning, and care plan reviewed and updated. The Treatment Administration Record (TAR) for 5/1-5/31/19 revealed [MEDICATION NAME] Ointment 0.44-20.6% applied to coccyx topically every day and night shift for ulcer to coccyx. Mix with stoma powder to a peanut butter consistency with a order date of 5/20/19 and discontinue date of 5/30/19. [MEDICATION NAME] powder ordered on [DATE] applied to coccyx topically every morning and at bedtime for wound management and to mix one packet of collagen powder with A&D ointment. Order was discontinued on 6/3/19. The TAR indicated a pressure redistribution mattress to bed every shift with an order date of 4/2/19. The TAR indicated the residents head of bed (HOB) to be elevated 30-40 degrees at all times every shift. The TAR for 6/1-6/30/19, revealed Collagen Matrix-Silver Sheet 4 applied to coccyx topically every day for for wound management and cover wound with a border comfort dressing after cleansing and apply collagen pad moistened with saline every day shift for wound management with an order date of 6/4/19. The TAR indicated the resident head of bed (HOB) to be elevated 30-40 degrees at all times every shift. A Wound Treatment Plan dated 6/5/19 for the Wound Specialist, revealed she assessed the resident for an area of concern to the coccyx. Staff reported it initially appeared like excoriation and initiated A&D ointment mixed with collagen powder. The wound did not improve and a collagen pad covered with super absorbent dressing was initiated yesterday and the etiology was changed to a pressure ulcer. The resident recently suffered [MEDICAL CONDITION] did not get out of bed. He is dependent on [DEVICE] for nutrition so the HOB is elevated at 45 degrees at all times. He does report wound is tender at all times. The physical examination revealed a stage III pressure ulcer to the coccyx measuring 3.2 x 1.1 x 0.1 cm. In an interview on 6/5/19 at 10:44 a.m., Staff A, LPN stated the resident did not respond to staff when he first admitted back to the facility in (MONTH) 2019 following a stroke. She stated he does not get out of bed now and hasn't since readmission. Staff A verified the resident is incontinent of urine and feces and identifiedthe area to his coccyx as open for a couple weeks. In an interview on 6/5/19 at 12:45 p.m., Staff B, Registered Nurse (RN) and facilities wound nurse stated she was aware of the resident's coccyx sore around the 20th of (MONTH) and recalled the area being reddened and related to moisture. She identified the resident as not very mobile and staff encourages the resident to turn/reposition. Staff B verified the resident as bed bound since readmit in (MONTH) when he suffered a stroke. Floor staff are expected to do weekly skin notes. Staff B stated she assessed the area on 6/4/19 and at that time updated the care plan and consulted the wound specialist who rounds at the facility on Wednesdays. She stated when the wound specialist came to assess the resident the area was confirmed to be a facility acquired stage III pressure ulcer. She verified the assessment documented on 5/11/19 would indicate an open area and would expect staff to inform her before 6/4/19. In an interview on 6/6/19 at 09:24 a.m., the Director of Nursing (DON) stated staff do an admit or readmit assessment that includes skin integrity and a Braden score and based off the assessment staff determined what interventions to put in place. She stated all mattresses are pressure relieving mattresses and the protocol for an air mattress is once a stage II pressure ulcer is identified they automatically add an air mattress. She stated it would have been beneficial for an air mattress to have been in place prior to the development of the stage III pressure ulcer. She identified the resident as more alert and verbal the last two weeks and can be resistive to turning but would expect staff to reposition and turn the resident every two hours. In an interview on 6/6/19 at 8:00 a.m., Staff B, RN and wound nurse stated the resident has been bed bound since his readmit in (MONTH) with [MEDICAL CONDITION] to the right side. She stated it is a nursing judgement when to apply an air mattress and verified the air mattress was placed on 5/13/19 not 12/1/18 per the care plan. She stated it would have been beneficial for an air mattress to be placed on the resident's bed when he was readmitted . She verified the resident's chart lacked documention that the resident had redness and excoriation to his coccyx prior to the open wound. In an interview on 6/6/19 at 10:07 a.m., the Nurse Consultant stated the facility had good intentions but didn't get interventions in place timely to prevent the pressure ulcer. She feels it would have been beneficial to have had the air mattress in place on readmit. In an interview on 6/6/19 at 10:19 a.m., the Wound Care Specialist stated her first interaction with the resident was on 6/4/19 and she gathered information per staff. She stated with the resident's HOB at 30-45 degrees it puts more pressure on the coccyx and agreed if an air mattress was in place prior to the wound development, it would have been beneficial. She stated the resident voiced it hurt and was uncomfortable. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. A document titled Skin Integrity Monitoring and Management dated 8/13/17 revealed the facility is committed to ensuring that a resident who enters the facility without pressure ulcers does not develop pressure ulcer unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcers was unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. Staff is to identify risk factors which relate to the possibility of skin breakdown and/or development of pressure injury which include, but are not limited to: impaired/decreased mobility and decreased functional ability, resident refusal of some aspects of care and treatment, cognitive impairment, exposure of skin to urinary and fecal incontinence, and malnutrition. In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan which includes using pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillow, etc.)

Based on record review, observation, resident and staff interviews and review of the facility policy and the Food and Drug Administration's Guide, the facility failed to assess bed rails for risk of entrapment and failed to ensure the space between the rail and mattress did not have a gap in which the resident could become entrapped for 1 of 60 residents. Resident#51 was placed in an immediate jeopardy and at risk for serious injury, impairment or death. On [DATE], Resident #51 was transferred to another bed with no entrapment risks and the immediate jeopardy was removed. The facility reported a census of 60 residents. Findings include: Review of the Food and Drug Administration's (FDA) Hospital Bed Safety Workgroup (HBSW) article titled Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, dated (MONTH) 2003, indicated, in pertinent part, Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team .Bed rail use for patient's mobility and/or transferring, for example, turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan .Inspect, evaluate, maintain, and upgrade equipment(beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment of patient needs, considering all relevant risk factors .If it is determined that bed rails are required .The mattress to bed rail interface should prevent an individual from falling between the mattress and bed. Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist items .should be ongoing . According to the FDA's Guidance for Industry and FDA Staff article titled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued [DATE], indicated for [AGE] years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. FDA received approximately 691 entrapment reports over a period of [AGE] years from (MONTH) 1, 1985 to (MONTH) 1, 2006. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or footboards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings. A. The FDA recommended dimensional limit for zones 1 through 4, and suggested if any alternative approach be least as stringent as the ones describe below: a. Zone 1 - within the rail. Zone 1 is any open space within the perimeter of the rail. Opening in the rail should be small enough to prevent the head from entering. The recommend space is less than 4 and ¾ inches, representing head breadth. b. Zone 3- between the rail and the mattress. Zone 3 is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, and shift of the mattress or rail, and the degree of play from loosened rails. The FDA recommended a dimensional limit of less than 4 and ¾ inches for the area between the inside surface of that rail. The HBSW considers a resident to be at high risk of injury when he or she cannot move safely from a bed to a wheelchair, cannot move safely from the toilet without assistance, had a previous entrapment episode, had previous bed-related injuries, or had fallen from a bed, or had difficulties using call alarms. 1. Resident #51 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS identified Resident #51 had [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15. A score of 10 identified the resident with moderately cognitively impaired. The MDS documented the resident required extensive assistance of two staff for bed mobility, toilet use, and hygiene, and had total dependence on staff for transfers. The Care Plan dated [DATE] revealed the resident had a spinal cord injury, history of falls, and impaired thought process/cognition. The Care Plan also indicated the resident had hallucinations, delusions, paranoia, and wished to die. The Care Plan interventions included ¼ side rails on the bed to aid in bed mobility and a J-Collar on at all times. The Care Plan directives for staff included using an air mattress to protect the skin, provide assistance to turn in bed, use caution during transfers and bed mobility to prevent the resident from striking arms, legs, and hands against any sharp or hard surface and to anticipate the resident's needs. A bed rail evaluation performed on [DATE] indicated Resident #51 needed bed rails for positioning/support and/or when rose from supine to sitting/standing position as a mobility enabler. The bed rails had not restricted resident movement. The resident's representative signed a consent for use of bedrails as an enabler on [DATE]. A bed safety action grid performed on [DATE] by Staff G, RN, documented a checkmark under Entrapment Zone 1- 7, and no checkmarks under potential interventions category. The Order Summary Report dated [DATE], included orders for ¼ side rails as an enabler for turning and repositioning in bed, and cervical collar at all times for cervical injury. The Vendor's Quality Control Checklist dated [DATE] identified DFLaL 42x mattress passed all functions. Observations identified the following: On [DATE] at 2:50 PM, #51 lying on an air mattress and had ¼ metal side rails up bilaterally (both sides) at the head of the bed. The bed had an opening or gap between the air mattress and side rails. On [DATE] at 2:35 PM - Resident #51 lying on back in bed and had a J-Collar around his neck. The resident laid on an air mattress in bed and had ¼ metal SR up on both sides toward the head of the bed. The motor for the air mattress hung on the end of bed and operational. A large opening or gap noted on both sides of bed between the mattress and side rails and the bedframe from the top of the bed to the foot of the bed where no mattress covered the area. On [DATE] at 2:36 PM- Federal Surveyor and Surveyor measured the distance between the top of the mattress with the larger opening to the SR. The opening or gap measured 4 inches on one side of bed, and 8 inches on the other side of the bed. Resident #51 stated he used SR to help him when he moved in bed. The resident expressed concern about the opening between the mattress and SRs, and concerned he could get stuck in-between the opening, The resident reported he had not been trapped in the gapped area between mattress and SR, but had concern it could happen. On [DATE] at 2:45 PM - Observations of Resident #51's bed identified a large gap between the air mattress and side rails. In the presence of the Administrator and DON, the surveyor measured at the largest opening from the mattress to the side rail. The opening measured 4 inches on one side of bed, and 8 inches on other side of bed. The Administrator and DON were advised of the immediate concern for risk of entrapment with the mattress on Resident #51's bed and the side rails, and the large gap observed on both sides of bed. The Administrator and DON stated they planned to have maintenance come right away to look at the bed. On [DATE] at 3:15 PM - The Corporate Operations Resource stated the staff are in the process of switching Resident #51 to another bed, and planned to check other resident's beds at the facility. At 3:22 PM, the Maintenance Supervisor reported he contacted the rental company regarding the bed for Resident #51. At the time, the Maintenance Supervisor reported Resident #51 had been in a Gendron bed. The Maintenance Supervisor measured the bedframe surface with a tape measure and reported it to be 48 inches wide. The Maintenance Supervisor reported he thought the air mattress size on the bed only 42 inches. The Maintenance Supervisor removed a packing slip inside a zip lock bag attached to the air mattress, and read the equipment name DFLaL42. The Maintenance Supervisor confirmed the mattress size was 42 inches but the bed should have had a 48 inch mattress for the type of bed/bedframe the resident had been in. On [DATE] at 10:45 AM, the DON reported staff entered work orders in the TELS system when equipment needed fixed, and then maintenance staff were notified of the work order. The DON stated when a safety concern was identified for equipment, they took the equipment out of service. The DON reported the Wellness Coordinator ordered rental equipment if needed, tracked equipment and sent equipment back when no longer needed the equipment. The DON reported when they used an outside company who brought equipment in, she thought equipment checked by the vendor before they used the equipment. The DON reported after safety concern identified on [DATE], the facility planned to ensure any vendor used, followed facility policy/procedure to ensure equipment safe. On [DATE] at 10:55 AM, the Maintenance Supervisor stated when equipment or something needed repaired, he received a work order via the TELS system, an electronic work order system. The maintenance supervisor reported work orders received for monthly and weekly checks, too. The Maintenance Supervisor reported preventative maintenance performed on equipment such as beds annually. Preventative maintenance checks on beds entailed a visual check of the bed, the side rail and function of the bed control but when a bed required repair he checked things over. The Maintenance Supervisor reported the nurses called the vendor when a resident needed special types of equipment, like a larger bed. When equipment brought in by the rental company, they expected the rental company had performed proper checks for functioning and safety of equipment. The facility policy and procedure titled, Equipment Maintenance (not dated), indicated the Maintenance Supervisor performed routine maintenance on specified equipment, as per manufacturer's recommendations and/or program policy, and routine inspections and maintenance recorded on preventative maintenance procedure log. In the event equipment required service or maintenance between scheduled checks, staff entered a work order into TELS. If equipment required repair, the facility contacted the vendor through which equipment purchased and made arrangements for repair or replacement. The Vendor's Quality Control Checklist dated [DATE] identified DFLaL 42x mattress passed all functions. On [DATE] at 9:30 AM, the Corporate Operations Resource reported the staff were educated on the appropriate bed and mattress fit on [DATE]. The in-service education included: monitor patients beds for gaps between rails and mattresses, report any gaps larger than 4 inches immediately, and resident's risk assessed prior to a resident being placed in the bed or any changes to the bed or mattress. On [DATE] at 10:15 AM, the Administrator reported a bed rail risk assessment form dated [DATE], and bed system measurement device test dated [DATE] completed on Resident #51 and all other residents at the facility. On [DATE] at 10:30 AM, the DON provided rental invoices for a Dermafloat LAL mattress 42 x 80 system for Resident #51 from [DATE] - [DATE], and a New Arise 1000 EX mattress 48 inch mattress system received and replaced on [DATE]. Note: At the time of the identification, the scope and severity was coded at a J, immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to D. The resident was removed from the bed and placed in a bed in which there was no entrapment hazards present. The staff received inservice training about appropriate bed and mattress fit, reporting immediately of gaps larger than 4 inches and each resident is to be assessed for risk prior to a resident placed in the bed or any changes to the bed or mattress. The Administrator provided a bed rail risk assessment form dated [DATE]. As of the [DATE] exit conference, the facility needed to continue to: · Monitor compliance with bed rail risk assesment forms, · Monitor so the beds are set up as manufacturer's recommendations, · Continue to inservice staff about appropriate bed and mattress fit and reporting of gaps.

Based on record review, staff and physician interviews and review of the policy/procedures, the facility failed to adequately assess an open wound and provide ordered interventions (wound vac) to promote healing and prevent infection (Resident #1). The sample consisted of 5 residents and the facility reported a census of 53 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 9/19/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The same assessment indicated the resident had poor memory and moderately impaired decision making skills. The MDS indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS identified the resident ' s decisions as poor and required cues and supervision. The MDS identified the resident required extensive assistance from staff for all activities of daily living (ADL's) except eating. The resident experienced occasional bladder incontinence. Review of the Interim Care Plan completed and dated on 8/26/16 failed to include assessment or intervention of a wound on the resident ' s leg. Review of the Skin Integrity Report dated on 8/26/16 revealed documentation of an open hematoma on resident's right lateral calf that measured 6 centimeters (cm) long, 3.4 cm wide, no depth documented and noted bloody drainage. The Care Plan initiated on 8/31/16 and revised on 9/14/16, indicated the resident had a problem with actual skin breakdown to the resident's right lower extremely. The Care Plan indicated the skin breakdown was related to trauma and the resident had limited mobility with the goal to be free of infection. The interventions directed the staff to monitor for the effectiveness and or side effects of medication, verbal and nonverbal signs of pain related to wound or wound treatment and medicate as ordered, provide wound treatment as ordered and complete a weekly skin assessment by a licensed nurse. A verbal order by the primary care physician dated 8/28/16, directed the staff that the resident needed PICO negative pressure wound treatment (wound vac) to right outer calf wound. The physician ordered a wound change every 7 days and as needed (PRN), continue same treatment until available. Review of the verbal order by the primary care physician dated 9/6/16 at 4:00 p.m. identified an order for [REDACTED]. Review of the ER report dated 9/6/16, indicated the facility sent the resident to the ER for an evaluation of the right lower leg wound. An assessment identified a large open wound on the lateral side of the right lower extremity with surrounding [DIAGNOSES REDACTED] (redness) to the knee and adjacent area with infection/abscess. The report indicated the [DIAGNOSES REDACTED]. The impression revealed a large right leg soft tissue ulceration extending into deep muscle. Review of the Wound Nurse Consult dated 9/7/16 revealed on right lateral left leg wound, measuring 5 cm long, 2.4 cm wide and 1.8 cm depth with tunneling at two sites, at the 12:00 position 8.4 cm and at the 6:00 position, 4 cm. Review of the policy/procedures titled Skin Integrity Management, revised on 3/15/16, directed the staff of the following; For wounds requiring daily dressing change or wounds without a dressing, monitor for signs of decline in wound status and if unanticipated decline in wound, surrounding tissue, or new or increased wound pain, complete the skin integrity report and notify the physician. On 9/28/16 at 2:02 PM, Staff A, Licensed Practical Nurse (LPN) was interviewed and stated when she changed the dressing for Resident #1 on 8/29/16, the date on the old dressing was 8/27, indicating it had not been changed on 8/28/16. Staff A stated the wound vac had not been ordered on 8/28 when the order had been taken and instead ordered a couple days later. The delivery to the facility was on Tuesday or Wednesday, not certain of the exact day but it (wound vac) sat until found on Tuesday 9/6/16, the day after Labor day. Staff A stated by then the wound smelled horrendous, with rotted flesh that fell out when unwrapping the leg. On 9/28/16 at 3:30 PM, Staff B, LPN was interviewed and stated the wound vac arrived on Friday, 5 days after being ordered and it had been locked in the office until after Labor Day on 9/5. The resident then transferred to the ER for infection in the wound on 9/6 (still did not have the wound vac placed per orders). Staff B stated when a wound is worse, they are expected to complete a full assessment of the wound including measurements and notify the doctor for further orders. On 9/28/16 at 2:35 PM, Staff C, LPN was interviewed and stated she had the wound vac to place on 9/6/16. Staff C stated when she removed the dressing, the tissue fell out of the wound. The resident had been sent to the ER for further evaluation of the wound. On 10/5/16 at 9:15 AM, Staff D, LPN was interviewed and stated when a wound becomes worse, they are to notify the primary care physician for further orders. Staff D stated the treatments are found in a 3 ring binder on the treatment cart. A notation about the wound vac would be documented in that binder. Staff D stated it was not noted in the binder that she could remember. She stated waiting on the wound vac usually only takes 1-2 days then they are expected to say something to the Director of Nursing. During an interview on 10/5/16 at 9:30 AM, the Primary Care Physician stated he was not aware the resident did not have the wound vac in place, it would have helped with the drainage and healing. During an interview on 10/7/16 at 10:00 AM, the ER doctor stated Resident #1 entered his ER with a wound that was beefy red, deep purple with tunneling and purulent drainage. The wound vac likely would have helped with the drainage. During an interview on 10/10/16 at 10:10 AM, the Director of Nursing stated the wound vac for Resident #1 had been locked in the business office all weekend. She stated anytime a wound changes or deteriorates the doctor is to be notified and yes, staff are expected to follow policy and procedures.

Based on observation, record review and resident, staff, and physician interviews and review of the facility policy/procedures, the facility failed to properly assess and implement adequate interventions in order to promote healing and prevent further wounds from developing (Resident #3, #4). Resident #4 had multiple skin issues upon a readmission to the facility. Since the admission, the resident ' s heels, elbows and sacrum area increased in size and an additional wound occurred on Resident #4 ' s foot. A pressure sore was identified on the coccyx of Resident #3 during observation of perineal cleansing. The area had not been assessed or interventions implemented. The facility identified a census of 60 residents and the sample consisted of 4 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 1/27/15. The MDS identified Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 14. A score of 14 identified the resident had no problems with cognition. The MDS reflected the resident required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use and hygiene. The MDS assessment reflected the resident had no risk for the development of pressure ulcers, had no venous, arterial or pressure ulcers. The MDS identified the resident had other skin problems. The Admission Resident Data Set (only completed at the time of admission, unless changes are indicated) dated 2/13/15 identified Resident #4 had a Stage II (A Stage II pressure ulcer is identified as a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. The ulcer may also present as an intact or open/ruptured blister) pressure ulcer located on the sacral area and areas on the anterior surface of the left foot and an area on the right heel. On 2/13/15, the Braden Scale For Predicting Pressure Sore Risk identified the resident scored a 16. A score of 16 determined the resident to be at risk (15-18) for pressure ulcers. The Care Plan dated 1/13/15 and 2/13/15, identified Resident #4 to be at risk `for skin breakdown (opposite of MDS dated [DATE]). The approaches included and directed staff to: a. Monitor the resident ' s skin with all cares and the nurse is to assess the skin weekly. b. Notify the physician/responsible party regarding presence of pressure ulcers. c. Encourage the resident to have a good nutritional intake. d. The resident has a pressure reducing mattress on the bed and a pressure reducing cushion on the seat of the wheelchair. The Care Plan did not address the heel pressure ulcers and interventions to prevent pressure. The Skilled Nursing PPS Notes dated 2/13/15 at 4:30 p.m. reflected the resident arrived to the facility from the hospital. The note reflected the resident depended upon staff for transfers and bed mobility. The resident had a Stage 2 pressure ulcer which measured 5.0 by 2.0 cm (centimeters) on the sacrum. Staff ordered a pressure relieving mattress. Two staff members assisted the resident to bed. At 5:45 p.m. the note reflected the nurse identified the resident had boggy heels, although not open and no treatment. (Boggy heels are an indication of a pending deep wound). The nurse obtained physician orders for a skin prep to both heels twice a day and Duoderm (dressing) to the sacral area-change every 3 days and as needed. The Weekly Pressure Ulcer assessment dated [DATE] identified a Stage II pressure ulcer on the right elbow which measured 1.6 by .9 by 0.1 cm. The ulcer assessment identified an unstageable pressure ulcer located on the right heel which measured 2.0 by 2.0 cm (different size than the skilled note) and black in color. The surrounding area of the wound had a boggy appearance. The preventative devices included Bunny Boots (a non-floating heel boot) and a pressure relieving mattress. The facility identified a Stage I (A Stage I ulcer is an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes of skin temperature, tissue consistency (firm or boggy), sensation and a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues). The assessment did not address the left heel or foot for prevention of pressure ulcers. The Skilled Nursing PPS Notes dated 2/14/15 6:00 p.m. to 6:00 a.m. reflected the pressure relieving mattress had arrived (for the bed). The Skilled Nursing PPS Notes dated 2/24/15 at 6:00 a.m. revealed the resident had heel protector boots (non-floating heel devices) in place to both feet. The Weekly Pressure Ulcer assessment dated [DATE] reflected the resident had a Stage I pressure ulcer on the right side of the foot (do not identify which foot). The nurse documented a measurement of 1 by 1.8 cm. The assessment identified the facility implemented a turning schedule. A Weekly Pressure Ulcer Assessment form documented the following: a. 2/26/15 - Right ankle - No measurements were completed, non- stageable, wound base color red, no type of wound base tissue documented, wound edges healing, no odor/drainage with the surrounding skin intact/healthy. (A non-stageable wound would not have a red base. The base would not be observable). The Weekly Pressure Ulcer assessment dated [DATE] did not identify an assessment of the surrounding skin on the right lateral foot. The Weekly Pressure Ulcer assessment dated [DATE] did not identify depth to the Stage II wound located on the right elbow. The Weekly Pressure Ulcer assessment dated [DATE] identified a new area on the right cuboid/foot. The assessment did not identify the stage of the wound and referred to a bluish purple wound base color. The nurse assessed the left heel (3/4/15) as a suspected deep tissue injury and identified a blood filled blister. A blood filled blister would be considered non-stageable due to the inability to view the wound bed. The Director of Nursing Services re-assessed the area when asked about the inaccurate assessment above. The assessment included the following: a. 2/26/15 - Right ankle - 2.0 centimeters (cm) long by 1.5 cm wide, non stageable, wound base tissue eschar (thick hard black substance), wound edges healing, no odor/drainage with the surrounding skin indurated. b. 2/26/15 - Left little toe - 0.3 cm by 0.3 cm, Stage I and non-stageable with wound base color red, no wound base tissue type documented. Wound edge healing, no odor/drainage and the surrounding skin intact and healthy. Since the nurse assessed the wound base as color red, there was no measurement of depth. c. 2/26/15 - Left 5th digit - no measurements or depth documented, trauma scabbed area, no wound base color, no wound base tissue [MEDICATION NAME], wound edge healing, no odor/drainage and the surrounding skin intact, healthy and dry. d. 2/26/15 - Right knee - 0.8 cm by 1 cm. documented, non-stageable, wound base black, no wound base tissue type documented, wound edge healing, no odor/drainage and the surrounding skin intact and healthy. e. 2/26/15 - Right knee - 0.9 cm by 0.6 cm, no depth, small scab not staged, wound base scabbed, wound base tissue type [MEDICATION NAME], wound edge healing, no odor/drainage and the surrounding skin intact, healthy and dry. f. 2/26/15 - Right side of foot - 2.0 cm by 1.8 cm, Stage I, wound based pink and red, wound base tissue type [MEDICATION NAME], wound edge healing, no odor/drainage and the surrounding skin intact and healthy (a Stage I pressure ulcer is intact and not an open wound so there would be no wound base color or tissue type). g. 2/26/15 - Right side of foot - 2.0 cm by 1.8 cm. The nurse did not identify a depth measurement. Stage II, wound base red, wound base tissue type granulation, wound edge healing, no odor/drainage and the surrounding skin documented as a "flap" appeared due to trauma. h. 2/26/15 - Right hallux - 1.1 cm by 1.0 cm., no depth, suspected deep tissue injury, wound base bluish-purple, wound base tissue intact, wound edge healing, no odor/drainage and the surrounding skin intact and healthy. i. 2/26/15 - Right big toe - 2.8 cm by 2.0 cm , no depth measurement, wound base red and bluish-purple, wound base tissue [MEDICATION NAME] and granulation, wound edge healing, no odor/drainage and the surrounding skin intact, healthy and dry. Additional measurements: a. On 3/2/15 - Right hallux - 1.1 cm by 1.0 cm., no depth, suspected deep tissue injury, wound base bluish-purple, wound base tissue intact with discoloration, wound edge healing, no odor/drainage and the surrounding skin discolored. On 3/3/15 - Right hallux - 1.0 cm by 1.0 cm., no depth, suspected deep tissue injury, wound base bluish-purple, wound base tissue intact with discoloration, wound edge healing, no odor/drainage and the surrounding skin discolored. On 3/4/15 - Right hallux - 1.2 cm by 1.0 cm., no depth, suspected deep tissue injury, wound base bluish-purple, wound base tissue intact with discoloration, wound edge healing, no odor/drainage and the surrounding skin discolored. b. On 3/2/15 - Right big toe - 2.7 cm by 1.9 cm , no depth, suspected deep tissue injury, wound base red and black, wound base tissue eschar/scabbing, wound edge healing, no odor/drainage and the surrounding skin dry. On 3/3/15 - Right big toe - 3.0 cm by 2.0 cm , no depth, suspected deep tissue injury, wound base red and black, wound base tissue eschar and scabbing, wound edge healing, no odor/drainage and the surrounding skin dry. On 3/4/15 - Right big toe - 3.3 cm by 2.0 cm , no depth (enlarged size), suspected deep tissue injury, wound base black, wound base tissue eschar and scabbing, wound edge healing, no odor/drainage and the surrounding skin discolored (change). c. On 2/13/15 - Right elbow - 1.6 cm by 0.9 cm, 0.1 cm deep, Stage II, wound base white, wound base tissue [MEDICATION NAME], wound edge healing, no odor, scant amount clear drainage and the surrounding skin discolored. On 3/2/15 - Right elbow - 2.5 cm by 2.6, 0.2 cm deep (enlarged in size) Stage II, wound base red with immediate surrounding tissue yellow and the outer edges red, wound base tissue granulation, wound edge healing, no odor or drainage and the surrounding skin discolored. d. On 2/13/15 - Right heel - 2.0 cm by 2.0, non-stageable, wound base black, wound base tissue [MEDICATION NAME], wound edge new, no odor or drainage and the surrounding skin boggy. On 3/2/15 - Right outer heel - 4.5 cm by 2.0 cm, non-stageable, wound base black, wound base tissue necrotic, wound edge healing, no odor or drainage and the surrounding skin dry and boggy. On 3/2/15 - Right outer heel - 5.1 cm by 2.9 cm, (enlarged) no depth, non-stageable, wound base black, wound base tissue [MEDICATION NAME], wound edge healing, no odor or drainage and the surrounding skin boggy. On 3/4/15 - Right outer heel - 5.0 cm by 2.9 cm, no depth, non-stageable, wound base black, wound base tissue [MEDICATION NAME], wound edge healing, no odor or drainage and the surrounding skin boggy. e. On 2/26/15 - Left heel - 6.5 cm by 7 cm, documented, Stage I, wound base red, no wound base tissue documented, wound edge healing, no odor or drainage and the surrounding skin intact and healthy. A Stage I pressure ulcer is intact and the nurse would not be able to view the wound base. On 3/2/15 - Left heel - 6.2 cm by 4 cm, no depth documented, suspected deep tissue injury, wound base bluish-purple blood filled blister, wound base tissue blistered, wound edge healing, no odor or drainage and the surrounding skin boggy. On 3/3/15 - Left heel - 6.7 cm by 3.6 cm, no depth, suspected deep tissue injury, wound base blood filled blister, wound base tissue blistered, wound edge healing, no odor or drainage and the surrounding skin boggy. On 3/4/15 - Left heel - 6.8 cm by 4 cm, (enlarged) no depth, suspected deep tissue injury, wound base blood filled blister, wound base tissue blistered, wound edge healing, no odor or drainage and the surrounding skin dry and boggy. f. On 3/4/15 - Right cuboid/foot - 0.1 cm by 0.5 cm, no depth, no stage documented, wound base color bluish/purple, no wound base tissue documented, wound edges new, no odor/drainage with the surrounding skin healthy/intact and dry. g. On 3/2/15 - Right lateral /foot - 2.2 cm by 1.6 cm, no depth, non-stageable, wound base color red and black (a non-stageable wound is when you cannot see the wound base), wound base tissue necrotic, wound edges healing, no odor/drainage with the surrounding skin dry. On 3/3/15 - Right lateral/foot - 2.8 cm by 1.5 cm, (enlarged) depth, non-stageable, wound base color red and black (a non-stageable wound is when no wound base can be identified), wound base tissue necrotic, wound edges healing, no odor/drainage, no condition of surrounding skin documented. On 3/4/15 - Right lateral/foot - 2.7 cm by 175 cm, no depth, non stageable, wound base color red and black, wound base tissue necrotic, wound edges healing, no odor/drainage, surrounding skin discolored. h. On 3/2/15 - Right outer ankle - 2.7 cm by 1.8 cm, no depth documented, suspected deep tissue injury, wound base color bluish-purple, wound base tissue intact and discolored, wound edges healing, no odor/drainage, surrounding skin dry. On 3/3/15 - Right outer ankle - 2.3 cm by 3.0 cm, no depth, suspected deep tissue injury, wound base color bluish-purple, wound base tissue intact and discolored, wound edges healing, no odor/drainage, surrounding skin dry. On 3/5/15 - Right outer ankle - 2.3 cm by 3.2 cm, no depth documented, suspected deep tissue injury, wound base color bluish-purple, wound base tissue intact and discolored, wound edges healing, no odor/drainage, surrounding skin intact, healthy and dry. i. On 2/13/15 - Sacrum 5.0 cm by 2.0 cm, 0.1 cm deep, Stage II, wound base color pink, wound base tissue [MEDICATION NAME], wound edges new, no odor, a small amount of serous drainage, surrounding skin healthy and intact. 2/19/15 - Sacrum- 5.0 cm by 2.0 cm, 0.1 cm deep , Stage II, wound base color pink, wound base tissue [MEDICATION NAME], no documentation on wound edges, no odor, a small amount of clear serous drainage, surrounding skin healthy and intact. 3/2/15 - Sacrum- 2.5 cm by 1.1 cm, 0.1 cm deep , Stage II, wound base color pink, wound base tissue granulation, wound edges healing, no odor, a small amount of clear serous drainage, surrounding skin healthy and intact. 3/3/15 - Sacrum- 3.3 cm by 1.2 cm, no depth , (enlarged in size) Stage II, wound base color pink, wound base tissue granulation, wound edges healing, no odor, a small amount of clear serous drainage, surrounding skin healthy and intact. 3/4/15 - Sacrum- 3.2 cm by 1.2 cm, Stage II, wound base color pink, wound base tissue granulation, wound edges healing, no odor or drainage, surrounding skin healthy and intact. During an interview on 3/4/15 at 9:10 a.m., the DON (Director of Nursing) stated she re-educated the nurses involved with documenting on the resident ' s incomplete skin sheets. According to a Pressure Ulcer Monitoring System form dated 4/04; the purpose had been to assist the center in monitoring and documenting the occurrence, treatment and progression of pressure ulcers. The procedure included the following: a. Perform a complete assessment of the pressure ulcer. b. Complete all sections of a patient's individual decubitus report. c. On a weekly basis the DON or designee would: 1. Assess the pressure ulcer and documentation. 2. Provide assurance that the primary physician had been alerted to the following: a. Ulcers that had not appeared to respond to the treatment. b. Ulcers that worsen in condition or increase in size. c. Any resident complaints of increased pain or discomfort, or a decrease in mobility or functioning levels. d. Signs of [MEDICAL CONDITION], presence of exudate, odor or necrosis. Another document titled Pressure Ulcer Prevention & Management, with a revision date of 10/15/14, included and directed staff to document the following: 1. The location of the ulcer. 2. The size and depth of the ulcer. 3. The description of the ulcer. 4. The drainage from the ulcer. 5. If any necrosis of the ulcer. 6. The ulcer's response to treatment. 7. How the ulcer had been affecting the resident. Photographs of the pressure ulcers were taken during the investigation. 2. Resident #3 had an MDS assessment with a reference date of 11/13/14 which identified [DIAGNOSES REDACTED]. The MDS assessment reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12. A score of 121 identified moderately impaired cognitive abilities. The MDS assessment documented the resident required extensive assistance of one staff member with bed mobility, dressing and toilet use, was non-ambulatory and had impairments on both sides of his/her upper and lower extremities. The MDS assessment documented the resident as frequently incontinent of bowel and bladder, was at risk for developing pressure ulcers and had other skin problems but no pressure ulcers. The Care plan dated 9/16/09 reflected the resident was at risk for urinary tract infections, skin breakdown and dignity issues due to occasional episodes of urinary incontinency and potential for skin breakdown due to his/her preference to stay in bed at all times, impaired physical mobility, [MEDICAL CONDITION] and diabetes mellitus. The approaches included and directed the staff to: a. Charge Nurse to perform weekly skin checks by the charge nurse. b. Staff are to monitor the skin condition for signs of breakdown or redness during cares. c. Apply any skin treatment as prescribed. During an interview on 2/12/15 at 1:10 p.m., the resident stated he/she had an open area on the coccyx area and it hurt badly. The resident stated the nurse the night before had looked at the area. The record did not have an assessment or an intervention for the open area. During observation 2/12/15 at 3:27 p.m., Staff G, Certified Nurse Aide, CNA and Staff F, CNA transferred the resident to bed following a shower, positioned the resident on his/her left side and dried the residents back. Staff G separated the resident's buttocks that revealed a pea sized open area on the resident's coccyx region and a red, rashy area under the resident's bilateral buttocks. A record review failed to identify an assessment and/or interventions for the open area. During observation on 2/13/15 at 1:45 p.m., Staff E, CNA and Staff H, CNA positioned the resident on his/her left side and removed the bed pan. Staff H cleansed stool from the resident's mid gluteal region wiping up and over the open area on the resident's coccyx region. Observation on 2/26/15 at 11:54 a.m., revealed the resident wearing a brief positioned in bed on a pressure reducing mattress, covered with a fitted sheet and 2 overlapped washable chux pads. Multiple layers of linens and a brief can decrease the effectiveness of the pressure reducing mattress. Staff F and Staff E provided perineal care. Staff F cleansed the resident's mid gluteal region up and over the open area on the coccyx as the resident flinched and pulled away. During an interview at the time, Staff B, Licensed Practical Nurse, LPN confirmed she observed an open area on the resident's coccyx. During an interview on 2/26/15 at 12:15 p.m., the Assistant Director of Nursing, ADON stated the staff performed weekly skin assessments. Review of the resident's Skin Assessment form revealed the following information: a. 1/2/15 - No skin concerns. b. 1/9/15 - No skin concerns. c. 1/23/15 - No skin concerns. d. 1/30/15 - No skin concerns. e. 2/20/15 - No documentation present related skin concerns. During an interview on 3/4/15 at 12:10 p.m., the resident ' s physician stated the open areas on the resident ' s buttocks were due to friction. The Physician stated the areas were unavoidable as the resident continued to self- transfer and reposition self. The physician stated if it was the facility policy to complete weekly assessments he would expect the assessments to be completed.

Based on observation, record review, and staff and resident interviews, the facility failed to protect Resident #10 from hazards during a transfer, failed to maintain the mechanical lift equipment to be in a safe condition, failed to educate staff on the identification of structural issues with the lift, and used a poor transfer technique with Resident # 5. The resident sample included 15 residents. The facility reported a census of 59 residents. Findings include: 1. The quarterly MDS (Minimum Data Set) assessment with a reference date of 02/24/2014 documented a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 identified the resident with no problems with cognition. The MDS reflected Resident # 10 required extensive assistance of 2 people with bed mobility, transfers, personal hygiene, and toilet use. The resident did not ambulate and used a wheelchair for locomotion. The MDS identified [DIAGNOSES REDACTED]. The Care Plan identified a problem on 6/4/14 with the resident experiencing an activity of daily living deficit and required assistance due to weakness, osteoarthritis, pain and debility. The approaches directed the staff the resident required 2 staff members and a Hoyer (mechanical) lift for transfers. The Care Plan identified a problem with the resident being at risk for injury from falls. The approach directed staff on 12/22/13 to perform neurological checks per facility protocol due to a Hoyer lift malfunction. The approaches did not have directives for checking the mechanical lifts prior to use for any observable defects in order to prevent further accidents. Resident # 10's medical record nursing notes documented an accident with the mechanical lift on 12/22/2013 at 5:15 P.M. The note reflected the nurse entered the resident ' s room and round the resident on the floor and lying on right side and back. The Hoyer lift had broken and the resident fell to the floor striking the right side of the forehead and face on the Hoyer lift frame. The resident had an 8 centimeter hematoma to the right side of the forehead and a 3 centimeter hematoma on the right cheekbone. The resident refused to go to the hospital. The nurse notified the resident's son, the on call physician, the facility Administrator, and the Assistant Director of Nursing. The nurse documented she informed the physician "on call" about the resident's vitals and neuro (neurological) checks which were stable, and hematomas (bruising- bleeding under the skin from the blood vessels). Resident #10 did not see a Physician until 12/31/2013. At that time, no further orders concerning the injuries from the fall were received. On 06/4/2014 at 10:40 A.M., Resident # 10 was interviewed and stated he/she had been dropped from the mechanical lift to the floor back in December, 2013. Stated the mechanical lift just came apart and down she/he went. The resident stressed he/she did not feel it was the fault of the staff. Resident # 10 refused to go to the hospital and did not recall the physician ever coming to the facility to check on the bruising to the left side of her/his forehead and face. The day after the fall, a niece took pictures of the bruising. Resident # 10's left forehead displayed red/purple/blue bruising. The left side of the eye displayed red/purple/blue bruising as did the cheekbone area. On 06/04/2014 at 10:10 A.M., Staff P and Staff Q (both Certified Nursing Assistants) were interviewed and stated around 5:00 P.M.,(could not remember the date), Resident # 10 requested assistance. After securing the sling to the mechanical lift, Staff Q lifted the resident up and out of the wheelchair. Staff P held on to the resident. Staff Q stated she had the mechanical lift up to bed level and over the wheelchair. Before the mechanical lift could be moved over to the bed, the bar broke and the resident went down on to the left side. Resident # 10 hit her/his head on the bar that protruded out from the mechanical lift between the legs of the lift and knocked her/his glasses off. No bleeding occurred. Once the nurse assessed the resident, a different mechanical lift was brought to the room and the resident was transferred back into the wheel chair. Resident # 10 refused to go to bed or to the hospital. Neither Staff P nor Staff Q could recall any training or in-service about checking the mechanical lift for defects prior to using the lift. They were told to check the wheels in order to ensure the wheels did not stick. There were told how to transfer a resident with the mechanical lift, and to check for the appropriate size of sling to use. Staff P and Staff Q stated no representative from the mechanical lift company ever gave an in-service concerning the use of the lift or checking for defects prior to the use. During an interview on 06/04/2014 at 8:00 A.M., the Director of Nursing reported the staff were in-serviced by physical therapy about how to use the mechanical lift with the staff demonstrating back to them. The staff were not in-serviced about an inspection of the mechanical lift for stress or defects prior to using the lift. The EZ lift instruction guide for the facility staff directed those operating the mechanical lift to check for loose nuts and bolts or damaged parts prior to use. In April 2014 the EZ Way company sent a memo stressing the importance of inspecting, properly maintaining, and replacing worn parts of the mechanical lifts as instructed in the EZ Ways Preventative Maintenance Guidelines. All the components to be checked were listed and pictured. The pivot area and actuator is part of the hanger assembly was on the list of stress points to be checked regularly. An EZ Way Inc. Safety Program Checklist identified on 01/03/2014, an EZ Way representative came to the facility and replaced the spreader assembly for the defective mechanical lift. On 06/04/2014 at 12:30 P.M., Staff U (Maintenance Supervisor) was interviewed and stated the mechanical lift, which dropped Resident # 10, was fixed. The facility did not have any records of maintenance being performed on any equipment prior to January 2014. The maintenance person during December 2013 had been terminated. 2. Resident #5 had an admission Minimum Data Set (MDS) assessment with a reference date of 5/16/14 which reflected the resident had a BIMS (Brief Interview Mental Status) score of 3. A score of 3 identified Resident #5 as severely impaired cognitively. The resident was admitted to the facility for orthopedic aftercare following surgery for [REDACTED]. The resident required extensive assistance of two staff members for transfers and ambulation. The MDS identified the resident ' s balance as not steady during transitions and walking due to the functional limitations of the right extremity. The interim Care Plan, initiated on the admission date of [DATE], directed staff to transfer the resident with 2 people and a gait belt. The Care Plan reflected the resident was non- weight bearing on the right leg and used a wheelchair for mobility. The plan identified the resident as a moderate fall risk. Review of the admission Orthopedic Skilled Nursing Home Orders revealed the resident was to be on non-weight bearing status for the right leg. Review of a physician telephone order dated 5/28/14 directed staff that the resident should not bear weight on the right leg. Observation on 6/3/14 at 8:00 a.m. revealed Staff H and Staff G, both Certified Nurse ' s Aides (CNAs), prepared the resident to transfer from the wheelchair to the commode. The CNAs placed the gait belt loosely around the resident and lifted the resident up from the chair completely without feet resting on the floor with the gait belt underneath the resident ' s armpits. The resident was placed on the commode. The resident cried out loudly when moved. Staff H left the room to answer a call light. At 8:08 a.m. the resident asked to be taken to bed. At 8:11 a.m. both CNAs lifted the resident to a standing position. The CNAs did not cue the resident to lift his/her foot off the floor and the resident remained weight-bearing on both legs/feet with Staff H holding the gait belt under the resident ' s armpits while Staff G performed perineal hygiene cares to the resident. The resident cried out when Staff G placed a disposable brief on the resident. The CNAs ambulated the resident to the bed with the resident bearing weight on both legs. During an interview with Staff K, CNA and Staff H, CNA, on 6/4/14 at 12:45 p.m. the CNAs stated they have three ways to check how individual residents are transferred/ambulated- 1. The method of ambulation is posted by Physical Therapy on a bulletin board in the resident ' s room , 2. Posted in the Care Plan, located in the chart. 3. Ask another staff member how the resident is transferred. When Staff H was asked why non-weight bearing status was not maintained for Resident #5 during the previous day ' s transfer, Staff H stated she was aware of the resident's non-weight bearing status. Staff H stated since the resident was on the commode and had to be stood up for a transfer, they decided to assist the resident to stand and quickly do perineal care before assisting the resident back to bed. 3. During a tour of resident rooms on 6/4/14 at 3:00 p.m. a broken area on the upper side rail of the resident's bed in room 418 was noted. The area was part of the plastic casing on the inner side of the side rail and protruded level with the surface of the mattress. The Administrator acknowledged it was a safety hazard however he was unaware of the issue. He stated maintenance would repair the issue immediately.

Based on observation, record review, and staff interviews, the facility failed to assess residents with a significant weight loss, provide timely interventions and communicate with other members of the health care team regarding the nutritional needs of the residents when necessary (Resident #4, #5). The facility reported a census of 59 residents. The sample consisted of 15 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment with a reference date of 5/16/14 reflected Resident #5 had a severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 3. The MDS identified Resident #5 required limited assistance of one staff member for eating. The resident was admitted to the facility for orthopedic aftercare following surgery for [REDACTED]. The interim Care Plan, initiated on admission date of [DATE], identified the resident needed prompting at mealtimes and encouragement to take fluids at meal. An undated entry on the subsequent care plan instructed staff to give supplements as ordered, to consult for a swallow study, and to assist with meals as needed. Review of the Admission 3 Day Weight record for Resident #5 revealed on Day 1 the resident weighed 116.4 pounds. The weight record for Day 2 and Day 3 were blank. The Conclusion section at the end of the form reflected if no weight discrepancy greater than 5 pounds, proceed with the normal protocol. If weight discrepancy is greater than 5 pounds, initiate daily weights on the Medication Administration Record [REDACTED]. Review of the facility Dietary Recommendations form completed at the Standards of Care committee meeting on 5/12/14 revealed the dietician recommended the following interventions for the resident: 1. Swallow study evaluation for safety (Speech Therapy evaluation). 2. Start House Supplement 60 cc (three ounces) four times a day 3. Change diet to mechanical soft if any problems prior to the swallow study. Review of the resident ' s May 2014 MAR indicated [REDACTED]. Review of a physician facsimile revealed the physician approved a swallow sturdy evaluation on 5/12/14 due to the resident ' s poor oral intake and difficulty swallowing. The study reflected the resident did not have difficulty swallowing but a mechanical soft diet was recommended due to the resident ' s edentulous (no teeth) status. Observation on 6/3/14 at 7:20 a.m. revealed the resident seated at the breakfast table and served a mechanical soft diet of a large square of coffee cake, a serving of ground sausage, scrambled eggs, and a bowl of hot cereal. Fluids served were a medium size glass of milk, a small glass of juice, and a small glass of water at this time. The resident was not cued or assisted by staff for the next twenty minutes. During this time the resident poured the juice into the cereal bowl. The resident attempted to drink from the small water glass and the water dribbled down the resident's chin into his/her lap. The resident then picked up the square of coffee cake and used the cake to wipe his/her mouth and chin. The resident balled up the napkin and placed it in the cereal bowl. The resident then took off the clothing protector and laid it over the food items. At 7:40 a.m. Staff G, CNA, sat next to the resident and handed the resident the glass of milk. The resident drank all of the milk. At 7:55 a.m. Staff H, CNA, sat next to the resident and Staff G. The CNAs cued the resident twice to take sips of fluids but did not assist or cue the resident to eat any food and wheeled the resident back to the room at this time. Review of the Registered Dietician (RD) notes for Resident #5 dated 6/2/14 revealed the resident ' s weight was recorded as 97 pounds. This weight represented a significant weight loss of 16.6 % in less than one month (a significant weight loss represents a loss greater than 5% in one month) between the date of admission (weight 116.4 pounds) and 6/2/14 (97 pounds). On 6/3/14 at 3:30 p.m. the Registered Dietician (RD) was interviewed and stated he meets with the Standards of Care (SOC) committee each Monday and the committee consists of the RD, Director of Nursing (DON), and Department Heads (social worker, activity director etc.). The RD stated the committee reviews current weight losses and changes at the meeting. He stated he would expect the nursing staff to complete the Admission 3 Day Weight record for each resident as per facility protocol so he is able to assess resident weight concerns as related to admission. The RD stated he would expect the nursing staff to initiate an oral House supplement when recommended. The RD stated a Dietician Recommendations form is completed at each SOC meeting and his recommendations are recorded on this form and followed by the nursing staff (see above interventions dated 5/12/14). On 6/5/14 at 3:30 p.m. The Director of Nursing was interviewed and stated she was unaware of the Admission 3 Day Weight record and did not know it was facility protocol to complete the form. Review of documentation dated 4/15/14 and titled Attention 4th Floor Nurses revealed residents were to be weighed daily consecutively for 3 days following admission and this is a day shift responsibility. 2. The annual MDS assessment with a reference date of 4/23/14 reflected Resident #4 had a BIMS score of 14 which identifies no cognitive impairment. The MDS noted the resident was independent with set up help only for eating. The MDS noted the resident [DIAGNOSES REDACTED]. Review of the resident ' s weight record identified the following weights in pounds- 12/1/13- 155.2 3/1/14- 154.8 4/1/14- 144.6 5/1/14- 134.0 5/22/14- 137.0 5/29/14- 135.4 The weights revealed the resident experienced a six month significant weight loss of 13% (12/1/13 through 4/1/14), a three month significant loss of 12% (2/1/14 through 5/1/14), and a one month significant loss of 7.3% (4/1/14 through 5/1/14). The Care Plan with a revision date of 4/30/14 identified the resident needed assist with activities of daily living and required set up assist for meals and cueing at times. A Care Plan entry dated 5/12/14 revealed the resident had a recent weight loss, current weight was 134.6, initiate House supplement liquid 60 cc (3 ounces) twice daily, and start weekly weights on the resident. The Care Plan did not identify the significant weight loss revealed by the documented weight on 4/1/14. Observation on 6/3/14 at 8:4 a.m. revealed the resident was transferred to the wheelchair by Staff I, CNA. The staff member stated the resident was going to the shower room for a shower and then would go down to the therapy room for his/her restorative exercises. When asked if the resident would receive breakfast the CNA asked the resident if he/she had breakfast yet. The resident replied " no breakfast " and nodded. The CNA stated the resident usually did not eat breakfast and liked to sleep in past breakfast time. The CNA stated the resident would be given a cup of coffee after the exercises. Observation on 6/4/14 in the dining room from 12:05 p.m. through 12:40 p.m. revealed the resident seated in the dining room with a puree lunch meal and three glasses of fluids without lids on the table. The resident had a large lidded cup of tea which the resident brought with him/her into the dining room. The dietary aide set up the resident ' s tray and spread butter on the resident ' s pureed noodle. During this time period the resident was able to feed him/herself thirteen bites of food despite having spastic muscle movements frequently. At 12:30 p.m. the resident attempted to pick up the glass of juice to take a drink but was unable to and instead moved the glass away. At 12:40 p.m. Staff I, CNA, sat by the resident and assisted the resident to drink the glass of milk and eat three more bites of food. The resident was then returned to his/her room. Observation on 6/5/14 at 11:00 a.m. revealed the resident was dressed and transferred to the wheelchair after arising. The resident stated he/she was on the way to the therapy room for exercises. When asked if he/she had breakfast that morning the resident replied no. At the request of the surveyor the CNA notified the kitchen and a hot pureed breakfast was brought up to the resident. The resident ate approximately 75% of the hot cereal with milk and stated " it tastes good " . The resident refused the rest of the pureed food. Review of the Registered Dietician (RD) notes for Resident #4 dated 4/19/14 revealed the resident ' s significant weight loss of 6 months was not documented by the RD. The RD questioned the 4/1/14 weight and of 144.6 and requested a re-weigh of the resident. The resident was not re-weighed at that time. Review of a Registered Dietician facsimile to the resident ' s physician dated 5/12/14 revealed the resident had experienced a significant weight loss of 6.9 % in one month. The note informed the physician the resident received a pureed diet and a house supplement liquid of 60 cc twice daily was implemented at that time. Review of the May 2014 MAR indicated [REDACTED]. On 6/3/14 at 4:00 p.m. the Registered Dietician (RD) was interviewed and stated he would expect nursing staff to re-weigh a resident if he requested. He stated his recommendations are noted on the facility Dietary Recommendations form completed at the Standards of Care committee meeting each Monday. He stated if the resident had shown a weight loss on 4/19/15 when he requested the re-weigh then he might have initiated the supplement earlier. On 6/3/14 at 4:00 p.m. the Director of Nursing was interviewed and stated it is protocol for the facility to weigh a resident on a weekly basis when a significant weight is identified. On 6/5/14 at 3:30 p.m. the Director of Nursing was again interviewed and she stated there were no recommendations by the RD on the facility Dietary Recommendations form with the date of 4/19/14. She stated all RD recommendations are recorded on facility Dietary Recommendations form at the meetings. She stated she does not routinely check the documentation in the RD ' s Quarterly Nutrition Assessment reports for additional recommendations. She stated she thinks the RD miss-dated the recommendation for the re-weigh and it should have been 5-19-14 or there was a miss-communication between the RD and the nursing staff. Review of the Quarterly Nutrition Assessment report documentation revealed if the RD had miss dated his visit, the reported weight in his documentation would have been the 5/1/14 weight of 134 lbs. This indicated the issue was most likely a problem of a miss communication between the RD and the nursing staff.

Based on record review and staff interviews, the facility failed to assess and provide timely intervention for 1 of 3 residents with an infection (Resident #6). The facility reported a census of 61 residents. Findings include: 1. Resident #6 had an admission Minimum Data Set (MDS) with a reference date of 11/25/11 which identified [DIAGNOSES REDACTED]. The MDS revealed Resident #6 required extensive assistance of two staff with toileting. The MDS revealed Resident #6 frequently experienced bladder incontinent episodes and occasionally incontinent of bowel. The Physical Therapy notes dated 12/5/11 revealed Resident #6 reported to the therapist that he/she had difficulty urinating and had a burning sensation. The note revealed the therapist reported the symptoms to the nurse. The Physical Therapy notes dated 12/6/11 revealed Resident #6 had inconsistent reports of problems with urination. The Physical Therapy notes dated 12/7/11 revealed the therapist encouraged the nursing staff to check the resident ' s urine. The therapy notes identified on 12/8/2011, the resident was admitted into the hospital. Review of the Nurse's Notes from 12/5/11 to 12/7/11 revealed no assessments of Resident #6's complaints of urinary discomfort. An interview on 12/22/11 at 9:34 a.m. Staff F reported Resident #6 had odorous urine on 12/5/11 and he/she documented it and told the nurse. Staff F stated he/she completed a form and gave it to the nurse on duty. On 12/22/11 at 10:38 a.m. the Director of Nurses (DON) was interviewed and reported looking into the concern. The therapist filled out a form on 12/5/11 and left it on the nurse ' s station. The DON indicated the facility changed the process and now the staff staple the form on the 24 hour sheet to ensure the nurse receives the form. The Nurse ' s Notes dated 12/7/11 at 2:15 p.m. revealed Resident #6 left the facility for a doctor appointment. At 10:00 p.m., the hospital called and reported Resident #6 admitted to the hospital. The hospital Physician Discharge Note dated 12/13/11 revealed a primary discharge [DIAGNOSES REDACTED].