Every finding on record at River Hills Village in Keokuk

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure dietary staff served the correct portion size to meet the nutritional needs of the 9 residents (Residents #2, #3, #13, #20, #28, #30, #36, #56, #62) with a mechanical soft or puree diet order for one of one meal service observation. The facility reported a census of 65 residentsFindings include: 1. During an observation on 9/16/2025 at 10:04 AM, observation of the lunch meal preparation for mechanical soft and pureed diets revealed the following: Staff N, Cook, placed eight servings, four ounces each serving, of beef pot roast into a machine that mechanically ground the meat and added beef broth. The total amount of ground meat measured seven cups. Staff N, Cook, then placed five servings, 4 ounces of beef pot roast per serving, plus five pieces of bread with butter into the Robot Coup. Staff N added an unmeasured amount of beef broth to the mixture. Staff N ground the meat, bread, butter and brother mixture to a pureed texture. Staff N measured the total amount of the pureed mixture to equal 5 cups. The Dietary Manager reviewed the food service diet portion size chart and reported Staff N should use two #8 scoops (for a total of 8 ounces). At 11:49 AM, Staff N, Cook, began food service in the memory care unit and then served the lunch meal in the main dining room. Staff N used one #8 white scoop (4 ounces) to serve each of the residents with a mechanical soft diet their meat. Staff N served a total of six residents a mechanical soft diet, Residents #2, #3, #13, #28, #36, and #62. Staff N used one #8 white scoop (4 ounces) to serve each of the residents with a pureed diet their meat, bread and butter. Staff N served a total of three residents with pureed diets, Resident #20, #30 and #56. Staff N, [NAME] completed the lunch meal service at 12:22 PM. During an interview at the conclusion of the meal, Staff N confirmed she should have used two #8 scoops to serve the pureed meat and a #8 scoop plus a #10 scoop to serve the mechanical ground meat.During an interview on 9/16/25 at 12:42 PM, the Dietary Manager reviewed the food service diet portion size chart, and based on the number of servings added to the food processer and the amount of food measured after the cook ground the meat, reported Staff N should use a #8 (4 ounces) scoop and a #10 (3 ounces) to serve the residents with a mechanical soft diet.2. The Minimum Data Set (MDS) assessment for Resident #2, dated 7/20/25, included the following documentation: the resident had diagnoses of dementia, dysphagia (difficulty swallowing), and malnutrition; the resident required supervision or touch assistance with eating; the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated a severe cognitive impairment.Review of the Electronic Health Record (EHR) revealed:a. A General Order, dated 6/14/23, with a physician's order for a mechanical soft diet.b. The Care Plan, last revised 9/15/25, identified Resident #2 at risk for malnutrition and weight loss.3. The MDS assessment for Resident #3, dated 8/13/25, included the following documentation: the resident had a diagnosis of dementia; the resident had difficulty swallowing; the resident required partial to moderate assistance with eating; the resident had a BIMS score of 1 out of 15, which indicated a severe cognitive impairment.Review of the EHR revealed:a. A General Order, dated 7/23/25, with a physician's order for a mechanical soft diet.4. The MDS assessment for Resident #13, dated 7/16/25, included the following documentation: the resident had diagnoses of dementia, dysphagia, and malnutrition; the resident required set up assistance with eating; the resident had a BIMS score of 5 out of 15, which indicated a severe cognitive impairment.Review of the EHR revealed:a. A General Order, dated 3/5/25, with a physician's order for a mechanical soft diet.b. Care Plan, last revised 8/13/25, identified the resident at risk for choking and weight loss.5.The MDS assessment for Resident #20, dated 8/13/25, included the following documentation: the resident had a diagnosis of dementia; the resident had difficulty swallowing; the resident was dependent on staff for eating; the resident had a severe cognitive impairment.Review of the EHR revealed:a. A General Order, dated 4/19/22, with a physician's order for a pureed diet.b. Care Plan, last revised 8/19/25, identified the resident at risk for choking and included a goal for the resident to maintain her weight.6.The MDS assessment for Resident #28, dated 8/27/25, included the following documentation: the resident had a diagnosis of dementia; the resident had difficulty swallowing; the resident required set up assistance with eating; the resident had a BIMS score of 0 out of 15, which indicated a severe cognitive impairment.Review of the EHR revealed:a. A General Order, dated 10/18/23, with a physician's order for a mechanical soft diet.7.The MDS assessment for Resident #30, dated 6/18/25, included the following documentation: the resident had a diagnosis of dementia; the resident had difficulty swallowing; the resident required set up assistance with eating; the resident had a BIMS score of 6 out of 15, which indicated a severe cognitive impairment.Review of the EHR revealed:a. A General Order, dated 7/7/25, with a physician's order for a pureed diet.8.The MDS assessment for Resident #36, dated 8/6/25, included the following documentation: the resident had a diagnosis of dementia; the resident required set up assistance with eating; the resident had a BIMS score of 1 out of 15, which indicated a severe cognitive impairment.Review of the EHR revealed:a. A Dietary progress note, dated 9/12/25, revealed [Name redacted, Resident #36] will follow a mechanical soft diet with a plate guard at all meals.b. Care Plan, last revised 9/12/25, identified the resident at risk for choking and weight loss.9. The MDS assessment for Resident #56, dated 7/16/25, included the following documentation: the resident had a diagnosis of Alzheimer's dementia; the resident had difficulty swallowing; the resident was dependent on staff for eating; the resident had a severe cognitive impairment.Review of the EHR revealed:a. A General Order, dated 2/21/24, with a physician's order for a pureed diet.b. Care Plan, last revised 7/22/25, identified the resident at risk for choking and weight loss.10. The MDS assessment for Resident #62, dated 7/30/25, included the following documentation: the resident had a diagnosis of Alzheimer's dementia; the resident had difficulty swallowing; the resident was dependent on staff for eating; the resident had a severe cognitive impairment.Review of the EHR revealed:a. A General Order, dated 4/28/25, with a physician's order for a mechanical soft diet.b. Care Plan, last revised 8/5/25, identified the resident at risk for choking and weight loss.Review of the facility policy, titled Food Service, dated 9/2010, revealed the food service staff were responsible for serving the food as ordered.

Based on meal services observation, facility policy review, review of the Federal Food and Drug Administration Code, and staff interview, the facility failed to ensure dietary staff served food under sanitary conditions for one of one meal service observations. The facility reported a census of 65 residents.Findings include:During an observation on 9/16/25 at 11:49 AM, Staff N, Cook, uncovered the pans on the steam table in the memory care dining unit, gloved, uncovered plates, and served the lunch meal to residents in the memory care unit. At 12:02 PM, Staff N completed the lunch service in the memory care unit. While keeping the same pair of gloves on, Staff N covered all of the food pans with lids, unplugged the electric cord for the steam table cart, picked the electric cord off the floor, wound the cord the up and placed the cord on the bottom of the steam table. Staff N then pushed the steam table cart to the main dining room. Staff N kept the same pair of gloves on and served the lunch meal to residents in the main dining room. During the main dining service, Staff N was observed to touch her gloves with some of the food she scooped onto the plates and she was observed to place food on the areas of the plate wear her unclean gloves had touched. On 9/16/2025 at 12:42 PM, the Dietary Manager reported they served a total of 32 residents in the main dining room and confirmed Staff N, Cook, should have changed gloves and washed her hands prior to serving food in the main dining room. The facility policy, titled Food Service, dated 9/2010, identified the food service staff were responsible for serving the food. The Food and Drug Administration (FDA) Food Code, dated 2017, identified under section 2-301.14 the following: food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including, but not limited to, after handling soiled equipment or utensils; during food preparation; as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and, after engaging in other activities that contaminate the hands.

Based on observation, clinical record review, facility policy review, and staff interviews the facility failed to ensure staff transferred a resident in a dignified manner for 1 of 1 resident (Resident #18) reviewed for dignity. The facility reported a census of 65 residents.Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated a severe cognitive impairment. The MDS indicated the resident had a bilateral lower extremity impairment and used a wheelchair. The MDS indicated the resident required partial/moderate assistance with sitting to standing; and dependent with chair/bed to chair transfer. The MDS list of diagnoses included non-Alzheimer's dementia and unspecified osteoarthritis, unspecified site.Review of Care Plan dated 8/19/25, revealed a Focus area of Resident Care Information. Interventions included Safe Resident Handling Procedures-Transfer method with assist x 1 manual stand aide for all transfers, date 5/13/24; and wheelchair for mobility, dated 4/21/25. The Care Plan also included a Focus area, dated 8/29/25, for resident being at risk for falling related to dementia, macular edema, atrial fibrillation, incontinence, unsteady gait, history of falling . Interventions included in part, assist x1 with manual stand aid for all transfers, dated 3/25/25 indicated assist x1 with manual stand aid for all transfers During an observation on 9/15/25 at 8:37 AM, Staff C, Certified Nurse Aide (CNA) transported Resident #18 in the non-mechanical stand aid from the dining room table to Resident #18's room. Resident #18 sat at the dining room table on the opposite side of Resident #18 room. During an observation on 9/15/25 at 12:50 PM, Staff C, CNA used the non-mechanical stand aid to transport Resident #18 to her room from the dining room. During an observation on 9/16/25 at approximately 8:30 AM, Staff C, CNA helped assist Resident #18 onto the non-mechanical stand aid and transported Resident #18 from the dining room to Resident #18 room. On 9/16/25 at 12:36 PM, Staff C, CNA assisted Resident #18 onto the non-mechanical stand aid. Staff C asked Resident #18 multiple times to stand, and eventually Resident #18 stood up. As Staff C transported Resident #18 to her room, Staff C told Resident #18, she couldn't be sleeping when Resident #18 was being pulled to her room, because Resident #18 needed to hold onto the bar. Staff C reminded Resident #18 a few times to stay awake and Staff C pulled her to her room. During an interview on 9/17/25 at 1:23 PM, Staff A, CNA queried on using the non-mechanical stand aid to transfer Resident #18 to her room, and Staff A stated she never saw anybody do it. Staff A asked why she wouldn't transfer Resident #18 from the dining room to Resident #18 room, and Staff A stated she thought it could be a dignity or safety concern. During an interview on 9/17/25 at 1:38 PM, Staff B, CNA queried if she ever transported Resident #18 from the dining room table to Resident #18 room using the non-mechanical stand aid and Staff B stated she did. Staff B asked the reasoning for it, and Staff B stated it had just become a pattern, and everyone did it. During an interview on 9/17/25 at 3:09 PM, Staff C, CNA queried if she used the non-mechanical stand aid to transport Resident #18 to her room and Staff C stated yes. Staff C asked the reason behind it and Staff C stated because the rooms were so close. Staff C stated when Staff C took Resident #18 to the shower, Staff C would put her in the wheelchair instead of using the non-mechanical stand aid. Staff C asked about the transfer yesterday after lunch and Staff C stated Resident #18 slept at the dining room table at times, and sometimes Resident #18 will close her eyes when Staff C transports Resident #18 to her room, but Resident #18 never let go of the bar.During an interview on 9/18/25 at 11:40 AM, Staff B, CNA queried if she had any dignity or safety concerns with transporting Resident #18 the non-mechanical stand aid and Staff B stated more of a dignity concern because having her on the stand while other residents and family can see Resident #18 transported across the room. During an interview on 9/18/25 at 12:43 PM, the Director of Nursing (DON) informed of Resident #18 being transferred to her room using the non-mechanical stand aid and the DON stated she thought Resident #18 should have been transported in Resident #18 wheelchair. The DON confirmed it was a dignity concern because with the distance, Resident #18 would be visible to the family and residents and it would stand out. The DON confirmed the non-mechanical stand aid needed to change position or for a short transfer, not wheeled across the room. Review of the undated facility policy, titled Resident Rights revealed the following statement: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, review of facility policy, staff, resident and resident representative interview, the facility failed to ensure the resident and the resident's representative were included in the care plan process for 1 of 1 resident sampled (Resident #4) for care plans. The facility reported a census of 65 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #4, dated 8/20/25, included the following documentation: the resident had diagnoses of heart failure, respiratory failure, cognitive communication deficit, and malnutrition; the resident had upper and lower body impairments bilaterally, utilized a wheelchair for mobility, and was dependent on staff for toileting hygiene and transfers; the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (indicative of a moderate cognitive impairment). On 9/16/25 at 8:57 AM, Resident #4 reported not being aware of being involved in the care planning process and was not sure that his family was involved in the process. Resident #4 reported his upper dentures were wore out and in need of repair or replacement. Resident #4 explained the problem with his dentures made it difficulty to eat. The resident was unsure if the facility was aware. He was not sure who he said something to about his dentures, or what was being done about it. On 9/17/25, review of the clinical record for Resident #4 revealed the following: a. The MDS assessment list included documentation of an admission assessment, dated 11/15/24, three quarterly assessments, dated 2/15/25, 6/18/25 and 8/20/25, and one significant change in condition assessment, dated 4/22/25. b. The facility document, titled Care Conference Report (care plan meeting list), included documentation of two care conferences, dated 11/18/24 and 12/9/24. The care conference meetings included documentation that both the resident and the resident's family participated in the meetings. The clinical record lacked documentation of a care conference, resident or family participation in the care planning process for the quarterly MDS assessments and significant change in condition MDS assessment. The clinical record lacked documentation the resident and his family had been invited to any care plan meetings. c. A facility document, titled General Order, dated 4/4/25, included a signed physician order written by Staff E, Licensed Practical Nurse (LPN), for the facility staff to make an appointment for Resident #4's dentures. The clinical record lacked any other documentation in relation to Resident #4 needing an appointment for his dentures. d. The facility document for Resident #4, titled Care Plan, and last revised 9/15/25, included care plan concerns related to the resident being at risk for weight loss and at risk for choking due to dysphagia (difficulty swallowing). The care plan did not identify the resident's concern with needing his dentures fixed. On 9/17/25 at 10:31 AM, during an interview, the family member designated as a Power of Attorney (POA) for Healthcare decisions reported not getting invited to any care conferences for Resident #4 since December 2024. The POA reported that they would attend the care conference meetings if they had been invited. The POA was unaware that Resident #4 had reported problems with his dentures and reported relying on facility staff to talk care of the resident's dental and physical health appointments. On 9/17/25 at 11:04 AM, Staff E, LPN, thought the resident was having problems with his upper dentures, and she recalled Resident #4 wanted to get his dentures fixed. She recalled getting an order for the resident to get his dentures fixed. Staff E explained when the staff received a physician order to set up an appointment, they filled out a transportation form and sent the form to Staff H, Transportation Aide. Staff H made all the resident appointments outside of the facility and provided transportation. Staff E reported she filled out a request for Resident #4 for his dentures. On 9/17/25 at 11:28 AM, the Assistant Director of Nursing (ADON)/MDS Coordinator reported she was responsible for the completion of all MDS assessments and care plans. The ADON/MDS Coordinator reported being responsible for setting up the care conference meetings for residents and sending invitations to residents and their family members; she did not keep a copy of the invitations. The ADON/MDS Coordinator reported she put a note in the clinical record under progress notes if the resident or their family member chose not to participate in the meetings. The ADON/MDS Coordinator explained they held care conference meetings for residents with any MDS assessment, including a significant change in condition MDS and quarterly MDS assessments. The ADON/MDS Coordinator reviewed the clinical record for Resident #4 and confirmed the resident had not had a care conference meeting, did not have documentation of an invitation to a meeting, and did not have documentation of a refusal to attend a care conference meeting. The ADON/MDS Coordinator explained she did not know what happened. On 9/17/25 at 11:35 AM, the ADON/MDS Coordinator reported she would include any dental concerns a resident or family member identified in the resident's care plan if she was aware of the concern. The ADON/MDS Coordinator reported she had not been aware of the dental concern for Resident #4. On 9/17/2025 at 11:39 AM, Staff H, Transportation Aide, reported Resident #4 had been on the waiting list for the College of Dentistry to get his dentures fixed since April 2025. Review of the facility policy, titled Care Plan Policy, dated 6/1/2022, revealed the comprehensive care plan would be prepared by an interdisciplinary team, that included, but was not limited to the resident and the resident's representative. The care plan would include the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 9/18/25 at 2:30 PM, the Administrator reported being aware of Resident #4's denture concerns. The Administrator reported she had spoken with the resident's other POA/family member regarding the resident's dentures. The Administrator reported the POA/family member the Administrator spoke with was considered the person that the facility called and spoke with first regarding any concerns with the resident. The Administrator explained the primary POA took the resident out for lunch every week, and the Primary POA had reported the Resident voiced concerns regarding his dentures during the those weekly lunch visits. The Administrator further explained the lack of providers for denture care that took the resident's insurance.

Based on clinical record review, resident interview, observation, staff interview and policy review, the facility failed to following professional standards of practice regarding the provision of wound care documentation and treatment for 1 of 1 residents sampled (Resident #4) with a pressure ulcer wound. The facility reported a census of 65. Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #4, dated 8/20/25, revealed a list of diagnoses which included heart failure, respiratory failure, and malnutrition. The MDS identified the resident with bilateral upper and lower body impairments, utilized a wheelchair for mobility, and dependent on staff for toileting hygiene and transfers. The Brief Interview for Mental Status (BIMS) score of 12 out of 15 identified Resident #4 with a moderate cognitive impairment.Review of the Care Plan, last revised 9/15/25, identified Resident #4 at risk for pressure ulcers related to decreased mobility, generalized muscle weakness, chronic obstructive pulmonary disease, oxygen use, indwelling catheter, admitted with Stage 3 (wound with a full loss of skin layer with the layer of fat exposed) pressure injuries (wound resulting from pressure, friction and/or moisture) to the left buttock, chronic kidney disease, diabetes, and mild protein-calorie malnutrition. The Care Plan included interventions related to mitigating the risk of the development of pressure ulcers including pressure relieving devices, skin assessment and turning and repositioning the resident. The facility document, titled Prescription Order, dated 6/30/25, included a physician order for the topical application of Miconazole antifungal cream 2 percent mixed with Triad cream and applied daily to coccyx, buttock and right hip area daily until healed.Review of the September 2025 Treatment Administration History for the time period of 9/1/25 to 9/17/25, identified a scheduled treatment to apply a Miconazole and Triad cream mixture to the coccyx, buttock and right hip daily between 5:00 AM and 7:00 AM. The Treatment Administration History included documentation Staff D, Licensed Practical Nurse (LPN), applied the treatment on 9/15/25 and 9/16/25, and Staff I, Registered Nurse (RN) applied the treatment on 9/17/25. During an interview on 9/16/25 at 8:57 AM, Resident #4 reported he had a sore on his bottom. Resident #4 reported nursing staff were performing wound care on his sore bottom, and he had a lot of pain with the wound.During an observation on 9/17/25 at 7:19 AM Staff D, LPN, performed wound care on Resident #4's buttock and scrotum area. Staff D also assisted Staff J, Certified Nursing Aide (CNA) perform personal cares which included incontinence care during the observation. During the course of applying wound care treatment, Staff D, LPN, measured a total of 4 open wounds; one upper right outer buttock wound measured 2.6 centimeters (cm) in length by 1.6 cm in width, a second right upper buttock wound measured 0.5 cm in length and 0.5 cm in width, a mid-lower right buttock wound measured 2.5 cm in length and 1.5 cm in width, and a wound to the back side of the scrotum measured 1cm in length and 0.5 cm in width. Observation revealed all four wounds had a shallow depth measurement of 0.1 cm approximately. Staff D, LPN, reported the wounds had all opened today (9/17/25). Staff D, LPN, applied the Miconazole and Triad cream mixture to the wound areas. Review of the electronic health record (EHR) revealed the following:a. A Nursing note, entered on 9/8/25 at 12:56 PM, Treatment applied to buttocks, blanchable (a reddened area that turned white when pushed on and indicative of area that had blood flow) light pink erythema (redness).b. A Nursing note, entered on 9/10/25 at 5:28 PM, Treatment applied to buttocks, blanchable light pink erythema.c. A Nursing note, entered on 9/12/25 at 1:28 PM, Treatment applied to buttocks, blanchable light pink erythema.d. A Nursing note, entered on 9/14/25 at 9:48 PM, Treatment applied to bottom, blanchable . Review of the EHR revealed no further documentation related to the condition of Resident #4's buttocks.During an interview on 9/17/2025 at 8:55 AM, Staff D, LPN, reported Resident #4's wounds had all been reddened, a darker pink in color, blanchable and not open on 9/15/25 and 9/16/25. Staff D, LPN, explained nursing staff did not document wound measurements on wounds that were not open. During an interview on 9/17/2025 at 1:27 PM, Staff K, CNA, reported she did work on 9/16/25 with Resident #4 during the day shift (6:00 AM to 2:00 PM). Staff K reported she informed Staff D, LPN of open areas on Resident #4 right buttocks during the 9/16/25 shift. During an interview on 9/17/2025 at 2:05 PM, Staff L, CNA, confirmed she worked second shift on 9/16/25 (2:00 PM to 10:00 PM) and provided personal cares to Resident #4. Staff L reported Resident #4 had at least one open area on his buttocks that was leaking fluid. Staff L, CNA, reported she told Staff F, RN, about the wound. Staff L, CNA, explained Staff F, RN, gave her some white cream in a medicine cup to put on the buttock wound. Staff L, CNA, reported she applied the cream, but did not know what the cream was that she applied. During an interview on 9/17/25 at 2:20 PM, Staff F, RN, reported he had worked second shift on 9/16/25. Staff F, RN, reported the wounds on Resident #4 were not open until Staff D, LPN, discovered them today (9/17/25). When asked if Staff L, CNA, had told him that the resident had an open wound on the resident's buttock that was leaking on 9/16/25 during second shift, Staff F, RN, confirmed Staff L, CNA, had told him about the wound. Staff F, RN, reported he had assessed Resident #4's buttocks on 9/16/25. Staff F reported he found one open wound on the lower buttocks area, but did not see the wound leaking. Staff F, RN, reported none of the upper right buttock or scrotum wounds were open on 9/16/25. Staff F, RN, reported he put Triad cream in a cup and gave to Staff L, CNA, to apply to the wound on 9/16/25. During an interview on 9/17/2025 at 2:24 PM, the Director of Nursing (DON) reported Staff D, LPN, found the wounds on Resident #4 today (9/17/25). The DON was unaware Resident #4 had at least one open wound on 9/16/25 during first and second shift. The DON reported the nurse should have documented the open wound, physician notification and notification of the Resident's Power of Attorney (POA) when the nurse discovered the wound. The DON reported she was going to talk with her staff and find out what happened. Review of the EHR revealed a Resident Progress Note, date 9/16/25 8:31PM (Recorded as a Late Entry on 9/17/25 2:50 PM) Upon entering room CNA were changing resident. Noted small stage 2 pressure right lower buttock 0.5 (cm in length) x 0.5 (cm in width). Slight drainage noted serosangous (serosanguineous, a watery, blood-tinged fluid). Treatment applied as ordered to entire area. NP (nurse practitioner) and POA notified. During an interview on 9/17/2025 at 3:33 PM, Staff L, Advanced Registered Nurse Practitioner (ARNP) stated she had a message from a nurse last night (9/16/25) around 8:31 PM regarding Resident #4 with an open buttock pressure ulcer. Staff L reported she did not change wound care orders and planned on coming to the facility to assess the resident herself later in the evening on 9/17/25. During an interview on 9/18/2025 at 9:33 AM, the DON she expected nurses would apply physician ordered wound care treatments, not the CNAs. During an interview on 9/18/2025 at 10:40 AM Staff I, RN, confirmed she worked 6:00 PM on 9/16/25 to 6:00 AM on 9/17/25 and that she applied the morning Miconazole and Triad cream mixture to Resident #4's buttock. Staff I reported that when she assessed Resident #4's buttocks area on 9/17/25, there was a large effected area that appeared macerated (softened skin, wrinkly in appearance), sore, dark red in color. Staff I reported the resident did have open wounds. Staff I reported she did not document the wounds, and could not state why. Staff I explained that she should have documented the assessment of the wounds in a progress note, notified the physician and opened an event documentation to track the wound. Review of the facility policy, titled Pharmaceutical Procedures, dated 1/5/23, revealed nursing staff were responsible for administering medications as ordered by the physician. The facility policy, titled Wound Care, dated 10/16/24, included directions to staff to follow physician's orders for wound care, document wound care with each treatment and no less than daily, open an event in the electronic health record for documentation on the wound. Wound documentation should include any changes in wound and any other pertinent observations.

Based on observation, interview, and record review the facility failed to ensure an insulin pen was primed prior to insulin administration for one of two residents reviewed for insulin during the medication administration task (Resident #26). The facility reported a census of 65 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status exam, which indicated severely impaired cognition. Per this assessment, the resident took insulin for seven of the last seven days. The Care Plan dated 8/22/23 revealed, Problem: [Resident #26] has diabetes. The intervention also dated 8/22/23 revealed, Approach: Administer insulin as ordered. Monitor for side effects. Observation conducted 9/11/24 at 11:20 AM revealed Staff A, Licensed Practical Nurse (LPN) prepared insulin via a Novalog Flexpen to administer to Resident #26. During preparation of the insulin pen to administer insulin to the resident, Staff A was not observed to prime the insulin pen prior to then administering insulin to the resident. On 9/11/24 at 11:30 AM when queried about priming, Staff A explained if the bubble was at specific place in the pen, it was sufficient. Staff A explained this was what she had been told. When queried who told her that, Staff A responded the Assistant Director of Nursing (ADON). On 9/12/24 at 9:57 AM during an interview with the ADON about how staff instructed to prime, the ADON responded that would be with [DON name redacted], and [DON name redacted] did clinical with all the nurses. When queried if she gave it what would do, the ADON responded prime. On 9/12/24 at 12:26 PM when queried about priming a Novalog Flexpen, the Director of Nursing (DON) explained to prime with two units, inject that, and dial the dose. The DON acknowledged from prior experience always had to inject 2 units. The Facility Policy titled Insulin Administration Procedure dated 2/04 did not address insulin administration via pen. Review of additional documentation provided by the DON titled Novalog Flexpen (insulin apart injection) 100 units/mL (milliliter) revealed the following: Step 3 Perform An air shot. For each injection: 1. Select a dose of 2 units. 2. Take off the outer needle cap (save it) and inner needle cap (throw it away) 3. With the pen pointing up, tap the insulin to move the air bubbles to the top. 4. Press the button all the way in and make sure insulin comes out of the needle. a. Repeat up to two more times with the same needle if needed. b. If insulin does not come out after three times, change the needle and try again. c. If insulin still does not come out after changing the needle, the pen may be broken.

Based on clinical record review, facility policy, resident and staff interviews, and facility investigation documentation the facility failed to use the necessary transfer equipment when assisting a resident in the bathroom, resulting in a lower leg fracture for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 64 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #2 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The MDS assessed the resident as dependent on staff for toileting hygiene and chair/bed to chair transfers. The MDS listed diagnoses included: stroke, arthritis, and hemiplegia and hemiparesis (paralysis on one side of the body) affecting the right side. The Electronic Health Record (EHR) revealed Resident #2 admitted to the facility on [DATE] after a hospitalization for a stroke. The Care Plan, dated 4/26/24, included a Problem area related to Resident Care. An Approach, dated 5/1/24, specified Safe Resident Handling Procedures - Transfer Method: Manual STAND AID Level of assistance; assist of 1; Must be wearing shoes for transfers. The Care Plan, also identified a Problem area for Risk of falling R/T (related to) recent illness/hospitalization and new environment, impaired mobility, generalized weakness, CVA (cerebrovascular accident, or stroke) with right sided hemiplegia, Anemia, COPD (chronic obstructive pulmonary disease), CKD (chronic kidney disease), HTN (hypertension, or high blood pressure), Arthritis, Neuropathy (pain related to nerve damage), incontinence, and possible side effects of medication. An Approach, dated 5/1/24, specified Assist x1 (of one staff) with Manual Stand Aid for transfers. A Progress Note, dated 5/1/24 at 10:46 AM, communicated Therapy recommendation: Assist x1 with Manual Stand Aid for transfers. A Progress Note dated 5/7/24 at 12:16 PM, revealed the resident complained of pain in right hip and leg. She stated her leg got caught under the wheel chair and behind her other leg when the CNA did a stand pivot transfer from the toilet to her wheelchair. Resident #2 stated she had pain in her hip like her socket is hurting on the right side. The Progress Note dated 5/7/24 at 12:27 PM, revealed nurse spoke with daughter about incident . NP (Nurse Practitioner) here and gave order to send to ER to rule out FX (fracture). Notified daughter, that we would be sending to [name redacted] ER (emergency room ) for x ray to rule possible fracture. Impressions for a X-Ray of the right knee due to injury, pain from the hospital Final Report dated 5/7/24: a. Obliquely oriented comminuted fracture through the proximal fibula. b. Increased density projects over the joint space interval which can be seen with CPPD (calcium pyrophosphate dihydrate) arthropathy (crystal build up in joint). A Progress Note dated 5/7/24 at 5:33 PM from nursing staff documented will utilize Assist x2 with Full Mechanical Lift for transfers, until therapy can re-evaluate transfer status. The Facility Investigation Witness Statements, dated 5/7/24, revealed: a. Staff A, Registered Nurse (RN): Staff A approached at 12:15 PM by Staff C, OTA (Occupational Therapy Assistant) and asked what happened to Resident #2. Staff A was unsure of any incident. Staff C pointed out that Resident #2 had an ice pack on her leg and the family told her they were concerned that she been injured during a transfer in her bathroom. Staff A immediately asked Resident #2 what happened and she stated her leg got caught under the wheelchair and behind her other leg when the CNA (Certified Nursing Assistant) took her off the toilet and put her in her wheelchair. Resident #2 stated she had pain in her hip like her socket and it hurt on the right side. Staff A then approached Staff B, CNA and asked what happened. She said her right leg got twisted up when she transferred her to the toilet. b. Staff B, CNA: Staff B took Resident #2 to the restroom and put her on the toilet with a stand pivot transfer. On the transfer back into the wheelchair Resident #2 leg was close to the wheelchair leg and it twisted. Resident #2 said ow [ouch] but did not yell out. Resident #2 said my knee kind of hurt so Staff B got an ice pack for her. Staff B did not let the nurse know right away because Staff B had not found her yet. But the resident saw her before me and told her. Afterwards, a fell ow CNA said Resident #2 was a stand aid. Staff B got her confused with another resident. c. Staff C, OTA: Staff C attempted to see Resident #2 for her OT therapy session. Upon entering Resident #2 room Staff C noticed that Resident #2 had an ice pack on her right knee. Staff C questioned what the ice pack was for and Resident #2 stated that her knee felt a little sore since going to the bathroom with the CNA earlier. Resident #2 stated it was a little sore but did not have any abnormal facial grimacing and was able to carry conversation and smile. Staff C spoke with Staff A and asked about the ice pack .Staff A stated she was unsure of an incident and would see what she could find out. Staff A returned to the gym around 12:30 PM with Resident #2 and asked if Staff C would assist in completing a sit to stand with the stand aid, as per care planned, to assess if there were any concerns with the current transfer recommendation. Staff C applied a gait belt around Resident #2 and instructed Resident #2 to perform a sit to stand transfer within the stand aid but to let me know if she was having any increased pain during the process. Resident #2 was able to set her feet on the platform of the stand aid without any additional difficulty or facial grimacing and was able to pull herself to a standing position with contact guard, very minimal, assist as per her normal. During weight bearing within the stand aid, Resident #2 reported having increased discomfort in her right hip. d. Assistant Director of Nursing (ADON): At approximately 12:00 PM to 12:30 PM, Staff A came to ADON office, and stated she needed to talk with me. Staff A then informed the ADON .an aide had come in to toilet [Resident #2] and now she complained of pain in her right leg. The ADON asked Staff A to go speak with the aides and find out who did the transfer and bring them back to the ADON office to discuss what occurred. At this time, Resident #2 sat in her wheelchair in the dining room, eating and having conversation with her table mate. No signs of distress noted asked how she felt. Resident #2 stated not bad, she had discomfort in her right leg .Staff B stated she transferred Resident #2 from the wheelchair to the toilet and then from the toilet to the wheelchair with an assist x 1 with pivot transfer. Staff B stated that Resident #2 right leg got twisted during the transfer from the toilet to wheelchair. The ADON asked Staff B if that was care planned transfer status of Resident #2 and she stated no, it wasn't, but at the time she got Resident #2 confused with another resident and didn't realize it at that time. Staff B reeducated on where to find the resident ' s transfer statuses. Staff B able to state all areas where it was posted. e. Resident #2: The girl took me to the toilet, got me up from the toilet and my bad leg caught on the wheelchair leg and twisted in. The CNA got me in the chair and it hurt and she got me an ice pack. During an observation on 7/15/24 at 12:48 PM- Staff D, CNA (Certified Nurse Aide) placed gait belt around Resident #2 waist and brought her wheeled walker to her and turned the chair to face the walker. Staff D helped Resident #2 up and escorted her out of the dining room holding on to the gait belt and walked beside her. During an interview on 7/15/24 at 1:06 PM, Resident #2 stated she been at the facility since April after she had a stroke and stated she hoped to go home in the beginning of August. She stated she wore a boot for a while because a girl kind of dropped her and busted her leg up. Resident #2 stated she never broke a bone before this and the fracture below her right knee. Resident #2 asked about the incident that caused her leg fracture, and she stated she remembered she wanted to go to the bathroom and then somehow started to fall. She stated it happened not long after she had her stroke. Resident #2 stated she cried out when it happened and the nurse came and checked on her soon after it happened. During an interview on 7/15/24 at 1:39 PM, Staff A, RN stated Resident #2 moved to a stand aid with an assist of 1 transfer status on 5/1/24. [On 5/7/24] Staff C asked her what happened to Resident #2 leg because she had an ice pack on it. Staff A stated Staff C told her, Resident #2 got hurt when a CNA transferred her to the bathroom . Staff A stated she approached the CNA [Staff B] and asked her if she used the stand aid for the transfer and at first she said yes .with the ADON . the CNA [Staff B] stated she didn't use the stand aid, she used a pivot transfer with Resident #2. Staff A stated the residents' transfer status were placed on the white board in the nurse's station for everyone to see and they kept it up to date. During an interview on 7/16/24 at 9:43 AM, Staff B, CNA stated she hadn't worked that hall very often. Staff B stated she remembered the incident with Resident #2 and she made a mistake and got two residents wrong. Staff B stated she did a stand pivot instead of using the stand aid. Staff B stated Resident #2 foot got caught and twisted when they did the stand pivot to the wheelchair. Staff B stated she told Resident #2 she would get a nurse and grabbed her an ice pack. Staff B stated she saw call lights going off and wanted to make sure all her residents safe before she spoke with the nurse. Staff B stated the incident was her fault and she didn't do it intentionally at all. Staff B stated Resident #2 said she felt a little bit of pain after it happened. During an interview on 7/16/24 at 10:51 AM, Staff D, CNA stated if anyone questioned the transfer status of a resident, they could look at the computer for the resident's care plan and look at the white board in the nurse's station. During an interview on 7/16/24 at 11:22 AM, Staff C,OTA stated the day of the incident she saw Resident #2 in the morning and Staff C noticed an ice pad on her knee. Staff C stated Resident #2 laughed about it and said she would let me know later. Staff C then asked Resident #2 if she wanted her to come back later for therapy since Resident #2 family present and she said yes. Staff C stated she asked the nurse if she knew what the ice pack was for and she said she didn't, but would find out. Staff C stated she wanted to make sure the stand aid transfers went okay. Staff C stated the nurse brought Resident #2 to her and they stood Resident #2 up and her hip didn't hurt and Staff C didn't think anything going on, but Staff A wanted to send her out to make sure nothing was wrong and the hospital found out, Resident #2 had a fracture. Staff C stated Ortho gave Resident #2 a choice between a boot or an immobilizer and she choose the immobilizer at first so they used the mechanical lift for transfers to prevent bending. Staff C stated a week after the incident Resident #2 moved to a boot and then transferred with the stand aid. During an interview on 7/16/24 at 3:12 PM, the DON (Director of Nursing) stated the CNA didn't transfer her properly and it was an unfortunate situation that happened. The DON states she would of expected the CNA know the correct transfer for Resident #2 and if she felt uncertain, she should have checked the care plan. During an interview on 7/16/24 at 3:53 PM, the Administrator stated she felt disappointed about the incident and she felt the CNA got Resident #2 mixed up with another resident and staff knew where to look for the resident's transfers. The Facility Safe Resident Handling Policy dated 11/12 revealed the following information: a. All residents assessed for safe resident handling and moving. The assessment will consider: 1. The resident's needs/rights and ability to participate with transfers or lifts 2. The variability in resident behaviors and cognition 3. Staff and resident safety. b. Lift assignment and strategy: 1. Residents evaluated for the type of lift necessary for their needs and the evaluation incorporated into the care plan. The lifting strategy may change during the day or the shift according to the resident's condition. These instructions were care planned and communicated to the staff.

Based on interviews, record review, and the facility policy review the facility failed to ensure accurate records for residents' code status for 2 of 24 residents reviewed for records (Resident #54 and Resident #121). The facility reported a census of 68 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition intact. Resident #54 Face Sheet revealed Do not resuscitate (DNR)/Do Not Intubate (DNI). Resident #54 Iowa Physician Orders for Scope of Treatment (IPOST) revealed the resident's representative signed the IPOST on 1/8/24 indicating DNR and the Advanced Registered Nurse Practitioner (ARNP) signed on 1/9/24. The Physician Orders dated 1/8/24 revealed an order for full code status. The Physician Orders signed on 1/9/24 by the ARNP revealed an order for full code status. The Physician Orders revealed Resident #54 full code order discontinued on 3/5/24 and the DNR order ordered on 3/5/24. During an interview on 3/5/24 at 3:37 PM, Staff A, Licensed Practical Nurse (LPN) queried on where the advanced directives found and she stated on the resident's face page. Staff A asked if she ever looked under the orders for code status and she stated yes, it they questioned it. Staff A stated she also looked under the resident documents for the resident's IPOST and they had a binder that contained the resident's IPOST. Staff A stated they had multiple places to look for the advanced directives. Staff A informed Resident #54 orders revealed a full code order and she stated the full code placed on the same day the resident admitted and they signed an IPOST on the day the resident admitted . Staff A stated she would ask the DON about it and get the order changed. The Facility Policy titled Advance Directives, dated 2/18, revealed, Documentation of the resident's advanced directives shall be present within the medical record and specified on the individual's Face Sheet. All Advance Directives shall be uploaded into [Electronic Health Record] and stored in the resident's clinical record. 45338 2. The Minimum Data Set (MDS) assessment for Resident #121 dated 3/5/24 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. The Physician Order dated 2/28/24 documented, Full Code. The End Date for the Physician Order revealed, Open Ended. The Signed Physician Order Report dated 1/28/24-2/28/24 revealed, Full Code, with Start Date 2/28/24-Open Ended. Review of the Iowa Physician Orders for Scope of Treatment (IPOST) for Resident #121, signed by the Advanced Registered Nurse Practitioner on 2/28/24, signed on the Patient/Resident line on 2/28/24, and signed by Social Services 2/28/24, revealed the option for Do Not Resuscitate (DNR)/Do Not Attempt Resuscitation selected. Review of the Resident Face Sheet for Resident #121 revealed Do Not Resuscitate (DNR) and Do Not Intubate (DNI) present. Continued review of Physician Orders for Resident #121 revealed Full Code order discontinued 3/5/24, and DNR Order present in Resident #121's record on 3/5/24. On 3/5/24 at approximately 4:27 PM during an interview conducted with the facility's Administrator and Director of Nursing (DON), it was explained residents were always entered as a full code until the IPOST signed by the Physician.

Based on interviews, record review, document review, and facility policy review, the facility failed to implement a system for filing and responding to grievances for 3 (Resident #22, Resident #38, and Resident #8) of 3 residents interviewed who were members of Resident Council. The deficient practice had the potential to affect all residents of the facility. Findings included: A review of a facility policy and procedure titled, Grievances, revised on 06/01/2022, revealed, The Facility shall ensure that the resident has the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Grievances shall be addressed by the facility and resolved in a timely manner. The procedure portion of the policy indicated, 1. Residents shall be notified, at the time of admission, of their right to file a grievances orally, or in writing, and of their right to file grievances anonymously; 4. Upon receipt of the grievance, the Grievance Officer or designee shall complete an investigation of the concern as soon as possible and provide appropriate follow through as required; 5. A written decision regarding the grievance shall be made available to the resident upon request; 9. The Grievance Log (NH-352) shall be maintained for 3 years. A review of an admission packet provided to residents or representatives upon admission revealed no evidence of information that explained the grievance process to the resident or representative. A review of Resident Council minutes, dated 04/2022 and recorded by the Activities Director, indicated residents had concerns regarding staff working on the second shift who were not helping with dinner and residents not receiving their food in a timely manner. Resident Council minutes, dated 06/07/2022, indicated residents continued to complain of second shift staff not assisting with meals in a timely manner. The minutes indicated the Activities Director notified management of the concern. Resident Council minutes, dated 07/13/2022, indicated residents had concerns regarding a mailbox looking crooked and ugly. Resident Council minutes, dated 08/10/2022, indicated a resident wanted a door to their room evaluated and another resident wanted old curtains removed. Neither resident was identified in the minutes. Resident Council minutes, dated 09/14/2022, indicated a resident had an issue with a chair in their room. The resident was not identified in the minutes. A review of Resident #22's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 10/12/2022 at 9:23 AM, Resident #22 stated they had multiple concerns with laundry over the last few months and had notified laundry staff and the Administrator, though nothing had been done. Resident #22, who was the president of Resident Council, stated laundry staff had ruined several shirts and pants, most of which started out as dark in color and now had what looked like bleach stains on them. Resident #22 stated the grievance procedure was never brought up in Resident Council meetings. Resident #22 stated the Activities Director took note of any concerns brought up during Resident Council, and the resident confirmed residents were not made aware if their complaint had been addressed by the facility. A review of Resident #38's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating intact cognition. During an interview on 10/12/2022 at 3:40 PM, Resident #38 stated they had no idea how to file a grievance or where the forms were kept. Resident #38 stated no one had ever told them how to file a grievance. Resident #38 stated they had many concerns over laundry bleaching their clothes. Resident #38 stated all their black clothing items were now brown and many of their lighter items were rust colored. The resident stated they had notified laundry staff and was told that laundry staff did not use bleach in the laundry process. A review of Resident #8's admission MDS, dated [DATE], revealed a BIMS score of 13, indicating intact cognition. During an interview on 10/12/2022 at 3:55 PM, Resident #8 stated they had never been told how to file a grievance or where associated forms were kept. Resident #8 stated their family took care of their laundry and they had no concerns or complaints. During a phone interview on 10/13/2022 at 9:30 AM, the Activities Director confirmed he did not utilize a grievance form during Resident Council meetings to record residents' concerns. The Activities Director stated he dealt with all concerns brought up in Resident Council meetings and reported the concerns to the proper department head, such as directing food issues to the dietary department head. The Activities Director stated he reviewed Resident Council concerns from the previous month with the residents to see if any issues were still a concern and confirmed he did not know if residents were made aware by department heads if the grievance had been addressed or resolved. The Activities Director stated he had never used the facility's grievance form in the past but was using it now. An interview was conducted on 10/11/2022 at 9:11 AM with the Director of Nursing (DON). The DON stated the facility did not have a formal grievance procedure, noting the facility simply addressed issues as they arose. The DON asserted the concerns about meals being served late was really about residents arriving to the dining room [ROOM NUMBER] minutes before meal service and then wanting to be served first. The DON stated the facility made a few adjustments in change of shift procedures, but confirmed there was no documentation regarding these changes. The DON stated the facility did not maintain any written documents of reported grievances or the facility's response to the grievances. During an interview on 10/11/2022 at 10:57 AM, the Administrator confirmed she was the Grievance Officer and noted the facility had no grievances from 07/2021 through 10/12/2022. The Administrator stated she attended most Resident Council meetings and was aware of resident concerns. The Administrator stated she addressed concerns as they arose and confirmed grievances and the facility's response to grievances were not documented anywhere. During a follow-up interview on 10/12/2022 at 12:19 PM, the Administrator stated the facility did not use a grievance form to record concerns deriving from Resident Council meetings. The Administrator confirmed the facility had an issue with a washing machine in the laundry department, noting the company who managed the laundry chemicals came to inspect the washer and made some adjustments. The Administrator confirmed that a grievance form with a documented resolution regarding laundry concerns was not filled out and the resolution was not discussed with residents. The Administrator stated she thought concerns about a door brought up during the 08/10/2022 Resident Council meeting was regarding a closet door but could not be sure and thought a concern about a chair brought up during the 09/14/2022 Resident Council meeting was regarding a battery on an electric chair, though she was not sure. The Administrator stated there was no written documentation to denote these issues had been resolved. The Administrator confirmed there was nothing in the admission packet explaining to residents the procedure for filing a grievance. The Administrator stated the grievance process was important, as it identified concerns and trends that could be used in Quality Assurance Performance Improvement (QAPI) meetings, and not addressing concerns could cause distress for residents.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure an oxygen nasal cannula and updraft nebulizer mask were contained when not in use for one (Resident #26) of three sampled residents who received oxygen therapy. Findings included: A review of a facility policy, revised 03/16/2017, titled, Oxygen Therapy, revealed, Objective: 1. To provide a source of oxygen to persons experiencing an insufficient supply of same. Procedure: 7. Oxygen set-up (cannula/mask, tubing) must be exchanged every 7 days. Safety Factors: 7. Be sure to prevent contamination of the oxygen equipment due to its presence in locations such as: Dining Room; Bathroom. A review of a Face Sheet revealed Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #26's annual Minimum Data Set (MDS) assessment, dated 08/31/2022, revealed the resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 6. Per the MDS, the resident received oxygen therapy. A review of Resident #26's Care Plan, reviewed on 05/19/2022, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan intervention directed staff to administer a handheld nebulizer treatment as ordered, monitor for side effects, change oxygen tubing weekly, and to administer oxygen as ordered. A review of Resident #26's October 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/10/2022 at 2:40 PM, an observation was made of Resident #26's nasal cannula prongs for oxygen delivery to the nose resting on the resident's bed next to his/her head. The oxygen updraft nebulizer mask was lying on top of a bedside table and was not bagged or dated. On 10/11/2022 at 8:34 AM, an observation was made of Resident #26's nasal cannula lying on the floor next to the head of the resident's bed. The resident's oxygen updraft nebulizer mask was lying on top of a bedside table and was not bagged or dated. Resident #26 was not in the room at the time of the observation. On 10/12/2022 at 8:14 AM, an observation was made of Resident #26's nasal cannula lying on the resident's bed near the head of the bed underneath a top sheet. The updraft nebulizer mask remained on top of the bedside table and was not bagged or dated. Resident #26 was not in the room at the time of the observation. On 10/12/2022 at 8:27 AM, an observation was made of Resident #26 being pushed in his/her wheelchair from the dining room by Staff E, Human Resources (HR) Manager, to the resident's room. Resident #26's nasal cannula, which was connected to a portable oxygen tank attached to the back of the wheelchair, was draped over the left handle, touching the back of the resident's wheelchair. After Resident #26 was pushed into his/her room, Staff A, Licensed Practical Nurse (LPN), and Staff E were observed transferring Resident #26 using a mechanical lift from the wheelchair onto the bed. The nasal cannula connected to the oxygen concentrator was lying on top of the resident's bed and the updraft nebulizer mask was lying on top of a bedside table. As Resident #26 was lowered down onto the bed, the nasal cannula dropped onto the floor, and Staff E picked it up off the floor and placed it on top of the bedside table next to the resident's updraft nebulizer mask. During an interview on 10/12/2022 at 8:47 AM with Staff A (LPN), she indicated Resident #26's updraft nebulizer treatments were administered as needed, and she was not certain when the resident last received one. Staff A further confirmed the mask should be bagged and dated when not in use and should not be lying on top of the bedside table. She also confirmed that the resident's nasal cannula connected to the portable oxygen tank and to the concentrator should be bagged and dated when not in use, noting it all should be changed out weekly. During an interview on 10/12/2022 at 8:53 AM with the Director of Nursing (DON), she confirmed Resident #26's nasal cannula and updraft nebulizer mask should be bagged and dated when not in use. She indicated her expectation was for staff to place the cannula and mask in a dated bag anytime staff took off the resident's nasal cannula or updraft mask, noting the equipment should be changed out at least weekly according to standards of practice to prevent the potential of spread of infection, even though their policy and procedure currently did not specifically address this issue. During an interview on 10/12/2022 at 3:00 PM, the Administrator revealed she expected staff to place a resident's oxygen tubing and/or updraft nebulizer mask in a bag when not in use to prevent the spread of infection.

Based on interviews, record review, and facility policy review, the facility failed to ensure medical records were accurate and complete for one (Resident #23) of three sampled residents reviewed for accurate and complete medical records. Specifically, the facility failed to ensure Proof of Use forms were maintained for residents who utilized controlled substances. Findings included: A review of a facility policy, revised 06/01/2022, titled, Medical Records, revealed, Policy: It is the policy of the facility that an active or inactive record shall be kept for each resident as outlined. This record shall be kept current, dated, signed, complete, legible, and available at all times to the personnel of the facility and any other entities as needed. A review of a facility policy, revised 04/12/2022, titled, Pharmaceutical Procedures, revealed a listed purpose of the policy was To provide the appropriate control of procurement, distribution, administration, and utilization of drugs to the facility. Further review of the policy revealed a Drug Administration and Documentation procedure for Controlled Substances denoting that, For all schedule II substances, a controlled substances record shall be maintained which lists on separate sheets, for each type and strength of schedule II substance, the following information: date, time administered, name of resident, dose, physician's name, signature of person administering dose, and number of doses remaining. A review of a Face Sheet revealed Resident #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #23's quarterly Minimum Data Set (MDS) assessment, dated 08/24/2022, revealed the resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10, received routine and pro re nata (PRN; as needed) pain medication, and received opioid medication one day of the seven-day look back period. A review of Resident #23's Care Plan, last reviewed by staff on 08/29/2022, revealed a problem onset regarding pain related to bilateral lower extremity (BLE) weakness, spinal stenosis, bilateral shoulder pain, [CONDITION(S)], and bursitis to the left knee. The care plan intervention directed staff to administer pain medication as ordered. A review of Resident #23's October 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #23's November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A further review of the record revealed no evidence of a Proof of Use (narcotic sign out) form for the narcotics documented as administered in the resident's record. During an interview on 10/12/2022 at 12:27 PM, Staff B, Medical Records, indicated she had no record of Resident #23's Proof of Use forms for the administration of [MEDICATION(S)]-acetaminophen medication in November of 2021. Staff B confirmed she only maintained a resident's Proof of Use forms in her office for 30 days and then shredded the forms after 30 days. Staff B indicated she only scanned a Proof of Use form into a resident's electronic health record when it was attached to a controlled substance inventory form. An interview with the Director of Nursing (DON) on 10/12/2022 at 1:29 PM revealed Resident 23's Proof of Use form for the [MEDICATION(S)]-acetaminophen that was administered to the resident in November of 2021 had been destroyed. The DON stated her expectation was for Staff B to scan and save controlled substance Proof of Use forms into the resident's electronic health record and to save the originals as well in the Medical Record office. During a phone interview on 10/12/2022 at 1:43 PM with the Pharmacist, he stated he was not aware the facility had not been keeping the resident's narcotic Proof of Use forms. During an interview on 10/12/2022 at 1:50 PM with the Administrator, she stated she was not aware staff were shredding the narcotic Proof of Use forms until the previous day, 10/11/2022, when the DON brought it to her attention. She said that her expectation concerning this issue was for staff to immediately start scanning the forms into the resident's electronic health record and to keep the original in a file cabinet in the Medical Record office.

Based on observation, record review, resident and staff interviews, the facility failed to answer call lights in a timely manner for five out of seven residents reported during the Resident Council Meeting (Residents #8, #9, #17, #23, and #49), for one resident interviewed (Resident #3) and an observation of one resident who had a call light on for more than 15 minutes (Resident #29). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also identified a Brief Interview for Mental Status (BIMS) score of 14 which indicated cognition intact and required staff supervision with walking and bathing. In an interview on 6/29/21 at 8:45 AM, the resident reported on 2nd shift and 3rd shift they are very short staffed on a daily basis, that she had to wait to more than 15 minutes to get call light answered. The resident reported she had a digital clock in her room with bright blue numbers she utilized to time the wait. 2. The MDS dated [DATE] identified Resident #8 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified a BIMS score of 13 which indicated cognition intact and required staff supervision with mobility, toileting and personal hygiene. The Care Plan with the goal target date of 12/13/20 identified the resident with the problem of being at risk for falling and directed staff to assist the resident with activities of interest. During the Resident Council Meeting held 6/28/21 at 1:30 PM, the resident reported that she had to wait more than 15 minutes to get her call light answered on a daily basis and there had been incidents where she became incontinent waiting for help to the bathroom, which embarrassed her and felt she could not do anything about it. 3. The MDS dated [DATE] identified Resident #9 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified the resident with a BIMS of 15 which indicated cognition intact and required extensive staff assistance with most activities of daily living. The Care Plan with the goal target date of 6/20/20 and identified the resident with [CONDITION(S)] and directed staff to transfer her with two assist using the full mechanical lift and provide incontinence care when incontinent of bowel. During the Resident Council Meeting held 6/28/21 at 1:30 PM, the resident reported that she had to wait more than 15 minutes to get her call light answered on a daily basis and there had been incidents where she became incontinent waiting for help to the bathroom, which embarrassed her and felt she could not do anything about it. 4. The MDS dated [DATE] identified Resident #17 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified a BIMS score of 14 which indicated cognition intact and required limited staff assistance with bed mobility, transfers, walking and personal hygiene and required extensive staff assistance with toileting. The Care Plan with the goal target date of 6/19/21 identified the resident with the problem of requiring assistance with bed mobility, transfers and dressing and directed staff to provide assistance with dressing. It also identified her with the problem of being at risk for falls and directed staff to manually assist with transfers and instruct her to call for assist before getting out of bed or transferring. Encourage the resident to stand slowly. During the Resident Council Meeting held 6/28/21 at 1:30 PM, the resident reported that she had to wait more than 15 minutes to get her call light answered on a daily basis and there had been incidents where she became incontinent waiting for help to the bathroom, which embarrassed her and felt she could not do anything about it. 5. The MDS dated [DATE] identified Resident #23 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified a BIMS score of 13 which indicated cognition intact and required staff supervision with transfers, walking and toileting. The Care Plan with the goal target date of 5/10/21 identified the resident with the problem of being at risk for falls related to a recent right above knee amputation and directed staff to: a. Provide stand by assistance as tolerated with toileting/peri cares. b. Assist of one for transfer with prosthetic and walker c. Assist resident with activities of interest. During the Resident Council Meeting held 6/28/21 at 1:30 PM, the resident reported that she had to wait more than 15 minutes to get her call light answered on a daily basis and there had been incidents where she became incontinent waiting for help to the bathroom, which embarrassed her and felt she could not do anything about it. 6. The MDS dated identified Resident #29 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan with the goal target date of 4/28/20 identified the resident with the problem of resident care information and directed staff with the following interventions: a. Bowel and bladder: incontinent. b. Mobility: full mechanical lift assist of two for transfers. During an observation of the call light on 6/29/21, the following observed: a. At 7:00 AM, call light to room [ROOM NUMBER] on, not flashing. Currently no staff in the hallway. The resident did not make any attempts to get up on her own. b. At 7:10 AM, above call light on x 10 minutes now. c. At 7:11 AM, Staff C, Certified Nurse Aide (CNA) walked by the room twice without checking on the resident. d. At 7:13 AM Staff C, CNA walked by the room without checking on the resident and walked into another resident's room. e. At 7:16 AM, the Human Resources Coordinator entered the resident's room and turned off the light and checked on the resident. The call light had been on for 16 minutes total. 7. The MDS dated [DATE] identified Resident #49 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified a BIMS score of 13 which indicated cognition intact and that she required extensive staff assistance with transferring in and out of bed, dressing and with toileting. The Care Plan with the goal target date 10/2/20, identified the resident with the problem of resident care information and directed staff with the following interventions: a. Bowel and bladder: incontinent. b. Mobility: full mechanical lift assist of two for transfers. During the Resident Council Meeting held 6/28/21 at 1:30 PM, the resident reported that she had to wait more than 15 minutes to get her call light answered on a daily basis and there had been incidents where she became incontinent waiting for help to the bathroom, which embarrassed her and felt she could not do anything about it. In an interview on 7/1/21 at 6:58 AM, Staff I, CNA reported staff should answer call lights within 15 minutes, no residents had complained to her about call lights not being answered in a timely manner and that they had enough staff to provide residents with the care they need as long as staff did not call in sick. She also reported that now that summer had arrived, there have been more call ins. In an interview on 7/1/21 at 7:05 AM, Staff G, CNA reported staff should answer call lights within 15 minutes, that residents in the Skilled Unit had complained about not getting their call lights answered in a timely manner. She also reported the facility did not have enough staff when someone called in sick, which happened frequently. In an interview on 7/1/21 at 7:23 AM, Staff J, CNA reported staff should answer call lights within 15 minutes, that anyone should be able to answer one to see what the resident needs. If that person needs a nurse to help, they should ask someone to help. She also reported she felt there had been enough staff to give residents the care they need except when staff call in sick and this happened once a month. Staff will call in sick more during the spring and summer. In an interview on 7/1/21 at 7:38 AM, Staff F, Licensed Practical Nurse (LPN) reported the staff should answer call lights within 15 minutes, that residents have complained to her about call lights not being answered timely, however, could not recall their names. She also reported she felt there had not been enough staff to provide residents with the care they need as staff have called in sick at least once a week. In an interview on 7/1/21 at 7:55 AM, Staff K, LPN reported staff should answer call lights in less than 15 minutes and that any staff member can answer a call light. If they can't help the resident, they need to call the CNA or nurse. She also reported that Resident #11 had complained about his call light not being answered timely. There had not been enough staff to provide residents with the care they need as staff usually called in sick once a week. When staff call in sick, the management staff will help out. In an interview on 7/1/21 at 8:13 AM, the Director of Nursing (DON) reported she expected staff to answer the call lights within 15 minutes, and Resident #11 had complained to her about not getting his call light answered timely. She also reported staff had called in sick mostly on the weekends, however, she is always on call and that other Administrative Staff will also provide help when needed. A review of the facility policy dated as last revised January 2004 and titled: Call Light documented the following: a. Answer the call light promptly. b. Knock before entering the room. c. Turn off the call light. d. Listen to the resident's request. Do not make him/her feel that you are too busy to help. e. Respond to the request. If the item is not available, or request is questionable, get assistance from the nurse and return to the resident with a prompt reply. f. Offer further services before leaving the resident's room

Based on observation, record review and staff interview, the facility failed to follow proper infection control measures for two of four residents with indwelling catheters (Residents #9 and #28), during wound care for three of four residents observed with wounds (Residents #9, #49 and #66). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #66 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact and did not identify the resident with any open areas in the skin. The Care Plan with the goal target date of 9/8/20 identified the resident with the problem of being at increased risk for skim impairment and pressure injury related to decreased mobility and directed staff to: a. Apply compression hose per orders. b. Boot to right foot per orders. c. Skin treatments per orders. An observation of wound care on 6/29/21 at 2:51 PM revealed the following: After the resident had a shower, the resident sat in a wheelchair with his right bare foot resting on the foot pedal without a barrier under the foot. A moderate amount of serosanguinous drainage noted from the open area on the heel. After Staff A, Licensed Practical Nurse (LPN) placed the alginate dressing to the wound, she had visible bloody drainage on her gloves afterwards. She did not change gloves before she placed the [MEDICATION(S)] and followed by wrapping the kerlix on the area. The gloves had visible sanguineous (bloody) drainage on them after she put the alginate dressing to the wound. Staff A then placed the scissors on top of towel which had other dressing supplies and did not remove it when the resident placed his foot which had the CAM boot (which protects the foot from stress and pressure) on the bed, next to the supplies. She then wrapped the resident's right foot with a clean chux (a disposable pad to soak up moisture) and placed the CAM boot on the right foot which had the appearance of Charcot foot (is a disease that attacks the bones, joints, and soft tissue in your feet). After she completed wound care, she did not disinfect her scissors which remained in her pants pocket and returned the bag with the unused dressing supplies to the treatment cart. A review of the Nurse's Notes revealed the following: a. On 6/21/21 1:50 PM, the Nurse Practitioner assessed the resident's right heel and wrote a new order for [MEDICATION(S)] with silver to change daily to right heel until healed. b. On 6/21/21 2:08 PM, the resident has an area to his right heel that measured 7 centimeters (cm) by 4 cm with an open area that measures 3 cm by 2 cm. The old dressing had serosanguinous drainage with a noticeable odor. The area had been cleansed with sound cleanser, applied [MEDICATION(S)] with silver to the wound bed with [MEDICATION(S)] dressing. The skin which surrounded the wound had a whitish/gray color and soft to touch. Resident stated that it had been tender to touch. c. On 6/28/21 1:15 PM received a preliminary report from the wound clinic which showed 3 different bacteria in the wound: proteus mirabilix (usually found in soil and water), [CONDITION(S)] oxytoca (usually found in the intestinal tract) and citrobacter koseri (which can cause urinary tract and wound infections). A review of the facility policy dated as last revised March 2004 and titled: Wound Care revealed standard precautions must be followed during care of the wounds and did not have documentation on wound care for open wounds, only for first aid with bleeding wounds and animal or human bites. 2. The MDS dated [DATE] identified Resident #9 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] (stroke) and [CONDITION(S)] (paralysis of the lower part of the body). It also identified the resident with a BIMS of 15 which indicated cognition intact and required extensive staff assistance with most activities of daily living. The Care Plan with the goal target date of 8/1/18 and identified the resident with the problem of an indwelling catheter and directed staff to: a. Provide catheter care as needed. b. Change catheter and drainage bag as ordered/needed. c. Monitor for signs and symptoms of urinary tract infection. d. Monitor output. Observations of the resident's catheter revealed the following: a. On 6/29/21 at 7:52 AM, the resident sat in her wheelchair in the main dining room with the Foley bag in dignity bag underneath the wheelchair seat and the tubing on the floor. b. On 6/29/21 at 7:55 AM, the Foley tubing remained on the floor as the Activity Aide unlocked the wheelchair and repositioned her in front of the table as tubing dragged across the floor. The Activity Aide locked the wheelchair and did not lift the tubing off the floor. c. On 6/29/21 at 8:27 AM, the resident remained in the main dining room with the Foley tubing on the floor underneath her wheelchair. d. On 6/29/21 at 1:46 PM, Staff M, Certified Nurse Aide (CNA), while emptying the resident's catheter bag, placed paper towel on the floor and placed the graduate on the floor beside the paper towel rather than on top of it, unclamped the spigot and drained the urine into the graduate. Staff M failed to cleanse the spigot with an alcohol wipe then returned the bag to the dignity bag. e. On 6/30/21 at 8:14 AM as the resident laid in bed, Foley bag not visible, upon lifting the sheets, found the bag on top of the mattress beside the resident. f. On 6/30/21 at 9:50 AM, Staff B, CNA hung the Foley bag onto a hook above bladder level at level above the resident's head. After the transfer to bed, 9 minutes later, Staff B placed the Foley bag below bladder level on to the bed frame. The Care Plan also identified the resident with the problem of being at risk for skin impairment (goal target date of 6/20/20) and directed staff to apply [MEDICATION(S)] as ordered. Observations of wound care revealed the following: a. On 6/30/21 at 9:56 AM, Staff A, LPN removed gloves, used alcohol hand sanitizer and donned new gloves, then removed [MEDICATION(S)] dressing from packet and dated. Then she removed the old [MEDICATION(S)] dressing from the resident's sacral area, sprayed gauze dressings with [MEDICATION(S)] spray, used correct technique to cleanse inward out and dabbed dry. She did not change her gloves before she placed the new collagen dressing to the wound, In an interview on 7/1/21 at 6:58 AM, Staff I, CNA reported when she needed to empty a catheter bag, she would wash her hands, put on gloves, take the container and put a barrier on the floor and put the container on top of the barrier, empty the bag into the container, clean the tip off with alcohol, empty the container into the toilet, rinse it and remove gloves and wash her hands. She also reported the catheter bag should never be above the bladder near the resident's head (such as during a transfer with a mechanical lift). Before she left the room, she would make sure the bag hung below the bladder, make sure the tubing did not have any kinks and make sure the urine is clear. In an interview on 7/1/21 at 7:05 AM, Staff G, CNA reported when she needed to empty a catheter bag, she would wash her hands for 20 seconds and put gloves on. Then she would use a plastic bag for a barrier, put the graduate (a container to empty the urine into) on the barrier, wipe the end of the catheter with an alcohol wipe, unclamp, empty it into the graduate, wipe the end with alcohol wipe, empty it out into the toilet, rinse the graduate, remove gloves and wash hands. She also reported before she left the room, she would make sure the bag is below the bladder and the end is closed and the urine isn't discolored. She would report any blood, if bag is leaking or unusual color to the nurse In an interview on 7/1/21 at 7:23 AM, Staff J, CNA reported when she needed to empty a catheter bag, she would wash her hands, glove up, grab a surface protectant, usually a plastic bag, place on the floor, place the graduate on the plastic bag, use an alcohol swab on the tip before she emptied the bag. She also reported the bag should always hang below the bladder, especially during a transfer with a mechanical lift and never leave the bag on top of the bed. Before she left the room, she would make sure to report any blood or crimping in the tubing to the nurse. In an interview on 7/1/21 at 11:30 AM, the Director of Nursing (DON) reported when the CNA had to empty a catheter bag, she would expect them to was their hands, don gloves, get alcohol wipes, put a barrier on the floor, put the graduate on top of the barrier, open the catheter tip, wipe with alcohol, empty it into the graduate, clamp it, wipe with another alcohol wipe, empty it into the toilet, rinse it out, remove gloves and wash hands. She would also expect them to ensure the bag is below the bladder, the tubing should never be on the floor and the bag should never be above the resident's bladder for example, during a transfer with the mechanical lift. In an interview on 7/1/21 at 7:38 AM, Staff F, LPN reported when she provided wound care, she would change her gloves before she started the treatment, after she touched dirty surfaces and afterward would remove her gloves and sanitize her hands. She would also disinfect the scissors with alcohol right after she used them. In an interview on 7/1/21 at 7:55 AM, Staff K, LPN reported when she provided wound care, she would change her gloves anytime they got dirty, after she removed soiled dressings and in between different treatments. She also would disinfect the scissors before and after wound care. In an interview on 7/1/21 at 11:30 AM, the Director of Nursing (DON) reported when nurses provided wound care, she would expect them to change gloves after they removed soiled dressings, between dirty and clean and to place a barrier underneath the supplies. She also would expect the nurses to disinfect the scissors before and after wound care, after cutting off a dirty dressing and before cutting a new dressing afterward. A review of the facility policy dated as last revised June 2005 and titled: Catheter Care did not address how to empty the catheter bag, keeping the bag below bladder level and keeping the tubing off the floor. A review of the facility policy dated as last revised March 2004 and titled: Wound Care revealed standard precautions must be followed during care of the wounds and did not have documentation on wound care for open wounds, only for first aid with bleeding wounds and animal or human bites. 3. The MDS for Resident # 28 dated 4/13/21, listed a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected the resident with a Brief Interview for Metal Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS documented the resident required limited assist of 1 staff for toileting and transfers. The Care Plan dated 8/6/19, identified the resident with a catheter related to [CONDITION(S)], and a history of urinary tract infection (UTI) with septic shock. The Culture Urine report dated 6/19//21, revealed mixed bacteria with predominance of 50,000 to 100,000 colony forming units (CFU) escherichia coli 50,000 to 100,000 CFU/milliliter (ml) enterococcus faecalis. The Prescription Order for Resident # 28 dated 6/19/21, directed [MEDICATION(S)] (antibiotic) 100 milligrams (mg) 4 times a day for 7 days for a UTI. On 6/30/21 at 7:12 AM through 8:45 AM, Resident # 28 sat at the table with 2 inches catheter tubing on the floor by his feet as he moved his feet back and forth. 4. The MDS assessment tool dated 5/25/21 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It noted one venous or arterial ulcer. Review of Resident #49's Care Plan noted chronic ulcers with an intervention dated 6/3/21 for skin treatments per orders. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 6/29/21 at 1:31 PM revealed Staff L, Licensed Practical Nurse (LPN), performing wound care to the right lower leg of Resident #49 while Resident #49 laid in bed. Staff L placed a plastic bag containing treatment supplies on the bed and scissors on the bed with no barrier. Staff L washed her hands at the sink, applied gloves, and removed the old dressing. Without hand hygiene, Staff L removed the gloves and applied new gloves from her left shirt pocket. She removed wound cleanser spray bottle and gauze pads from the treatment supplies bag, applied wound cleanser to the gauze, and cleansed the ulcers. Staff L then set the wound cleanser bottle on the bed without a barrier. Without hand hygiene, Staff L removed her gloves and applied gloves from her left shirt pocket. She opened a Xeroform package from the supplies bag and applied Xeroform to the ulcers. Staff L removed gloves and, without hand hygiene, took a glove from her left shirt pocket and placed it on her right hand. Staff L wrapped the leg with Kerlix, cutting it with the scissors located on the bed, and placed the scissors back on the bed. Upon completion of the wound care, Staff L placed the bag of supplies, wound cleanser bottle, and scissors on the top of the bedside drawers without a barrier. Staff L hand sanitized and brought the bag of supplies, wound cleanser, and scissors from the room and placed them on the top of the treatment cart without a barrier prior to placing the supplies back in the cart without any disinfection of the items. On 7/1/21 at 8:30 AM the DON expressed expectations that staff sanitize their hands when changing gloves. Gloves should be changed between clean and dirty, after cleaning wounds, and before applying a new dressing. Staff should sanitize scissors before and after wound cares. Supplies should be set on a barrier and not set directly on a surface without a barrier.

Based on clinical record review and staff interviews, the facility failed to develop a Baseline Care Plan within 48 hours of admission for 1 of 4 residents reviewed who admitted to the facility in the past year (Resident #63). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) Assessment Tool dated 6/3/21 listed an admitted [DATE] for Resident #63 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident as receiving oxygen as well as antidepressant and anticoagulant medications. The resident's Brief Interview for Mental Status (BIMS) scored 14 out of a possible 15, indicating intact cognition. Review of the Care Plan revealed staff initiated the Care Plan on 5/3/21 with the focus areas of nutrition, admission to skilled care, fall risk, pain, and risk for pressure ulcers. On 5/4/21 the facility added focus areas of anticoagulant medication, depression and anxiety, [CONDITION(S)] and asthma requiring oxygen and [CONDITION(S)], and diabetes. The Base Line Care Plan Policy dated 11/28/19 stated the Baseline Care Plan should be developed within 48 hours of a resident's admission by the admitting nurse or the supervising nurse on duty. On 7/1/21 at 7:45 AM, Staff F, Licensed Practical Nurse (LPN), reported nurses do not touch the care plans. The Director of Nursing (DON) or MDS (Minimum Data Set) Coordinator are responsible for updates. On 7/01/21 at 8:52 AM The DON reported upon admission the nurse, MDS Coordinator, or DON initiates the Care Plan right away in the electronic health record. It is expected that the Care Plan be started within 24 hours. On a weekend or when the DON and MDS Coordinator are not in the facility, it is expected that the nurse on the floor starts the Care Plan.

Based on observation, record review and staff interviews, the facility failed to update Care Plans for 3 out of 17 residents reviewed in regards to a resident receiving oxygen therapy (Resident #11), a resident with a no added salt diet (Resident #30), and a resident on a diuretic medication (Resident #58). The facility reported a census of 67 residents. Findings included: 1. The Minimum Data Set (MDS) Assessment for Resident #30 dated 5/11/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident needs set up and supervision with meals. The Care Plan for Resident # 30 dated 07/26/2019, identified congestive heart failure and is at risk for fluid overload and [CONDITION(S)]. She is on a fluid reduction. The Care Plan failed to reflect a no added salt diet. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/30/21 at 8:20 AM, Resident #30 sat at the tray table and asked for salt and pepper. Staff G, Certified Nurses Aide (CNA) asked out loud to no specific staff, can she have that. Staff G then got the resident 1 packet of salt and pepper and applied to her eggs. Resident #30 ate 100% of the scrambled eggs. Observation on 6/30/21 at 11:27 AM, Resident #30 sat in the dining room area at tray table with yellow grip socks, [CONDITION(S)] noted to bilateral feet. Interview on 6/30/21 at 1:43 PM, the MDS Nurse reveled the facility doesn't accept a diet order for no added salt, it changed to general liberalized diet. The MDS Nurse revealed the expectation is, if a resident wants something against the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/30/21 at 1:49 PM, the Director of Nursing (DON) reported if a resident had a diet for no added salt and the resident wanted salt, she would educate the resident before giving the resident what they wanted. The DON indicated a no added salt diet is not expected on the Care Plan. 2. The Minimum Data Set (MDS) Assessment for Resident #58 dated 5/11/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected the resident with short term memory problems, moderately impaired with decisions poor, supervision/cues, required. The MDS documented the resident needs set up and supervision with meals. The Care Plan for Resident # 58 with a revision dated 6/21/2020, failed to identify the resident's use of a diuretic medication. The Care Plan failed to direct the staff to monitor for effectiveness, and side effects of a diuretic. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/30/21 at 1:40 PM, the MDS Nurse stated an expectation of diuretics on the Care Plan. Interview on 6/30/21 at 1:49 PM, the DON reported expecting diuretics on a resident's Care Plan. The policy titled Care Plan Policy dated 11/28/19, directed at point #7 The Comprehensive Care Plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practical, mental and psychosocial well being. 3. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also identified the resident required extensive staff assistance with transfers, walking, toileting and personal hygiene and required oxygen therapy. A review of the Care Plan with the goal target date of 9/8/21 identified the resident with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. Administer oxygen as ordered (initiated 6/29/21). b. Monitor pulse oximetry as ordered/needed (initiated 6/8/21). The Care Plan did not address the need to change the oxygen tubing once a week. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 7/1/21 at 7:38 AM, Staff F, Licensed Practical Nurse (LPN) reported if residents had continuous oxygen this should be addressed on the Care Plan to show nurses should change the tubing once a week, usually on second shift and that only the MDS Nurse could make changes to the Care Plan. In an interview on 7/1/21 at 7:55 AM, Staff K, LPN reported if residents had continuous oxygen this should be addressed on the Care Plan to show the tubing should be changed once a week. In an interview on 7/1/21 at 8:13 AM, the Director of Nursing (DON) reported if a resident had continuous oxygen this should be addressed on the Care Plan to show the tubing should be changed once a week. The facility policy dated as last revised 3/16/17 titled: Oxygen Therapy documented the following: a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Oxygen set up (cannula/mask, tubing) must be exchanged every 7 days. c. Documentation should address the use of oxygen in the Care Plan. d. Safety factors: be sure to prevent contamination of the oxygen equipment due to its presence in locations such as the dining room and bathroom.

Based on observations, record review and staff interviews, the facility failed to follow 2 Physician's Orders for a resident's hydration for 1 out of 1 residents reviewed (Resident #30). The facility reported a census of 67 resident. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #30 dated 5/11/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident needs set up and supervision with meals. The Care Plan for Resident #30 dated 07/26/2019, identified congestive heart failure and is at risk for fluid overload and [CONDITION(S)]. The Care Plan directed fluid reduction of 2000 milliliters (ml) daily. Special Instructions included: 500 ml for each meal, nursing 75 ml for medications, 125 ml evenings and 125 ml at snack time for a total of 2000 ml every 24 hours cardiology. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurses Notes dated 6/21, lacked documentation related to the resident exceeding her allotted fluid intake. On 06/29/21 at 12:47 PM, Resident #30 sat at the tray table with 2 large cups, one contained water, and 1 contained milk, and a small cup contained water. res took 100% fluids. On 06/30/21 at 7:51 AM, staff served Resident #30 a small glass (200 ml) water and milk. At 08:15 AM, Resident #30 drank 100% milk and water On 06/30/21 at 8:20 AM, Resident #30 asked for more water and Staff G, Certified Nurses Aide (CNA) provided a small cup (200 ml) of water to Resident #30. Resident #30 drank 100% of the water. Total of 600 ml at breakfast. On 06/30/21 at 8:32 AM, Resident #30 asking for water, tapping her cup on the table. Staff G reported you have had your max for breakfast. The Physician's Order Report Diet Flow Sheet dated 12/26/19 and updated 5/8/21, directed no added salt. On 06/30/21 at 8:20 AM, Resident #30 asked for salt and pepper Staff G, CNA asked can she have that, and provided the resident 1 packet of salt to her eggs On 06/30/21 at 11:27 AM, Resident #30 sat in dining room area at tray table yellow grip socks with [CONDITION(S)] noted to bilateral feet. Interview on 07/01/21 at 08:48 AM, the Director of Nursing (DON) reported she expected staff to follow Physicians orders, and document fluid intake on the (MAR).

Based on observation, record review, and resident and staff interviews, the facility failed to have orders in place for oxygen flow rate, oxygen saturation checks, and/or oxygen tubing changes for 2 of 3 residents reviewed using supplemental oxygen (#11, #63). The facility also failed to ensure continuous oxygen delivery and a clean nasal cannula for 1 of 3 residents (#11). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 6/3/21 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded the resident as receiving oxygen therapy. The resident's Brief Interview for Mental Status (BIMS) scored 14 indicating intact cognition. Review of Resident #63's Medications Administration Record (MAR) and Treatments Administration Record (TAR) from 5/20/21 until 6/30/21 revealed no orders related to oxygen flow rate, monitoring oxygen saturations, or oxygen tubing changes after 5/21/21. Review of the Care Plan revealed entries dated 5 /4/21 to: a. Administer oxygen as ordered. b. Monitor the pulse ox (oxygen saturation levels) as ordered/needed. c. Report to physician for any new orders if needed and document. Review of documented oxygen (O2) saturations in the vitals tab of the electronic health record revealed less than daily oxygen saturation checks from 5/30/21 to 6/30/21. Review of the Progress Notes revealed: a. On 5/21/21 at 4:40 PM, Resident #63 returned to the facility from the hospital on 2 Liters of oxygen. b. On 5/29/21 at 3:04 PM, Staff encouraged Resident #63 to allow oxygen flow to be turned down to 1.5L (Liters) c. On 5/30/21 at 5:30 PM, Resident #63 on 2L of oxygen. d. On 6/23/21 at 1:02 AM, Resident #63 with oxygen in place per nasal cannula. An observation on 6/28/21 at 2:40 PM, revealed Resident #63 with a nasal cannula in place, oxygen tubing attached to a portable oxygen tank on the back of her wheelchair with the flow rate set at 1 Liter. The oxygen concentrator was running at 2 Liters. The oxygen tubing attached to the oxygen tank and concentrator contained no date of when placed. On 6/30/21 at 1:03 PM, Resident #63 reported wearing oxygen continuously during the day via nasal cannula and through a [CONDITION(S)] (sleep apnea treatment) at night. The resident reported using portable tanks when out of her room for therapy. Resident #63 stated she had used supplemental oxygen at 2 Liters since having COVID-19 with pneumonia in December. The resident could not recall how often staff changed the oxygen tubing or the frequency of oxygen saturation checks. On 6/30/21 at 2:25 PM Staff E, Certified Nursing Assistant (CNA) reported Resident #63 utilized oxygen all the time. On 6/30/21 at 2:38 PM Staff K, Licensed Practical Nurse (LPN), stated oxygen orders should be on the TAR for residents who utilize oxygen. When a resident received oxygen, nursing checked their oxygen saturation levels every shift and documented them in the vitals tab of the electronic health records. The TAR contained documentation regarding the weekly change of oxygen tubing. When a resident discharged to the hospital, staff discontinued the orders in the electronic health record and needed to re-enter the orders on re-admission. The Director of Nursing (DON) or nurses entered the new orders. The Night Nurse double-checked the orders. On 7/01/21 at 8:52 AM, the DON reported expectations that: a. The orders for oxygen are on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] b. Changing of the oxygen tubing weekly is on the TAR for nurses to do. c. Oxygen saturations are checked every shift and as needed when a resident is on supplemental oxygen. On 7/01/21 at 10:55 AM, the Administrator stated the missing orders should have been caught when double checked on the next shifts. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . It also identified the resident required extensive staff assistance with transfers, walking, toileting and personal hygiene and required oxygen therapy. A review of the Care Plan with the goal target date of 9/8/21 identified the resident with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. Administer oxygen as ordered (initiated 6/29/21). b. Monitor pulse oximetry as ordered/needed (initiated 6/8/21). The Care Plan did not address the need to change the oxygen tubing once a week. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It did not have orders to change the tubing once a week. In an interview on 7/1/21 at 7:55 AM, Staff K, Licensed Practical Nurse (LPN) reported if residents had continuous oxygen, the tubing should be changed once a week by the nurse and should be documented on the Treatment Administration Record (TAR) In an interview on 7/1/21 at 7:38 AM, Staff F, LPN reported if residents had continuous oxygen, the second shift nurses usually changed the tubing once a week on Friday or Saturday and should document this on the TAR. In an interview on 7/1/21 at 8:13 AM, the Director of Nursing (DON) reported if a resident had continuous oxygen , she would expect the nurses to change the tubing once a week and document this on the TAR. The facility policy dated as last revised 3/16/17 titled: oxygen therapy had documentation of the following: a. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Oxygen set up (cannula/mask, tubing) must be exchanged every 7 days. c. Documentation should address the use of oxygen in the Care Plan. d. Safety factors: be sure to prevent contamination of the oxygen equipment due to its presence in locations such as the dining room and bathroom.

Based on observation, record review, resident and staff interviews, the facility failed to document assessments of the resident's fistula (a connection between an artery and vein to allow access for [CONDITION(S)]) before and after [CONDITION(S)] for one of one residents reviewed (Resident #66). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #66 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] heart failure, end stage [CONDITION(S)] (kidney failure) and diabetes mellitus. It also identified the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact and did not identify the resident with any open areas in the skin. The Care Plan with the goal target date of 9/9/20 identified the resident with the problem of end stage [CONDITION(S)] that requires [CONDITION(S)], he goes to the [CONDITION(S)] Center on Monday, Wednesday and Friday. And directed staff to monitor the [CONDITION(S)] port/shunt in right arm for bleeding. If profuse or quick bleeding, apply direct pressure and contact Emergency Medical Services (EMS). A review of the [CONDITION(S)] Communication Forms revealed the following: a. No Assessments documented at all on the following dates: June 2, 4, 16, 18 and 28. b. Of the eight completed forms, assessments were not documented on the following dates: June 7, 9, 11, 14, 23, 25 and 30. In an interview on 7/1/21 at 7:38 AM, Staff F, Licensed Practical Nurse (LPN) reported the nurses should assess the resident's fistula before and after they go to [CONDITION(S)], check for the thrill and document this on the TAR (treatment administration record) In an interview on 7/1/21 at 7:55 AM, Staff K, LPN reported the nurses should assess the resident's fistula before and after they go to [CONDITION(S)], feel or listen with a stethoscope to hear the bruit and document this on the TAR. In an interview on 7/1/21 at 8:13 AM, the Director of Nursing (DON) reported she expected the nurses to assess the resident's fistula before and after they go to [CONDITION(S)], check for the thrill, check for signs of infection at the site and document this on the TAR which meant the site looked normal. If the fistula appeared infected, they should have charted that in the Progress Notes. In an interview on 7/1/21 at 11:30 AM, the DON reported the facility did not have a policy on [CONDITION(S)] and the staff should complete documentation as per the facility [CONDITION(S)] Communication Form directs them to do.

Based on clinical record review and staff interview, the facility failed to provide 2 of 3 residents the required form Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF- ABN) in a timely manner and/or in writing when Skilled Services had been exhausted or services no longer covered (Residents #12 and #37). The facility reported a census of 67 residents. Findings Include: 1. Record review for Resident #12 indicated the resident received Skilled Services from 1/14/21 to 3/17/21. The facility used form CMS-R-131 Advance Beneficiary Notice of Non-coverage (ABN) instead of the required CMS Form # , SNF-ABN, to notify the resident representative. The representative did not sign the form. The facility completed the form and documented notification by phone. 2. Record review for Resident #37 indicated the resident received Skilled Services from 2/17/21 to 5/14/21. The facility used form CMS-R-131 Advance Beneficiary Notice of Non-coverage (ABN) instead of the required CMS Form # , SNF-ABN, to notify the resident representative. The representative did not sign the form. The facility completed the form and documented notification by phone. The facility notified the resident representative on 5/13/21 at 10:00 AM, less than 48 hours before Skilled Services ended, failing to follow the CMS guidelines. On 6/29/21 at 3:20 PM, the Social Service Director reported being responsible for notifying residents or resident representatives when residents come off Skilled Care. She used the forms provided from corporate and unless unusual circumstances, she tried to provide notifications at least 48 hours in advance. She recalled no unusual circumstances with Resident #37 and stated failed to get the notification done timely. She made phone calls to representatives during visitor restrictions and did not send out the notices for signature unless requested to do so by the representative.

Based on clinical record review and staff interview, the facility failed to notify the state Long Term Care (LTC) Ombudsman for 2 of 3 residents reviewed for transfers out of the facility (Residents #8 and #63). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented the resident admitted to the facility on [DATE] and re-entered from the hospital on 2/8/21. A Progress Note dated 2/3/21 at 2:36 PM documented Resident #8 admitted to the hospital directly from an appointment. A Progress Note dated 2/8/21 at 12:38 PM revealed the resident had returned to the facility. 2. The MDS assessment dated [DATE] for Resident #63 documented the resident admitted to the facility on [DATE] and re-entered from the hospital on 5/28/21. A Progress Note dated 5/17/21 at 8:55 PM documented Resident #63 left the facility via ambulance at 8:45 PM for the emergency room . A Progress Note dated 5/18/21 at 11:21 AM revealed the resident admitted to the hospital. A Resident Progress Note on 5/21/21 at 4:40 revealed the resident returned from the hospital. A Progress Note on 5/23/21 at 6:36 PM documented Resident #63 left the facility at 6:14 PM by ambulance for the emergency room . A Progress Note on 5/23/21 at 9:32 PM revealed the resident admitted to the hospital. A Progress Note on 5/28/21 at 2:08 PM stated the resident returned to the facility. Review of the facility provided spreadsheet faxed to the LTC Ombudsman for the months of February and May revealed no documentation of the transfers out to the hospital for residents #8 and #63. On 6/30/21 at 1:54 PM, the Administrator reported she does not notify the LTC Ombudsman of residents transferring to the hospital if the resident is expected to come back.

Based on record review, observations, and interviews the facility failed to prevent, assess, and implement interventions for pressure ulcers for 2 of 2 sampled (Resident #17, #23). The facility reported a census of 62. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 had [DIAGNOSES REDACTED]. Resident #17 had mild cognitive impairments. Resident #17 admitted to the facility on [DATE]. The MDS dated [DATE] documented Resident #17 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #17 had bowel incontinence and had a nephrostomy (tube inserted directly in the kidney) and an indwelling urinary catheter (inserted into the bladder). Resident #17 had a risk for development of pressure areas. The MDS documented no open areas, no pressure wounds and no pressure reducing devices in the chair or on the bed. The Care Plan dated 4/4/19 identified a problem of increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness. The Care Plan updated 2/14/19 directed the staff to complete a treatment to pressure area and venous ulcers as ordered by MD. The care plan failed to direct the staff to float the heels. A Braden Scale for Predicting Pressure Sore Risk dated 1/23/19 documented Resident #17 scored a 12. A score of 10-12 put Resident #17 at high risk. The form documented the resident had very limited sensory perception, occasionally moist skin, is chairfast (does not walk), very limited mobility, probable inadequate nutrition and a friction and shear problem. The Braden form documented the resident required moderate to maximum assist in moving. Complete lifting without sliding against sheets impossible. Frequently slides down in bed, requiring frequent repositioning with maximum assist. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction. The Progress Note dated 2/1/19 at 11:02 a.m. documented Resident #17 had an open area on the right heel that measured 1 centimeter (cm) in diameter and wound bed mostly covered with a dry scab and slight amount of bleeding present. The staff floated Resident #17's heels and applied a dressing to the right heel. The Event Report dated 2/14/19 documented a Stage II Pressure Injury to the right heel measuring 0.9 cm (length) by 0.9 cm (width) by 0.2 cm (depth). The staff notified the physician. The MDS identified the following descriptions of pressure ulcers: a. A Stage I, 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. b. A Stage II, 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. c. A 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. d. A Stage IV, 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. Review of a Wound Management records revealed the following measurements of the right heel: a. On 2/14/19, a Stage II, 0.9 cm (length) by 0.9 cm (width) by 0.2 cm (depth). b. On 2/21/19, a Stage II, 0.8 cm (length) by 0.5 cm (width). c. On 2/28/19, 0.7 cm (length) by 0.6 cm (width). d. On 3/7/19 a Stage III, 1.5 cm (length) by 1.0 cm (width) by 0.3 cm (depth). e. On 3/14/19, 1.5 cm (length) by 0.7 cm (width) by 0.4 cm (depth). f. On 3/18/19, area debrided at wound clinic and measurements after debridement: 1.3 cm (length) by 0.8 cm (width) by 0.3 cm (depth). g. On 3/29/19, a Stage III, 1.5 cm (length) by 0.5 cm (width). h. On 4/1/19, a Stage III, wound debrided and after debridement area measured 0.8 cm (length) by 0.6 cm (width) by 0.3 cm (depth). i. In hospital 4/3/19 to 4/6/19 and 4/7/19 to 4/10/19 Not measured. j. On 4/15/19, area healed. The clinical record lacked assessments of the pressure ulcer from 2/1/19 to 2/14/19. An observation on 4/17/19 at 1:45 p.m. revealed Staff E (Licensed Practical Nurse) completed the wound treatments to the right lower leg. Resident #17 had no open area on the right heel and Prevalon boots on both feet. During an interview on 4/17/19 at 4:50 p.m., the Director of Nursing, (DON) stated an expectation of staff to implement preventative measures for residents at high risk. The DON acknowledged the absence of wound measurements or assessment to the right heel from 2/1/19 to 2/14/19. The DON had no knowledge that the wound progressed to a Staged III. The DON planned to follow up with the MDS Nurse in regards to the staging. 2. The MDS assessment dated [DATE] revealed Resident #23 had [DIAGNOSES REDACTED]. Resident #23 had no cognitive impairments. The MDS dated [DATE] revealed Resident #23 required extensive assistance of 2 staff for bed mobility, dressing, toilet use, and personal hygiene, and completely depended on 2 staff for transfers and bathing. The MDS documented Resident #23 at risk of developing pressure ulcers and had 1 unhealed Stage II (partial thickness loss of skin) pressure ulcer. The MDS revealed Resident #23 had a turning and repositioning program. The Braden Scale for Predicting Pressure Sore Risk dated 10/3/17 revealed Resident #23 at high risk for the developing pressure ulcers. Care Plan revealed Resident #23 at risk for skin impairment due to decreased mobility related to [MEDICAL CONDITION] following surgical spine fusion, incontinence, high blood pressure, and obesity and directed staff to encourage Resident #23 turn from side to side in bed and use wedges for positioning. The Care Plan failed to indicate Resident #23 had a pressure ulcer. During an observation on 4/16/19 at 2:05 p.m., Staff E LPN (Licensed Practical Nurse) measured Resident #23's the open coccyx (tailbone) ulcer. The area measured 4.3 cm by (length) by 1.2 cm (width) by 0.2 cm (depth) and had a pink and white wound bed. Observations on 4/17/19 at 8:45 a.m., 9:53 a.m., 10:43 a.m., 11:08 a.m., 11:55 a.m., and 1:04 p.m. revealed Resident #23 in bed on her back with the head of the bed elevated approximately 30 degrees. Resident #23 failed to have the wedges in place during the observations. Facility Wound Care sheets for the coccyx wound from 2/13/19 to 4/18/19 revealed the following assessments: a. On 2/13/19, listed as full thickness in one area of the assessment and partial thickness in another area of assessment, 4.1 cm (length) by 1.5 cm (width) by less than 0.2 cm (depth). b. On 2/21/19, a Stage II, 2.75 cm (length) by 0.5 cm (width) by x no (depth). c. On 3/14/19, a Stage III, 2.2 cm (length) by 0.7 (width) by no (depth). d. On 3/29/19, 3.4 cm (length) by 0.8 cm (width) by no (depth). e. On 4/3/19, a full thickness, 3.4 cm cm (length) by 0.8 cm (width) by no (depth). f. On 4/12/19, 7 cm (length) by 1.4 cm (width) by 0.2 cm (depth). The clinical record lacked assessments of the coccyx wound from 2/21/19 to 3/14/19 (3 weeks). The MDS failed to reflect Resident #23 had a Stage III (full thickness loss of skin) pressure ulcer. During an interview on 4/16/19 at 8:21 a.m., the resident stated staff members were supposed to utilize wedges to position her from side to side. During an interview on 4/17/19 at 2:38 p.m., the Director of Nursing (DON) stated staff should attempt to position the resident off her side and stated the care plan should list pressure ulcers under the skin section. She stated she would want the care plan updated in a timely manner. During an interview on 4/18/19, the DON stated she could not locate any additional measurements between 2/21/19 and 3/14/19 and 3/14/19 and 3/29/19. She stated moving forward she would designate one nurse to complete weekly measurements. During a subsequent observation, the DON showed the surveyor the black wedges the resident should have had under her to position her from side to side. The Pressure Injury Prevention and Treatment Protocol revised 10/15 stated the facility would measure the size of the wound, complete weekly individual treatment reports, and reposition residents who could not turn and position themselves in bed.

Based on record review, observations, and interviews the facility failed provide supervision and interventions to prevent accidents for 2 of 3 sampled (Resident #46 and #160) and failed to safely store potentially hazardous items. Resident #160 sustained a fractured humerus and a subarachnoid hemorrhage (bleeding within layers of the brain). The facility reported a census of 62 residents. Findings: 1. The face sheet dated 4/17/19 revealed Resident #160 had [DIAGNOSES REDACTED]. Resident #160 admitted to the facility on [DATE]. The Falls-Fall Acknowledgement sheet dated 1/17/19 revealed Resident #160 had age over 70, cognitive impairment, visual impairment, use of cane or other assistive device, previous falls and drug therapy as risk factors. The Care Plan dated 1/17/19 revealed Resident #160 at increased risk for falls due to muscle weakness and unsteady gait related to recent hospitalization , [MEDICAL CONDITION] medications, and [MEDICATION NAME] degeneration. The care plan directed staff to leave the night light on in the room when dark and assure the resident had non-slip, well fitting footwear on prior to standing/walking. A Progress Note dated 1/17/19 at 2:54 p.m. Revealed Resident #160 admitted to the facility for strengthening. Resident #160 had a scab to the back of her head from a fall a month ago. A Progress Note dated 1/17/19 at 4:09 p.m. stated staff found the Resident #160 outside of the room with no assistance near the front desk and staff redirected and educated her to have staff assistance at all times. A Progress Note dated 1/18/19 at 5:00 a.m. stated the Resident #160 up without assistance at the nursing station and staff assisted the her back to her room. A Progress Note dated 1/18/19 at 1:30 p.m. stated the Resident #160 up unassisted multiple times and staff educated the resident related to her need for assistance and safety. A Progress Note dated 1/191/19 at 12:36 p.m. stated the Resident #160 up unassisted numerous times and education was not effective. Resident #160 had her coat on and stated she was going to the movies. A Progress Note dated 1/19/19 at 12:50 p.m. stated Resident #160 up without assistance and staff redirected and reminded her to utilize staff for her safety. A Progress Note late entry dated 1/20/19 at 7:27 a.m. for 1/19/19 at 8:00 p.m. documented Resident #160 in bed and and the nurse educated her on how to use the call light A Progress Note dated 1/20/19 6:34 a.m. revaled staff found Resident #160 lying on her left side in her room with dried blood all over the ground. Resident #160 had a large bruise and blood on the left side of her face with dried blood in both nostrils. Staff called Emergency Medical Services and transfered her to the hospital. A Progress Note dated 1/20/19 6:49 p.m. Revealed Resident #160 admitted to the hospital with [REDACTED]. The Event Report dated 1/20/19 documented Resident #160 in bed at the 3:30 a.m. check. The Written Statement dated 1/20/19 documented Staff G (Nurse Aide) completed her last round at 3:45 a.m. to 4:00 a.m. and Resident #160 sleeping at that time. The survey team attempted to contact Staff G on 4/16/19 at 5:19 p.m., 4/16/19 at 5:45 p.m., 4/17/19 at 8:13 a.m., and 4/17/19 at 9:12 a.m. The Written Statement dated 1/20/19 documented Staff H (Licensed Practical Nurse) last rounded at 4:30 a.m. to 5:00 a.m. and Resident #160 in bed with the door to the room cracked. The Written Statement dated 1/20/19 revealed Staff I documented Resident #160 up constantly and she found Resident #160 at 6:20 a.m. on the floor of her room. The Surveyor attempted to reach Staff I by phone without unsuccess. A Physician's Certification for Medicare Hospice Benefit form dated 1/28/19 documented a terminal [DIAGNOSES REDACTED]. A History and Physical dated 1/31/19 revealed Resident #160 had a fall at nursing home and sustained a subarachnoid hemorrhage, facial bone fractures, and left humerus fracture. A Discharge Summary dated 2/1/19 revealed Resident #160 discharged from the hospital to a family member's home on Hospice care. The Certification of Vital Records sheet issued on 3/1/19 revealed Resident #160 passed away on 2/3/19. The sheet voided as the cause of death had wrong information listed. The Typed Written Statement dated 1/19/19 the Administrator documented Resident #160 up alone in her room standing more than 4 times. The statement stated the Administrator instructed staff that the resident needed a close eye since she more than likely was not going to be compliant and to be sure and pass that on in report. The Care Plan lacked updated interventions on how staff needed to adresss Resident #160's repeated self transfers and failed to direct staff to check on the resident more frequently. During an interview on 4/16/19 at 5:32 p.m., Staff F (Registered Nurse) stated on the morning of the fall she finished report and it was after 6:30 a.m. when a CNA called for her and they found the resident on the floor in her room on her left side with dried blood in her hair, on her arm, and on the floor. Staff F stated she thought the resident had a head injury so she called an ambulance and sent the resident out to the hospital. During an interview on 4/16/19 at 5:24 p.m., Staff H (Licensed Practical Nurse) stated she worked on the resident's unit during the night shift on 1/19/19-1/20/19 and worked with 1 CNA. She stated she wasn't sure of the time but she wrote it in her report but thought she looked in at the resident at maybe 4:00 a.m. and the resident was in bed. During a subsequent interview on 4/16/19 at 6:11 p.m., Staff H stated the night the resident fell was her first night taking care of the resident and she was unaware that the resident got up on her own. During an interview on 4/17/19 at 2:31 p.m., the Director of Nursing (DON) stated the resident had falls in assisted living prior to coming to the facility. She stated the resident self-transferred in her room and staff tried to get her to wait for help. She stated staff should check on her more frequently, every half hour to an hour. During an interview on 4/17/19 at 2:51 p.m., the Administrator stated the resident had had falls in assisted living and once at the facility the staff observed her up several times unassisted. She stated staff should check on the resident every 30-40 minutes and stated they tried education. She stated she was not sure of what else they could have done to prevent the fall. During an interview on 4/17/19 at 4:00 p.m. the DON stated the facility did not have a policy related to fall prevention. 2. The MDS assessment dated [DATE] documented Resident #46 had [DIAGNOSES REDACTED]. Resident #46 had severe cognitive impairments. The MDS dated [DATE] documented Resident #46 required supervision of one staff with bed mobility, transfers, walking in his room, toilet use, and personal hygiene and limited assistance of 1 staff for dressing. Resident #46 had two falls without injury and two falls with a non-major injury. The Fall Risk Assessment Tool dated 5/23/18 documented Resident #46 at a high fall risk. A care plan dated 9/20/18 revealed Resident #46 at risk for falls related to confusion, muscle weakness, and occasional incontinence, and commonly refuses to use his walker and upset when encouraged to use it. Review of the 14 Event Reports from 9/20/18 to 4/15/19 revealed the following: a. On 9/21/18, staff found the resident on the floor in his room. b. On 9/24/18, staff found the resident on the floor in his room. c. On 10/26/18, staff found the resident on the floor in his room. d. On 11/11/18, staff witnessed Resident #46 stand up from dining table without walker and walk a few feet, he lost his balance and fall on his right side. e. On 1/14/18, staff witnessed resident bend down to pick something up, lose balance, and fall backwards onto the buttocks. f. On 1/6/19, staff found the resident lying on the floor beside bed. The resident reported he slid out of bed. g. On 2/8/19, staff found the resident lying on the floor near the bed. The resident reported he rolled out of bed. h. On 2/11/19, staff witnessed that resident took steps backwards, stumbled and fell backwards to the floor and hit head on the floor. The resident had an area of swelling and a dark purple bruise to the head. i. On 2/14/19, staff found resident lying on the floor next to his bed, facility waiting to hear from family regarding low bed or a bolster mattress. j. On 2/16/19, staff found Resident #46 sitting on bathroom floor with his back against the wall. k. On 2/17/18, staff found the resident on floor beside the bed. The resident reported he rolled out of bed. l. On 3/11/19, staff found the resident on the floor beside the bed. The resident reported he fell out of bed. m. On 3/13/19, staff found the resident on the floor at the end of the bed. The resident reported he was looking for something on the floor and could not get back up. He had a large bump on his left cheekbone. n. On 4/3/19, staff found the resident lying on the floor on his right side. The resident stated he lost his balance. The progress note dated 4/7/19 revealed Resident #46 had a dark purple bruise on his bottom, tender to touch measuring 14.2 cm(centimeters) x 4 cm. The care plan included the following updates: a. On 9/20/18, independent in the unit with walker b. On 9/20/18, a night light and clutter free environment. c. On 9/21/18, alternate call light. d. On 9/24/18, a regular bed. e. On 9/28/18, encourage the walker. f. On 11/12/18, continue to work with therapy. g. On 11/15/18, encourage to wait for staff to assist. i. On 1/6/19, continue to monitor. j. On 2/8/19, continue to monitor, no intervention needed for resident rolling out of bed as family requested a regular bed. k. On 2/12/19, check for UTI (urinary tract infection) and submit therapy evaluation. l. On 2/18/19, waiting to hear from family regarding low bed or bolster mattress. m. On 3/15/19, resident will have a bolster mattress put on his bed. n. On 4/3/19, encourage to wait for assistance and continue to monitor. The Care Plan lacked further new, specific, resident-centered interventions aimed at fall prevention. The facility failed to implement a bolster mattress on 2/14/19. Resident #46 fell three more times near the bed after 2/14/19. On 3/15/19, the facility implemented the bolster mattress. During an observation on 4/16/19 at 12:36 a.m., Resident #46 sat at the table after lunch. The Unit Coordinator asked Resident #46 if he would like to participate in the upcoming activity. Resident #46 stood up and walked independently to his room with a walker. Once in his room, he abandon the walker and walked into the bathroom. During an interview on 4/17/19 at 2:29 p.m., the DON stated the resident had quite a few falls and they worked with him to encourage the use of the walker and to ask for assistance. She stated after some falls there was not a new intervention to put into place and she would need to go through each fall to see what he was doing at the time. 3. During an observation on 4/17/19 at 4:35 p.m. with the Assistant Director of Nursing (ADON) present, revealed a cart containing a half box of lancets (a small plastic cylinder that holds a sterile grade steel needle) sat at the nurse's station within reach of residents. During an interview on 4/17/19 at 5:05 p.m., the DON reported that going forward they will keep the lancets behind a locked door. The facility failed to ensure a safe environment.

Based on record review, and resident, responsible party, staff and physician interviews, the facility failed to ensure residents received care and treatment in accordance with professional standards based on a comprehensive assessment for 1 of 5 residents reviewed (Resident #5). On 2/14/18, Resident #5 began having nausea, vomiting and loose stools. The facility failed to notify the physician of the resident's complaints of nausea and her continued vomiting and loose stools. On 2/19/18, the resident's Responsible Party took her to the physician's office. The physician directed the family to take the resident to the hospital to be treated for [REDACTED]. The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 2/19/18 revealed Resident #5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented the resident scored 4 out of 15 possible points on the Brief Interview for Mental Status (BIMS) cognitive assessment (severe cognitive impairment), had symptoms of [MEDICAL CONDITION] present, and required extensive assistance of staff for transfers to and from bed, ambulation (walking), bathing, dressing and toilet use. The MDS revealed the resident remained continent of bowel with occasional urinary incontinence, weighed 89 pounds and was identified as an unplanned significant weight loss of 5 percent or more. The nursing care plan documented the resident as at risk for dehydration on 2/8/18, with a 5/8/18 goal for the resident to have adequate hydration. The care plan directed staff to encourage fluids, monitor for symptoms of dehydration (dry mouth, dry skin, fatigue, weakness, poor skin turgor), and monitor labs. Nurse's Notes contained the following entries: 2/7/18 at 1:22 p.m. by Staff J, licensed practical nurse (LPN), admitted to facility, weight 103.2 pounds. 2/7/18 at 11:54 a.m. by Staff K, LPN, open area to gluteal cleft, 2 centimeters (cm) by 0.5 cm, with redness to surrounding skin, area tender to touch. 2/8/18 at 2:02 p.m. by Staff J, request sent to physician for [MEDICATION NAME] (a protein supplement drink), vitamin C and Zinc orders related to current skin conditions. 2/9/18 at 4:15 p.m. the facility's registered and licensed dietician stated the resident ate 76 to 100 percent of meals, and estimated her caloric requirements between 1410 and 1535 calories, with 38 to 47 Grams of protein, and 1175 milliliters of water per day, noted request for [MEDICATION NAME], Vitamin C and Zinc related to multiple areas of impaired skin integrity. 2/14/18 at 9:02 a.m. by Staff J, physician faxed (document transmitted by facsimile) for resident's request for scheduled laxative, with order for 1 Senna S 8.6-50 milligram tablet administered oral daily (a laxative) received. 2/14/18 at 10:26 p.m. by Staff K, resident not hungry for supper, started to have some loose stools and moderate amount of vomiting of undigested food while at the table. The resident was very tired and requested to go to bed. Abdomen slightly firm with some distention noted. Had 2 more smaller emesis and loose stools with some formed stool, continue to monitor status. 2/15/18 at 12:28 p.m. by Staff J, increased complaints of nausea, clear soda encouraged. 2/15/18 at 11:15 p.m. by Staff K, the resident had a couple of loose stools with 1 formed stool, no emesis, ate chicken noodle soup for supper. 2/16/18 at 11:58 p.m. by Staff R, LPN, multiple loose stools, afebrile, no complaints of nausea. Faxed MD (on a Friday evening) with request for [MEDICATION NAME] order (anti-diarrhea medication), awaiting a response. 2/17/18 at 1:11 p.m. by Staff N, LPN, 1 loose stool, refused to get up for breakfast, clear liquids given, poorly taken, drank around 200 milliliters, vomited a small amount of liquid which appeared to be the [MEDICATION NAME]. 2/18/18 at 5:18 a.m. by Staff M, LPN, 1 loose stool, no emesis. 2/18/18 at 8:17 p.m., by Staff L, LPN, 1 loose stool, never wants to eat when put at table has small emesis and then gets to go to her room, once in her bed she is fine, wants to go home. 2/19/18 at 1:05 p.m. by Staff J, out of facility with family. 2/19/18 at 11:10 p.m. by Staff S, LPN, contacted resident's responsible party (RP) due to the resident had not returned to the facility, RP stated they took her to the doctor and she was admitted to the hospital. Records of bowel movements (BM) revealed the resident had: 4 large, 1 medium and 1 small BM on 2/14/18 2 large and 2 small BM on 2/15/18 1 large BM on 2/16/18 5 large BMs on 2/17/18 3 large BMs on 2/18/18 1 medium and 1 large BM on 2/19/18 A weight of 101 pounds was recorded at 6:10 a.m. on 2/10/18. A weight of 89 pounds was recorded at 11:17 a.m. on 2/18/18. The Medication Administration Record [REDACTED]. The Change in a Resident's Condition policy, dated 12/03, directed staff: 1. The resident or resident's representative and attending physician shall be promptly notified of changes in the resident's condition or status. 2. The nurse will notify the physician when there is a significant change in the resident's physical, mental, or psychosocial status, or if there is a need to alter the resident's treatment significantly, or if deemed necessary or appropriate in the best interest of the resident. 3. Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's condition or status. Staff interviews revealed: 4/2/18 at 4:25 p.m., Staff H, certified nursing assistant (CNA), stated the resident didn't eat well, said she didn't feel good and didn't want to eat, staff encouraged her to eat. Staff H reported she offered super cereal (high calorie cereal) and resident refused it. 4/2/18 at 4:31 p.m., Staff I, CNA, stated the resident didn't want to eat and vomited 1 or 2 times after a couple of bites of food at the table. Staff I gave the resident lemon-lime soda, which seemed like-it helped, but she would throw that up as well, because she threw everything up. 4/2/18 at 4:35 p.m., Staff J, LPN, stated the resident complained of nausea but denied it when asked, and didn't act as ill as what her family said. During another interview on 4/3/18 at 8:36 a.m., Staff J stated they gave [MEDICATION NAME] daily for skin/wound problems, but the resident said she thought it made her stomach upset and she had loose stools. The resident didn't eat or drink a lot. 4/3/18 at 9:08 a.m., Staff K, LPN, stated the resident's appetite was poor, didn't want anything to eat, and had nausea and vomiting for a couple of days. Staff K thought the doctor was faxed about the resident's her nausea. Staff stated they offered clear liquids and soups; the resident had liquid stools but also had formed stools, and reported her abdomen was slightly firm with sluggish bowel sounds. 4/3/18 at 9:37 a.m., Staff L, LPN, stated the resident had issues with eating, but would eat ice cream. Staff L commented she was not sure if it was the food or because she wanted her family to take her home. 4/3/18 at 5:40 a.m., Staff M, registered nurse (RN), stated the resident had loose stools, she didn't administer medication to the resident on the night shift, and thought it was passed in report the resident threw up so she could go back to her room. Staff M stated if a resident complained of nausea and threw up she would check their vital signs and would call the doctor if needed, she wouldn't fax that information. 4/3/18 at 9:15 a.m., Staff F, CNA, stated the resident got sick after she ate and threw up, she saw this twice, the resident threw up at the table and the nurse knew that. The resident said she was constipated, but when she went to the toilet she expelled clear liquid mucous with a small amount of light brown stool, and the nurse knew that as well. 4/3/18 at 9:51 a.m., Staff G, CNA, stated the resident didn't eat much and she threw up in the dining room after she drank a certain drink ([MEDICATION NAME]), but was able to eat if she didn't drink it. Staff G stated the nurse knew the resident threw up after the drink. 4/3/18 at 11:05 a.m., upon request for any documentation that the residents conditions were reported as appropriate to the physician, the director of nursing (DON) provided a copy of the 2/16/18 fax with request for [MEDICATION NAME]. The DON stated she expected staff to timely notify the physician, resident, family or RP of resident condition changed or requests for treatment changes for changes in resident conditions. 4/3/18 at 8:44 a.m., the nurse at the resident's physician office, stated after thorough search at the office she was not able to find any other communication from the facility about the resident's nausea, vomiting, loose stools or weight loss. The nurse reported the resident was seen in the office on 2/19/18, she was very weak and the doctor told her family to take her to the emergency room because she was dehydrated. An office visit note dated 2/19/18 documented the resident was evaluated for acute dehydration and abdominal pain, and presented with 4 days of vomiting, very weak, tired, and barely able to hold her head up. The note revealed the resident hypotensive (low blood pressure), acutely ill, and the physician suspected a partial intestinal obstruction or ileus (partial bowel paralysis). The physician had also documented the resident had experienced intractable vomiting with nausea and acute and profound dehydration. Office staff gave [MEDICATION NAME] (an anti-nausea medication) 50 milligrams via injection in the office, and the resident went to the emergency room for further assessment and administration of intravenous fluids. A hospital history and physical dated 2/19/18 revealed the resident admitted to the hospital after an ambulance transfer from another hospital, dehydration from 5 day history of nausea, vomiting and diarrhea, loss of appetite with 9 pound weight loss, and a BUN 104 mg/dl (blood urea nitrogen, a test of kidney function with normal range 7 to 20 milligrams per deciliter) and Creatinine of 3.1 mg/dl (another indication of kidney function with normal results from 0.5 to 1.1 mg/dl. Both results were critical lab values-when tested in (MONTH) (YEAR), the resident's BUN was 38 and Creatinine 1.7). The abdominal X-ray revealed multiple dilated loops of bowel, a large inguinal hernia that contained bowel and was suggestive of a bowel obstruction. A hospital Discharge Summary dated 2/23/18 revealed the resident had been hospitalized for [REDACTED]. During an interview on 4/10/18 at 9:37 a.m., the resident's hospital physician stated the resident had a [MEDICAL CONDITION] gastritis/gastroenteritis with 5 to 6 day history prior to hospitalization , was very dehydrated, and required intravenous (IV) fluid administration. The physician added that the IV fluid worsened the resident's [MEDICAL CONDITION], required additional interventions, and lengthened her hospital stay. During an interview on 3/27/18, the resident's Responsible Party (RP) stated the resident had thrown up in the facility dining room for at least 3 to 4 days and she couldn't keep food down. The RP reported the staff didn't inform the doctor the resident wasn't eating and had gotten weaker, so he/she drove the resident to the doctor's office for assessment. The doctor said the resident had severe dehydration, and told them to take her to the hospital. The RP drove the resident to the closest hospital, but that hospital didn't have an available bed due to flu; hospital staff put the resident in an ambulance for her transport to another hospital.

Based on observation, record review, and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed (Resident #1). On 3/26/18, Resident #1 fell from a lift sling when two Certified Nursing Assistants failed to follow manufacturer mechanical lift directives regarding sling placement during a transfer. The resident sustained [REDACTED]. The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 3/6/18 revealed Resident #1 had [DIAGNOSES REDACTED]. The MDS revealed the resident displayed severe cognitive impairment without symptoms of [MEDICAL CONDITION], and required extensive assistance by at least 2 staff for transfers to and from bed and chair, dressing, bathing, toilet use and personal hygiene. The nursing care documented the resident as at risk for falls problem related to lower leg amputation and disorientation from [MEDICAL CONDITION] process, initiated 4/16/11. The care plan directed staff the resident required a full mechanical lift transfer by 2 staff, initiated 4/16/11 and documented an all staff in-service on full mechanical lifts, initiated 3/27/18. A history and physical report dated 3/29/18 revealed the resident admitted to the hospital on [DATE] with a closed [MEDICAL CONDITION] femur (thigh bone) related to a fall from a mechanical lift at the nursing home. The report revealed the resident was at high risk for surgical intervention related to age and the resident's other disease processes. An orthopedic progress note dated 3/27/18 described the surgery as canceled and revealed the resident admitted to hospice services. The facility's self-reported incident, submitted 3/26/18, documented Resident #1 slid out of the front of the lift sling, landed on her buttocks on the floor. This occurred when staff transferred the resident from a Broda chair (wheel chair that reclines) with a mechanical lift by 2 certified nursing assistants (CNAs), and identified the resident's pants made of a slick material and the resident's movement while in the sling during the transfer as possible factors that contributed to the fall. The administrator's written description of the fall investigation revealed the resident was transferred with a mechanical lift by 2 CNA's, Staff A and Staff B. The investigation revealed the Administer interviewed Staff B. Staff B guided the resident in the sling during the transfer, kept 1 hand on the sling as she used the other hand to move the Broda chair, the resident made an abrupt move during that time and the resident slid forward out of the sling to the floor. Staff A reported the resident wore new pants made from a slick material; Staff A operated the lift controls as Staff B held the sling, she elevated the resident high enough above the chair to clear it, Staff B held the sling and attempted to push the Broda chair out of the way. When Staff A backed the mechanical lift a bit to make room for Staff B to get to the front, the resident moved in the sling during that time, slid out of the front of the sling while elevated above the chair and landed on her bottom on the floor. The sling used was correct for the resident's weight and transfer method, all loops attached to the lift during the transfer, and the lower edge of the sling positioned at the resident's mid-thigh. Both CNA's reported a couple inches of the end of the resident's amputated leg hung over the lower edge of the sling. Staff performed a reenactment of the transfer with the lower edge of the sling positioned at the knee, mid-thigh, and higher than mid-thigh and found when positioned higher than mid-thigh there was enough flex with weight distribution to force weight forward and allow a slide, especially if pants were slick. A written statement by Staff A, dated 3/26/18, stated she operated the lift controls, Staff B held the sling and as she moved the lift back so Staff B could move the Broda chair, the resident jerked or stiffened and shifted herself. Staff A wrote as Staff B moved the chair, the resident slid bottom first out of the sling and hit floor. Staff A documented the sling had been positioned at mid-thigh, and the resident's pants were new and slicker than normal. A written statement by Staff B, dated 3/26/18, stated she had her hand on the sling with the resident lifted enough above the Broda chair to clear it, and used her other hand to move the chair away. Staff B documented as Staff A pulled the lift away from the chair, the resident suddenly moved in the sling and went out the front of the sling, and landed with her rear end on the floor. Staff B wrote the sling was positioned at mid-thigh and her [MEDICAL CONDITION] was maybe 2 inches out from the sling. Facility documents revealed a Tollos Ultralift, model TUL 3510XH and labeled as #2 by the facility, used during the 3/26/18 incident. Product information sheets by Tollos described: 1. The long seat six strap sling designed for general purpose as well as single and double leg [MEDICAL CONDITION] (staff also called it a full body sling). 2. The bottom edge of the long seat six strap sling should be located directly behind the knees. Staff interviews revealed: 3/28/18 at 10:16 a.m., Staff A stated the long seat sling should be placed at the knees, the sling positioned at mid-thigh during Resident #1's transfer on 3/26/18, the resident had slid down in the chair after they got her up that day. During another interview on 4/3/18 at 10:42 a.m., Staff A stated the sling was positioned at the mid-thigh and looked low enough, the 2 CNA's could have tried to work the sling down under her but thought it was down far enough. Staff A stated she now knew the sling had to be positioned at the knees. 3/28/18 at 11:13 a.m., Staff B stated when she transferred the resident back to bed with Staff A (on 3/26/18), the bottom of the sling was at the mid-thigh area, and the resident's amputated leg hung over the sling about 1 to 2 inches. Staff B reported she felt the resident's shoulder or back move when in the sling as she held the sling with 1 hand and moved the Broda chair with the other hand; Staff B was not sure which direction the resident went when she moved, and the resident had involuntary movements of her back. Staff B stated she knew before she watched the video the bottom of the sling was supposed to be at the knee level. 3/28/18 at 10:20 a.m., Staff C, CNA, stated the bottom of the full body sling is placed at the resident's knees. 3/28/18 at 11:39 a.m., Staff D, CNA, stated the top of the full body sling is placed above the shoulders, and the bottom would be at the knee. 3/28/18 at 11:36 a.m., Staff E, CNA, stated the middle loops of the full body sling is placed at the hip area, the bottom of the sling was usually at the knee area. 3/28/18 at 8:06 a.m., the administrator stated all CNA's watched a training video on use of the Tollos lift that included transfer with the long seat sling (also called full body sling) when on orientation, the facility periodically performed skills update education with all staff, and competency of CNA staff assessed annually that included a review of the Tollos video. After the incident, the facility was in the process of mandatory education with all CNA's and nurses that included the Tollos training video and staff required to perform a return demonstration of a mechanical lift transfer with the director of nursing (DON), assistant director of nursing (ADON) or the human resource manager (also a CNA). 3/28/18 at 10:04 a.m., the administrator stated Resident #1 sat a little reclined in the Broda chair, so she could have slid down a little on the sling which would have brought the bottom of the sling closer to the buttocks. 4/3/18 at 11:05 a.m., the DON stated she would have expected staff to reposition the lift sling to the correct position beneath the resident prior to transfer with mechanical lift.

Based on record review and interviews the facility failed to provide adequate supervision to ensure against hazard from self or elements in the environment and the health service supervisor failed to supervise the implementation of the written health care plan. The facility identified a census of 79 residents. Findings include: 1. The face sheet for Resident #3 identified [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) with a reference date of 7/3/12 revealed Resident #3 required limited assistance of one staff person with bed mobility and ambulation. The MDS reflected the resident could transfer independently. The Fall Risk assessment dated [DATE] revealed Resident #3 scored a "20". A score of 10 or higher indicated a high risk for falls. The Care Plan dated 4/3/2012 identified a problem with the resident at increased risk for falls due to a cognitive impairment and being in new surroundings. The approach directed staff to use a pressure alarm in bed and to assistant the resident with ambulation, wheel walker and gait belt on 7/24/2012. The approaches directed staff to provide a toilet program during the night hours. The Event Report sheet dated 8/14/12 at 9:10 p.m. revealed the staff found Resident #3 lying on the right side on the bathroom floor. The sheet revealed staff left Resident #3 in the bathroom alone. The sheet revealed Resident #3 was taken to the bathroom just before the fall. Resident #3 complained of right hip pain. Resident #3 had outward rotation of the right hip. The sheet revealed the nurse contacted the physician and the family. The medics transported Resident #3 to the emergency room . The Major Injury Determination Form revealed Resident #3 had an injury on 8/14/12 at 6:15 p.m. that resulted in two skin tears and a fractured right hip. The physician determined the resident sustained [REDACTED]. On 9/5/12 at 5:50 p.m., Staff A (Certified Nursing Assistant) reported a resident with an alarm should not be left alone on the toilet. Staff A reported one staff had to watch the common area at all times. Staff A did not leave the common area if another aide or the nurse were not present. On 9/5/12 at 4:25 p.m., Staff B (Certified Nursing Assistant) was interviewed and reported when an alarm sounded he/she yelled to the other staff to let them know to cover the common area. Staff B reported they do not leave the common area unless another staff is present. On 9/5/12 at 5:07 p.m., Staff C (Certified Nursing Assistant) was interviewed and reported a staff person had to be in the common area at all times. Staff C reported the other staff working that night had another resident in the bathroom. Resident #4 asked to go to the bathroom. Staff C assisted Resident #4 to the shower bathroom. Staff C reported the nurse left the unit as he/she assisted Resident #4 to the bathroom. Staff C propped the door to the shower room open. Staff C reported Resident #4 had a bed alarm because he/she had a fall in the bathroom once. Staff C heard an alarm sounding and yelled out for the other aide. The aide did not respond. Staff C left Resident #4 on the toilet to respond to the alarm. Staff C reported Resident #3 made it from the bed to the toilet by the time he/she responded to the alarm. Staff C told Resident #3 to stay on the toilet and went back to assist Resident #4. Staff C assisted the resident from the shower room to his/her room. Staff C assisted Resident #4 to bed. Resident #4 requested an ice pack. Staff C left the room for the ice pack and returned with it. Staff C then went back to Resident #3 and found him/her on the floor in the bathroom. The Director of Nursing (DON) was interviewed on 9/5/2012 at 11:55 a.m. and stated she thought the fall happened during shift change. The nurses were giving report and supper at 5:00 p.m.

Based on record review and interviews, the facility failed to notify the physician regarding a significant change in condition for one of three reviewed residents (Resident #1). Resident #1 experienced increased pain, increased swelling, and decrease in mobility to the right knee following a fall. The facility failed to notify the physician of the changes in the resident's condition for 5 days falling the resident's fall; an x-ray completed at that time revealed the resident had a fractured right kneecap. The facility reported a census of 77 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool, with a reference date of 8/30/11, Resident #1 had intact cognition. The MDS further indicated the resident required assist of one staff member with bed mobility, transfers, and dressing, toilet use, and personal hygiene. The MDS documented the resident had a surgical wound. The MDS documented Resident #2 had been on a scheduled pain medication and occasionally experienced pain in the last 5 days. The resident's Plan of Care, dated 6/09/11, indicated the resident had occasional right knee pain due to arthritis, utilized scheduled medication daily, used Biofreeze as needed, and wore a knee brace. Interventions listed directed staff to administer medications as ordered by the physician, for staff to investigate and document pain type, intensity, and location, notify the physician with any increase in pain, or with pain that is unable to be relieved by available measures, and to apply his/her knee brace every a.m. and remove at bedtime. The care plan directed staff to assist the resident with one staff member, gait belt, and walker for transfers and ambulation, followed by a wheelchair. A Safety Events-Falls report dated 10/11/11 at 8:41 p.m. revealed the resident fell while in the bathroom while a CNA (Certified Nurse Aide) assisted the resident with cares. The resident had been standing up without shoes or non-skid socks on, without his/her right knee brace on, and no gait belt, when the resident stepped and went down to the floor landing on the top of his/her right knee. Staff indicated the resident denied pain, and had a reddened knee, but no swelling immediately after the fall. Progress Notes dated 10/12/11 at 6:37 a.m. indicated the resident had bluish bruising and [MEDICAL CONDITION] to the entire right knee and a small bruise to his/her right great toe. The resident complained of significant pain when bending his/her right knee, and that staff would continue to monitor the resident. Progress Notes dated 10/12/11 at 12:41 p.m. revealed the resident had increased [MEDICAL CONDITION] and pain to the right knee, and increased pain to the right knee foot. The note stated the resident didn't ambulate that shift due to pain and weakness of right lower extremity. Progress Notes dated 10/12/11 at 7:30 p.m. indicated the resident continued to have moderate [MEDICAL CONDITION] of the right knee which was slightly warm to touch. Resident was unable to bear weight and the resident' right knee brace would remain off until the swelling subsided. The resident had received scheduled Tylenol and Biofreeze which was effective for controlling his/her pain. Progress Notes dated 10/13/11 at 12:48 p.m. revealed the resident continued to have moderate [MEDICAL CONDITION] of the right knee and complaints of pain from fall; the resident remained non-ambulatory. Progress Notes dated 10/13/11 at 6:05 p.m. revealed the resident continued to have moderate [MEDICAL CONDITION] to right knee with light bruising. The note further stated the resident had taken Tylenol for pain but that the resident continued to have pain, especially with transfers. The resident's brace continued to be off until his/her [MEDICAL CONDITION] subsided, and his/her range of motion continued to be decreased. Progress Notes dated 10/14/11 at 8:49 p.m. indicated the resident's right knee continued to be swollen and warm to touch; range of motion was still decreased and the resident still could not wear the knee brace. The note indicated staff had provided the resident with an ice pack, Tylenol and Biofreeze. Progress Notes dated 10/16/11 revealed the resident had a softball sized reddened area to the center of his/her right knee, with [MEDICAL CONDITION] around the knee. The knee was firm to touch and the resident's skin was tender to the touch from the mid-thigh down. Staff notified the resident's physician who ordered an x-ray of the right knee the following morning. The x-ray report dated 10/17/11 revealed a probable [MEDICAL CONDITION]'s right knee cap. Progress Notes dated 10/18/11 at 11:19 a.m. indicated the resident continued with [MEDICAL CONDITION] and discoloration of the right knee, non-weight bearing to the right lower extremity since his/her fall, and utilizing a stand-aide or two person assist for transfer. The resident continued to complain of pain to right knee, received Tylenol and reported some effectiveness with this. Progress Notes dated 10/18/11 at 3:27 p.m. indicated staff had received new orders from the resident's physician to have the resident follow-up with an orthopedic doctor for the right knee. The orthopedic physician dictation dated 10/24/11 revealed the resident had been evaluated regarding his/her complaints of swelling and pain to the right knee. The x-rays revealed a [MEDICAL CONDITION]. Treatment included placing the resident's right leg in a knee immobilizer and to follow-up with x-rays in a month. The resident's MAR (Medication Administration Record) dated October 2011 indicated staff had assessed the resident's pain on each shift. The pain assessments prior to 10/11/11 documented the resident had complained of pain only one time that was a 2 on a scale between 1-10; 1 being the least amount of pain and 10 being the worse. After 10/11/11 staff documented the resident had pain every day that was rated as high as a 7. The MAR indicated [REDACTED]. The PRN MAR indicated [REDACTED]. The MAR further revealed the resident requested the PRN Tylenol on 10/15, 10/16, 10/17/11 for complaints of right knee pain and general discomfort. During an interview on 11/17/11 at 2:31 p.m., the DON (Director of Nursing) indicated that staff should have notified the resident's physician prior to 10/16/11 regarding the resident's change of condition to the right knee following a fall on 10/11/11. During an interview on 11/17/11 at 10:10 a.m., Resident #1 reported that after the fall on 10/11/11 she/he did not have immediate pain or swelling of the right knee, but by the next morning his/her right knee had swelling and significant pain and could not wear the knee brace. The resident indicated the pain got really bad over the next few days and he/she complained to the staff about the pain and the resident thought that staff would contact the physician. The resident further reported he/she could not bear weight on the right knee, could not wear the brace to the right knee and had significant pain and swelling to the right knee the morning after the fall. The resident indicated he/she never had that much pain or swelling to his/her knee before the fall. The resident reported that staff finally notified his/her physician a week later and had x-rays done that showed a fracture to the right knee. The resident reported the physician ordered a knee immobilizer and that had helped a great deal with the pain. During an interview on 11/17/11 at 1:31 p.m., Resident #1's physician indicated that the facility did not notify him/her of the change of status of the resident's right knee after the fall on 10/11/11 until 10/16/11. The physician reported that the facility should have notifed him/her sooner of the resident's increased pain, swelling, and inability to bear weight following the resident's fall.