Every finding on record at River Valley Nursing and Rehabilitation

Based on facility record review, staff interviews and facility policy review the facility failed to provide registered nurse coverage 8 hours a day for 2 out of 30 days reviewed. The facility identified a census of 34 residents. Findings include: Review of the schedule for nursing staff on 7/18/26 and 7/19/26 revealed the facility had nurse coverage of licensed practical nurse only for both days in a 24 hour period. On 8/20/26 at 11:38 AM the Director of Nursing revealed the facililty should have a registered nurse (RN) on staff for 8 hours a day minnumum. She explained the weekend of 7/18/26 and 7/19/26 the RN who would have worked was out of town and they had agency staff cover for the weekend and it should have been an RN. On 8/20/26 at 12:35 PM the Administrator stated the facility should have 8 hours a day RN coverage. She revealed the reason no RN worked the weekend of 7/18/26 and 7/19/26 related to the staff normally scheduled was out of town and they had to use agency staff. The facility provided a polilcy titled Staff, Sufficient and Competent Nursing revised March 2026 revealed sufficient staff would be a registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled for more than eight (8) hours depending on the acuity needs of the residents and based on the facility assessment.

Based on observation, staff interviews and employee file review the facility failed to employee a Certified Dietary Manager (CDM) from 7/15/26 through 8/20/26. The facility reported a census of 34 residents. Findings include:On 8/17/26 at 10:20 AM the Dietary Director reported he's also maintenance. Staff B said his background is a Chef.The current Facility Active Employee Report listed Staff B as the Dietary Director.Staff B Dietary Director personnel file showed a hire date of 5/21/26 as the Maintenance Tech. The Updated Form For Worksite Employee dated 7/15/26 showed Dietary Manager. Staff B employee file lacked any dietary training records or qualification for the Dietary Manager.On 8/20/26 at 11:43 AM the Administrator reported Staff B failed to have the training to be the facilities CDM. The facility failed to provide a policy.

Based on observation, clinical record review, staff interviews and facility policy review the facility failed to report an allegation of abuse for two of three residents reviewed (Resident#29 and #9). The facility reported a census of 34 residents. Findings include;1. The Minimum Data Set (MDS) assessment for Resident#29 dated 5/6/26 listed diagnoses of schizophrenia and psychotic disorder. The MDS reflected a Brief Interview of Mental Status (BIMS) score of 7 out of 15, severe impairment. The MDS identified Resident#29 independent with walking, transfers and eating.The Care Plan for Resident #29 dated 5/28/26 directed ongoing psychiatric medication management. The Care Plan failed to identify potential behavioral risks.2. The MDS assessment for Resident#9 dated 7/8/26 listed diagnoses of seizure disorder, traumatic brain injury, and anxiety. The MDS reflected a BIMS score of 9 out of 15, moderate impairment. The Care Plan for Resident#9 dated 9/11/25 directed ongoing psychiatric medication management. The Care Plan documented the resident has a behavior problem at times including grabbing other people and exhibiting aggression at times. The Progress Note dated 6/14/26 at 2:01 PM reflected Resident#29 sat in Resident#9's chair. Resident#9 went up asked Resident#29 to move. Resident#29 started yelling at Resident#9. Resident#9 sat on couch. Resident#29 continued to sit in his chair. Resident#9 went over to Residen#29, placed his hands on Resident#29's shoulder and neck made contact Resident#9 stated Resident#29 was going to die today. Staff B, Dietary Manager removed Resident#9 from Resident#29. Resident#9 sat on couch staff continued to make sure residents were apart.The Verbal Aggression Report dated 6/14/26 at 7:45 AM revealed Resident#29 sat in resident#9's chair. Resident#9 asked Resident#29 to move, Resident#29 became verbally aggressive towards Resident#9 yelling at him. Resident#9 stated Resident#29 was going to die today. Resident#9 went from behind Resident#29, placed hands on shoulder, Staff B removed Resident#9's hands from Resident#29's neck and directed Resident#9 to sit on the couch Resident#29 continued to yell out loud. Both parties were removed Staff C Registered Nurse (RN) called the Director of nursing (DON) and follow her direction. Notified the Provider and the Administrator.The Progress Note for Resident#9 dated 6/14/26 at 9:57 AM reflected Staff C Registered Nurse (RN) sat at desk charting heard loud noises from dining room. Resident#29 sat where Resident#9 normally sat. Resident#9 yelled I'm going to kill him. Residnet#9 went over to Resident#9 put his hands on Resident#29's neck. Dietary staff yelled for other dietary staff to help. Resident#9 stated Resident#29 was going to die today. Staff B Dietary Manager removed Resident#9's hand from Resident#29 neck and guided Resident#9 to sit on the couch.The Verbal Aggression report dated 6/14/26 at 7:45 AM revealed Resident#9 went to sit in his chair in the dining room and Resident#29 sat in his chair Resident#9 told him that's where he sat Resident#29 started yelling at Resident#9. Dietary staff had Resident#9 sit on couch. Resident#9 proceed to get up go towards Resident#29 yelling he was going to kill him and he was going to die. Dietary witnessed this Resident#9 went over to Resident#29 and put his hands on his shoulder and dietary staff yelled for male dietary staff to help. Staff B went and removed Resident#9 from Resident#29. Staff B got Resident#9 to sit on couch. Resident#29 continued to yell, staff redirected. The record showed Staff C notified the DON and the AdministratorReview of facility reported Incidents (FRI) since previous recertification survey dated 8/28/25 failed to include an incident dated 6/14/26. On 8/17/26 at 11:31 AM Resident #9 got up from the dining room table walked over to the couch leaned over and told the guest she sat in his spot. The guest moved out of Resident#9's spot and he sat down. On 8/19/26 at 9:37 AM Staff C reported she sat at the nurses station and heard staff calling for her help. Staff C said she saw Resident#9 with his hands from the back around Resident#29 neck. Staff C said Staff D, previous Dietary Manager and Staff B were there and got him away from Resident#29. Staff C said she called the DON at the time and was told to call the Administrator, who failed to get answer the phone. Staff C said she checked both the residents over and kept them apart. Staff C reported she had to report the incident to the DON but she failed to know what the facility did after the incident. On 8/19/26 at 2:48 PM Staff E Previous DON said if the situation between Resident#9 and Resident#29 happened it was reportable within 2 hours to the state agency (SA).Staff E said that she failed to know based in the witnesses. Staff E said the Administrator reported things to the SA. On 8/19/26 at 2:52 PM Staff C reported she talked with the Administrator about the incident and they felt it wasn't aggressive behavior. On 8/19/26 at 5:39 PM Staff B reported he was in the kitchen Staff D called him out so they could help a man in the area. Staff B said both residents were confused. Resident#29 sat in Resident#9's dining room chair. Staff B said Resident#9 got upset because Residetn#29 sat in his chair. Resident#29 failed to get up. Resident#9 put his hand on Resident#29 shoulder, not aggressive, just get out of my chair. Staff B said when he got over to them he asked Resident#29 to move over to the couch and he got up when he asked him to move. Resident#9 did said he was going to kill Resident#29 but it was not to hurt him. On 8/20/26 at 10:39 AM the current facility Administrator stated if she was the Administrator at the time of the incident between Resident#9 and Resident#29 she would report it to the SA. The facility provided a policy titled Abuse, Neglect, and Exploitation dated 7/29/26 directed Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse, and certain resident to resident altercations. The policy reflected the facility will report all alleged violations to the Administrator, SA, adult protective services and all required other organization within the time frames:Immediately, but not more then 2 hours after the allegation is made, if the event that cause the allegation involve abuse.

Based on clinical record review, staff interviews and facility policy review the facility failed to investigate an allegation of abuse for two of three residents reviewed (Resident#29 and #9). The facility reported a census of 34 residents. Findings include:1. The Minimum Data Set (MDS) assessment for Resident#29 dated 5/6/26 listed diagnoses of schizophrenia and psychotic disorder. The MDS reflected a Brief Interview of Mental Status (BIMS) score of 7 out of 15, severe impairment. The MDS identified Resident#29 independent with walking, transfers and eating.The Care Plan for Resident #29 dated 5/28/26 directed ongoing psychiatric medication management. The Care Plan failed to identify potential behavioral risks.2. The MDS assessment for Resident#9 dated 7/8/26 listed diagnoses of seizure disorder, traumatic brain injury, and anxiety. The MDS reflected a BIMS score of 9 out of 15, moderate impairment. The Care Plan for Resident#9 dated 9/11/25 directed ongoing psychiatric medication management. The Care Plan documented the resident has a behavior problem at times including grabbing other people and exhibiting aggression at times. The Progress Note dated 6/14/26 at 2:01 PM reflected Resident#29 sat in Resident#9's chair. Resident#9 went up asked Resident#29 to move. Resident#29 started yelling at Resident#9. Resident#9 sat on couch. Resident#29 continued to sit in his chair. Resident#9 went over to Residen#29, placed his hands on Resident#29's shoulder and neck made contact Resident#9 stated Resident#29 was going to die today. Staff B, Dietary Manager removed Resident#9 from Resident#29. Resident#9 sat on couch staff continued to make sure residents were apart.The Verbal Aggression Report dated 6/14/26 at 7:45 AM revealed Resident#29 sat in resident#9's chair. Resident#9 asked Resident#29 to move, Resident#29 became verbally aggressive towards Resident#9 yelling at him. Resident#9 stated Resident#29 was going to die today. Resident#9 went from behind Resident#29, placed hands on shoulder, Staff B removed Resident#9's hands from Resident#29's neck and directed Resident#9 to sit on the couch Resident#29 continued to yell out loud. Both parties were removed Staff C Registered Nurse (RN) called the Director of nursing (DON) and follow her direction. Notified the Provider and the Administrator.The Progress Note for Resident#9 dated 6/14/26 at 9:57 reflected Staff C Registered Nurse sat at desk charting heard loud noises from dining room. Resident#29 sat where Resident#9 normally sat. Resident#9 yelled I'm going to kill him. Residnet#9 went over to Resident#9 put his hands on Resident#29's neck. Dietary staff yelled for other dietary staff to help. Resident#9 stated Resident#29 was going to die today. Staff B Dietary Manager removed Resident#9's hand from Resident#19 neck and guided Resident#9 to sit on the couch.The Verbal Aggression report dated 6/14/26 at 7:45 AM revealed Resident#9 went to sit in his chair in the dining room and Resident#29 sat in his chair Resident#9 told him that's where he sits Resident#29 started yelling at Resident#9. Dietary staff had Resident#9 sit on couch. Resident#9 proceed to get up go towards Resident#29 yelling he was going to kill him and he was going to die. Dietary witnessed this Resident#9 went over to Resident#29 and put his hands on his shoulder and dietary staff yelled for male dietary staff to help. Staff B came and removed Resident#9 from Resident#29. Staff B got Resident#9 to sit on couch. Resident#29 continued to Resident#29. The record showed Staff C notified the DON and the AdministratorOn 8/17/26 at 11:31 AM Resident #9 got up from the dining table walked over to the couch leaned over her and told the guest she sat in his spot. The guest moved out of Resident#9's spot and he sat down. On 8/19/26 at 9:37 AM Staff C reported she sat at the nurses station and heard staff calling for her help. Staff C said she saw Resident#9 with his hands from the back around Resident#29 neck. Staff C said Staff D, previous Dietary Manager and Staff B were there and got him away from Resident#29. Staff C said she called the DON at the time and was told to call the Administrator, who failed to get answer the phone. Staff C said she checked both the residents over and kept them apart. Staff C reported she had to report the incident to the DON but she failed to know what the facility did after the incident. On 8/19/26 at 2:48 PM Staff E Previous DON said if the situation between Resident#9 and Resident#29 happened it was reportable within 2 hours to the state agency (SA). Staff E said that she failed to know based in the witnesses. Staff E said the Administrator reported things to the SA.On 8/19/26 at 2:52 PM Staff C reported she talked with the Administrator about the incident and they felt it wasn't aggressive behavior. Staff E reported the facility failed to complete interviews, get statements from the staff and she failed to locate any investigation of the incident between Resident#9 and Resident#29.The facility provided a policy titled Abuse, Neglect, and Exploitation dated 7/29/26 directed an immediate investigation is warranted when suspensions of abuse, neglect or exploitation, or reports of abuse ,neglect, or exploitation occur. The policy identified interviewing all involved persons, including the alleged victim and the alleged perpetrator, witnesses, and others, who might have knowledge of the allegation.

Based on clinical record review and staff interviews the facility failed to update a pre-admission screening and resident review (PASARR) for one out of one resident reviewed with change in psychiatric diagnosis (Resident #8). The facility identified a census of 34 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident#8 dated 4/8/26 listed diagnoses of anxiety disorder, depression and bipolar disorder. The MDS indicated Resident #8 was not a level 2 for PASSR for serious mental conditions. Review of the preadmission screening and resident review completed 1/5/24 prior revealed a level I outcome and failed to include the diagnosis of bipolar disorder. Review of a list of diagnosis in the electronic health record for Resident #8 revealed a diagnosis of bipolar disorder dated 5/1/25. On 8/20/26 at 12:23 PM Staff F, RN, MDS Coordinator stated if the resident had a new diagnosis or change in condition or behaviors I should submit a new PASSAR. If Resident #8 had a diagnosis of Bipolar Disroder that should have been on her PASSAR. On 8/20/26 at 12:24 PM the Administrator stated she would expect staff to follow regulations for PASSAR. The MDS Coordinator is the staff responsible to submit the PASSAR. or policy [NAME] is the one responsible for submitting the PASSAR On 8/20/26 at 12:45 PM Staff F verified she should have submitted a new PASSAR on admission for Resident #8 due to the diagnosis of bipolar disorder and she has completed it now.

Based on observation, clinical record review, staff interviews and facility policy review the facility failed to use Enhanced Barrier Precautions (EBP) during care for a resident for one out of three residents reviewed (Resident# 1). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident#1 dated 7/29/26 listed diagnoses of cerebrovascular accident (CVA) (stroke), coronary artery disease (CAD) and obstructive uropathy (a blockage in the urinary tract that stops urine from flowing normally from the kidneys to the outside of the body). The MDS documented the Brief Interview for Mental Status (BIMS) score 13 out of 15, memory skills are normal and cognitively intact, with little to no impairment. The MDS listed Resident#1 used an indwelling catheter. The MDS reflected Resident#1 required a feeding tube while a resident. The Care Plan for Resident#1 dated 9/09/24 directed Resident#1 needed Enhanced Barrier Precautions related to the use of feeding tube placement and foley catheter. On 8/18/26 at 1:37 PM Resident#1 room door held the EBP sign and a holder for the EBP supplies. Staff A Registered Nurse (RN) entered the room completed hand hygiene, applied gloves. Staff A checked Resident#1 placement of the tube feeding, checked gastric content. Staff A provided the feeding and flush as ordered and failed to wear the gown for the EBP. Staff A Registered Nurse (RN) wore gray scrubs and sweatshirt. On 8/18/26 at 1:40 PM the Director of Nursing (DON) looked in the room to pull the room door shut after the roommate entered in the room. On 8/20/26 at 12:18 PM the Administrator reported she expected the staff to use the EBP as directed. On 8/20/26 at 12:21 PM the DON reported she expected the staff to use the EBP when dealing with the tube feeding and catheters. The facility provided the policy titled Enhanced Barrier Precautions dated December 2024 directed EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).Personal protective equipment (PPE) is changed before caring for another resident.Face protection may be used if there is also a risk of splash or spray.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:dressing;bathing/showering;providing hygiene or grooming;changing briefs or assisting with toileting;transferring;providing bed mobility;changing linens;prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care);device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); andwound care (any skin opening requiring a dressing).

Based on a record review, staff and family interviews, and a policy review, the facility failed to refund an overpayment within 30 days after 1 of 1 residents passed away at the facility (Resident #5). The facility reported a census of 37 residents. Findings include:Resident #5's admission Record documented an admission date of 1/24/24 and a discharge date of 11/12/25.Review of a Check Request dated 11/20/25 documented that $6,840 dollars belonged as a refund to Resident #5's trust account. Resident #5 maintained a payor source of private pay and paid in full for the month but passed away prior to the end of the month.Review of Resident #5's Statement for December 2025 documented a surplus of $6,840.00 in the facility's account.Review of Resident #5's Statement for January 2026 documented a surplus of $6,840.00 in the facility's account.Review of Resident #5's Statement for February 2026 documented a surplus of $6,840.00 in the facility's account.Review of Resident #5's Statement for March 2026 documented a surplus of $6,840.00 in the facility's account.Review of Resident #5's Statement for April 2026 documented a surplus of $6,840.00 in the facility's account.Review of Resident #5's Statement for May 2026 documented a surplus of $6,840.00 in the facility's account.On 6/3/26 at 1:10 PM, Resident #5's Power of Attorney (POA) revealed the facility called her today and informed her they worked on refunding the money and planned to mail it out to her. She revealed Resident #5 passed away in November and she received nothing since. She originally gave the facility a couple months to refund the overpayment, then started calling them, and eventually went to the facility to personally try talking with them. Staff told her the person who handled the refunds lacked presence at the facility at that time. She tried to contact the business manager, who acted quite rude on the phone and hung up on her. The facility failed to contact her. She sent a certified letter in February, but heard nothing, so she reported the matter to the state, and the facility randomly called her today.On 6/8/26 at 4:45 PM, the Administrator revealed the [NAME] President of Operations (VPO) with the facility's management company lacked awareness that he needed to approve the request before the facility could refund the money.Review of the facility's administrative policy, last revised March 2021, titled Conveyance of Resident Funds, instructed the facility that the resident's personal funds and a final accounting of funds are to be returned to the resident, the resident's representative, or to the resident's estate, as applicable, within thirty days from the date of the resident's discharge, eviction from the facility, or death.

Based on clinical record review, facility policy review, resident and staff interview, the facility failed to develop and implement a discharge planning process, including identifying discharge goal, preferences and necessary referrals to assist 1 of 2 residents (Resident #2) who expressed a desire to leave the facility. The facility reported a census of 37 residents. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE], reviewed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The list of diagnoses included diabetes, Parkinsonism (a group of neurological disorders that cause motor symptoms like slowed movement, muscle stiffness, tremors, and balance issues), non-Alzheimer's dementia and schizophrenia. The MDS indicated Resident #2 utilized a walker and wheelchair, required partial/moderate assistance to walk and shower/bathe, and substantial/maximal assistance for toileting hygiene. On 6/2/26 at 3:05 PM, Resident #2 overhead telling staff he just wants to leave and go somewhere else.Review of the Resident #2's Care Plan revealed a Focus area to address I wish to remain in this facility long term due to my medical condition. Initiated: 9/16/25. Interventions included:a. Encourage the resident to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. Initiated. 9/16/25.b. Evaluate the resident's motivation to return to the community. Initiated. 9/16/25.The Care Plan did not include Focus areas or Interventions to address the residents request to leave and go somewhere else. During an interview on 6/4/26 at 12:05 PM, the Administrator on 6/4/26 stated she is going to send out referrals today for Resident #2 to go to a smoking facility.Via an email exchanged n 6/8/26 at 1:17 PM, the Director of Nursing (DON) stated four referrals have been sent out for Resident #2.During an interview on 6/9/26 at 10:23 AM, Resident #2 stated no one has talked to him about discharging.During an interview on 6/9/26 at 10:25 AM, Social Services staff stated she wasn't aware of any referrals made for Resident #2 during his current stay to discharge. She explained she might've sent a referral 2 months ago to a facility but they refused to accept the resident. The Social Service staff stated Resident #3 had not mentioned wanting to leave the facility. She added the only conversation she typically has with the resident is about his finances.During an interview on 6/9/26 at 10:41 AM, the Administrator stated she and the Social Services staff discussed discharging with Resident #2. He informed them that he spoke with the prior administrator about him discharging to another facility.During an interview on 6/10/26 at 12:59 PM, the facility Advanced Registered Nurse Practitioner (ARNP) stated Resident #2 just wants to leave, he brought it up a couple of months ago, and the facility did referrals, she was unaware of the outcome. During an interview on 6/10/26 at 1:34 PM, Staff H, Certified Medication Assistant (CMA) stated Resident #2 wants to go somewhere else because he wants to smoke more. Staff H stated Resident #2 started saying he wanted to leave about a month ago, and Staff H told the prior Administrator.During an interview on 6/10/26 at 2:21 PM, the DON stated Resident #2 shouts out that he wants to get out of the facility and go somewhere else, and he has done that since admission. The DON stated that today another facility communicated that they might take Resident #2.During an interview on 6/10/26 at 3:32 PM, the Administrator sdtated she was never told Resident #2 wanted to be discharged . The Administrator stated that facility staff members sent out referrals when the matter was brought to her attention last week, and they sent referrals to smoking facilities.Review of the facility policy Resident Rights revised October 2025 directed that residents have multiple rights while living at the facility including but not limited to: communication with and access to people and services, both inside and outside the facility; self-determination; exercise their rights without interference, coercion, discrimination, or reprisal from the facility; and be informed of, and participate in, their care planning and treatment.

Based on a clinical record review, staff and resident interviews, and a policy review, the facility failed to implement Restorative care to assist a resident in maintaining his highest practical level of walking for 1 of 1 resident (Resident #2) reviewed for restorative care. The facility reported a census of 37 residents. Findings include: 1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The list of diagnoses included diabetes, Parkinsonism (a group of neurological disorders that cause motor symptoms like slowed movement, muscle stiffness, tremors, and balance issues). The MDS indicated Resident #2 utilized a walker and wheelchair, and required partial/moderate assistance to walk 10 feet, 50 feet with two turns and 150 feet. Review of Occupational Therapy Discharge summary dated [DATE] revealed Resident #2 received services from 1/19/26 to 4/8/26, and discharged due to highest practical level achieved. The summary documented the ambulated 160 feet with partial assistance. Discharge recommendations included: 24-hour care, Shower chair with back, Assistance with ADL's, Assistance device for safe functional mobility, Grab bars, Home exercise program.Review of the electronic health record (EHR) revealed the following:a. A Health Status Note entered on 4/16/26 at 2:45 PM: New Order - Restorative care, daily PT would like to walk daily. b. A Health Status Note entered on 4/17/26 at 10:47 AM by the Director of Nursing (DON): Order not needed as this is nursing judgement. Will discuss with nursing department and therapy. Review of Resident #2's Care Plan revealed the following Focus areas:a. I require assistance with ADL's r/t (related to) impaired balance. Initiated: 9/15/25. Interventions included, in part:1. PT/OT evaluation and treatment per MD orders. initiated: 9/15/25.b. I am at risk for falls r/t Gait/balance problems, incontinence, Psychoactive drug use. Initiated: 9/15/25. Interventions included, in part, all initiated on 9/15/25:1. I ambulate with assist of 1 gait belt and walker. Initiated2. Anticipate and meet the resident's needs;3. Encourage the resident to participate in activities that promote exercise, physical active for strengthening and improved mobility.A Focus area to address the specific need for Restorative program not included in the Care Plan.During an interview on 6/1/26 at 3:10 PM, Resident #2 stated that staff don't walk him. He stated they're supposed to walk him every day. The resident stated now he can't walk, and then added he probably can. During a second interview on 6/2/26 at 3:05 PM, Resident #2 stated that he last walked when therapy worked with him. He revealed that staff members won't walk him, and he just wants to leave the facility and go somewhere else.During an interview on 6/9/26 at 3:14 PM, Staff N, Occupational Therapist (OT) stated Resident #2 enjoyed walking. Staff N stated that therapy staff is expected to get individuals to their highest functional level, and then afterwards facility staff take over and maintains that level. Staff N stated sometimes that includes a restorative program or walking program.During an interview on 6/9/26 at 3:30 PM, Staff O, Certified Occupational Therapy Assistant stated Resident #2 has a history of stating that facility staff members did not walk him when he was receiving services. Staff O stated that staff members chart this information in a binder, and the Minimum Data Set (MDS) Coordinator works remotely to review it. Staff O believed that Resident #2's restorative program included bilateral lower extremity (both legs) strengthening and walking for 15 minutes six to seven times a week.During an interview on 6/9/26 at 4:08 PM, Staff A, Licensed Practical Nurse (LPN) stated Resident #2 can transfer in and out of bed but does not walk. Staff A stated that Resident #2 does not have a restorative program.During an interview on 6/10/26 at 12:59 PM, the facility Advanced Registered Nurse Practitioner (ARNP) stated Resident #2 asked for a walking program, and the ARNP stated that if Resident #2 wanted it, the program should still be going.During an interview on 6/10/26 at 2:00 PM, Staff L, Certified Nursing Assistant (CNA) stated she manages scheduling and Restorative Care. Staff L stated Resident #2 does not have a Restorative Program, and is not on the Restorative list. Staff L stated she never heard of doing a walking program with Resident #2 and did not see an order for a walking program in April 2026. Staff L noted that if an order exists, it should go straight to the MDS Coordinator.During an interview on 6/10/26 at 2:21 PM, the DON stated the MDS Coordinator leads the Restorative program. The DON stated that the MDS Coordinator told the prior administrator she was no longer doing the program, which has been the case for maybe a month. The DON stated Resident #2 is not on a Restorative program, though staff members try to get him to walk now and then. The DON stated Resident #2 did not need a restorative program per nursing judgement because he probably would not do it.During an interview on 6/10/26 at 3:03 PM, the MDS Coordinator stated she does not believe Resident #2 is on a Restorative program, though did he receive Occupational Therapy a while back. The MDS Coordinator stated she never got updated on Resident #2 needing therapy and noted that nursing would have received the form since she is not in the building. The MDS Coordinator stated she goes into the building once a week, performs assessments for a couple of hours, and then leaves.Review of a facility policy titled Restorative Nursing Services, revised July 2017 included a a Policy Statement which declared: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. The Policy Interpretation and Implementation section directed, in part:1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies).3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care.4. The resident or representative will be included in determining goals and the plan of care.

Based on clinical record review, policy review, and resident, staff and physician interviews, the facility failed to notify the physician of changes in a resident's condition, failed to intervene in a timely manner that included the collection of a urinalysis specimen for immediate processing, and failed to communicate laboratory results that indicated treatment was required to a resident's physician after their discharge for 1 of 3 residents reviewed with urinary catheters (Resident #4). The facility reported a census of 29 residents. Findings include: Review of the Minimum Data Set (MDS), dated [DATE], for Resident #4 revealed a list of diagnoses which included neurogenic bladder, paraplegia, stage IV (4) pressure ulcer of the left buttocks (a full-thickness tissue loss where skin, fat, and muscle have been destroyed, exposing underlying bone, tendon, or muscle), osteomyelitis (infection of the bone) of other site, anxiety and depression. The Brief Mental Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The Assessment revealed the resident always able to make herself understood and always able to understand others. The assessment indicated Resident #4 required moderate staff assistance to transfer to and from bed and chair, bathing and toileting. The MDS documented the resident used a urinary catheter. Review of Physician Orders revealed, in part:a. Cleanse umbilicus catheter site with soap and water and pat dry daily on day shift, ordered 7/23/25.b. Attempt Clean Intermittent Catheterization to umbilicus with coude tip (type of catheter) pointing inferior, resident may perform by self, every 4 hours for maintenance document ml (milliliters) of urine output upon return, ordered 8/20/25.c. SP (suprapubic) catheter capped at all times except for cares and flushes, ordered 9/1/25.d. A physician order transcribed by Staff A, RN (Registered Nurse) on 10/17/25 at 11:32 a.m., with the facility Nurse Practitioner (NP) identified as the authorizing provider, directed staff: UA (urinalysis) with C&S (culture and sensitivity report) if indicated to be done Monday early AM to be sent to lab Monday AM.Review of Resident #4 Care Plan revealed the following Focus areas and associated interventions: a. I am at risk for urinary tract infection (UTI) related to use of urinary catheter, initiated 7/23/2025, with goal I will remain free from signs or symptoms of UTI, target date 11/3/25, included the following interventions: 1. Monitor resident for signs or symptoms of UTI and report abnormalities to MD, initiated 7/23/2025. 2. Provide resident with laboratory testing as ordered by MD, initiated 7/23/2025 Created on: 07/23/2025. b. I have a Urinary Tract Infection and am at risk of complications that does not meet McGeer criteria (a set of clinical definitions used to identify and monitor healthcare-associated infections (HAIs) in long-term care facilities), initiated 9/21/2025, with goal the resident's urinary tract infection will resolve without complications by the review date, and notation the goal resolved on 10/1/25, listed interventions that included: 1. Encourage adequate fluid intake, initiated 9/21/2025. Give antibiotic therapy as ordered. 2. Monitor/document for side effects and effectiveness, initiated 9/21/2025.3. Give antipyretics, analgesics and antispasmodics as ordered/as needed. Monitor/document for side effects and effectiveness, initiated 9/21/2025. 4. Monitor VITAL SIGNS as ordered and as needed. Notify MD of significant abnormalities, initiated 9/21/2025.5. Monitor/document/report to MD signs or symptoms of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral changes, initiated 9/21/2025. 6. Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated, initiated 9/21/2025.7. Resident/family/caregiver teaching should include: Good hygiene practices: Females to wipe and cleanse from front to back, Clean peri area well after BM in order to help prevent bacteria in urinary tract, cranberry juice or prune juice to help keep urine acidic, Void at first urge. Do not hold urine for extended amount of time, Wear clean underwear daily, Take the full course of antibiotic therapy even if much improved after a few days of therapy, initiated 9/21/2025. Reveal of the electronic health record (EHR) revealed the following Nursing Progress Notes: a. On 10/12/25 at 11:17 p.m., Staff B, Registered Nurse (RN) stated Genitourinary: Cloudy in appearance. Mucous noted. No urinary complaints.b. On 10/16/25 at 5:08 a.m., Staff B, RN stated Genitourinary: Mucous noted. Cloudy in appearance. No urinary complaints.c. On 10/17/25 at 11:34 a.m., Staff A, RN stated New order for UA (urinalysis) to be collected early Monday AM to be sent Monday AM for C&S (culture and sensitivity) if indicated.d. On 10/18/25 at 11:26 p.m., Staff B, RN stated Genitourinary: Foul smell noted. Mucous noted. Hematuria noted. Cloudy in appearance. Urine retention noted. Urinary catheter intact.e. On 10/20/25 12:41 a.m., Staff B, RN stated Genitourinary: Cloudy in appearance. No urinary complaints. Urinary catheter intact. Obtained UA specimen at 12:04 a.m. and placed in cooler on ice for lab pickup.Review of the Resident #4 10/20/25 UA with C and S (culture and sensitivity - a lab test to help decide which antibiotic to prescribe) laboratory final results 10/25/25 revealed: Light yellow colored urine, clarity turbid (defined as thick with suspended matter, an abnormal result, normal result clear), 1+ blood (abnormal, normal negative for blood), Nitrites positive (abnormal, normal result negative), 3+ leukocytes (abnormal, normal result negative), greater than 50 white blood cells (abnormal, normal less than 6 white blood cells), moderate bacteria (abnormal, normally absent), mucous present (abnormal, normally absent), budding yeast present (abnormal, normally absent), white blood cell clumps present (abnormal, normally absent).The culture and sensitivity report revealed the resident's urine was infected with more than 100,000 CFU (colony forming units per milliliter) Klebsiella Pneumoniae and 20,000 to 25,000 CFU Enterococcus Faecalis, both bacteria not normally in the urine, the resident had a urinary tract infection (UTI) that required treatment with at least 2 different antibiotic medications.During an interview on 10/30/25 at 3:32 p.m., Resident #4 stated shad been telling staff for about 2 weeks prior to her discharge that she thought she had a UTI, they knew she was having symptoms of a UTI and didn't do anything about it until the day before she was discharged . Resident #4 stated on 10/17/25 Staff A, RN was in her room for her care and when she spoke to the nurse about her continued UTI symptoms. Staff A said we're not dealing with this today, we'll deal with this on Monday (10/20/25), and that's when they collected her urine specimen. Resident #4 stated on 10/24/25 she was feeling very ill, with fever of 101, rapid heart rate, flank pain, thick foul-smelling urine with mucous, called her urologist, they prescribed an antibiotic based on her symptoms 10/25/25, and she had not received the results of her UA that was done on 10/20/25During an interview on 10/30/25 at 11:03 a.m. Staff A, RN, stated she remembered writing the order for the UA on Resident #4, but didn't remember the specific's as to why it was ordered to collect the specimen on 10/20/25. The resident had reported to her that she was having cloudy urine, but she had not observed this herself, it was usually the CNA's (Certified Nursing Assistants) that emptied the graduate and cleaned the resident after she self-catharized, they would have observed her urine but they had not reported concerning symptoms to her in the time leading to her facility discharge. She might have written the order that way because if the lab doesn't have somebody that can pick up the specimen the facility didn't have a way to get the specimen to the lab because it's located 100 miles away. During an interview on 10/30/25 at 10:24 a.m. the Director of Nursing (DON) stated their lab came every Tuesday for lab draws and could gather specimens at that time, if staff needed labs done or a specimen collected on other days, they had to order it as a STAT (immediate) for lab to collect the specimen that day, and staff know to do that and have done that. During an interview on 10/30/25 at 4:11 p.m. Staff C, facility MDS nurse stated she had no understanding of why the UA ordered on 10/17/25 was scheduled for 10/20/25. If it was a STAT order or if their laboratory was unable to pick up the specimen staff could take specimens to 1 of the local hospital labs and Staff A must not have known that at the time, that was the only explanation she could offer. During an interview on 10/30/25 at 10:32 a.m., the facility's Advanced Practice Registered Nurse Practitioner (ARNP) stated she did see the notation about the resident's 10/20/25 UA results, did not remember the nurses speaking to her about this when she was at the facility on 10/19/25, and did not authorize the order for it. If the resident was having symptoms of an UTI, she would have directed them to collect the UA at that time and not wait 3 days. During an interview on 10/30/25 at 4:15 p.m., when quarried why she wouldn't have collected the urine specimen on 10/17/25 when she wrote the order at 11:32 a.m., Staff A, RN stated because she didn't think the laboratory would pick up the specimen. When asked if she obtained the order from Staff D, the facility ARNP, or had she contacted a different provider for the order, Staff A stated she notified Staff D about it. When informed that Staff D denied that any staff had informed her the resident had symptoms of a UTI or requested an order for a UA with C and S, and would have directed staff to collect the specimen at that time and not wait 3 days, Staff A stated she had nothing more to say about the matter.During an interview on 11/10/25 at 7:20 p.m., Staff B, RN, stated I didn't do anything wrong, I did everything appropriately and as I was instructed. When asked what that statement referred to, she stated it was about getting the UA on the resident, Staff A told her to get it early in the morning when she worked Sunday night, so it could go out Monday morning with labs. When asked about the order, to obtain the specimen 3 days after the order was written, was that normal? Staff B stated that is how it was ordered and that is what she did, she didn't do anything incorrectly. When asked if there were any problems with their lab, or getting the lab to pick up their specimens, Staff B stated the only issue she was aware of was there was a specimen on another resident that the lab wouldn't take because it was not labeled correctly, otherwise she was not aware of any problems with their lab transporting specimens when needed.During an interview on 11/10/25 at 10:40 a.m. Staff C, MDS nurse stated the 10/17/25 UA order was not authorized or signed by any medical provider because it was entered as a provider written order in their computer system, and those orders were not sent to the provider for written authorization. She learned to always enter orders in the computer as telephone orders and those went to the provider for authorization and signature. The facility was in the process of staff education related to the matter.The facility's Laboratory Services and Reporting policy, dated 2024, directed:a. The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.b. The facility must provide or obtain laboratory services to meet the needs of its residents. c. The facility is responsible for the timeliness of the services.

Based on observation, clinical record review and staff interview, the facility failed to implement infection control practices when completing wound dressing changes for 1 of 1 resident (Resident #1) reviewed for wound care. The facility reported a census of 28 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: sepsis, renal insufficiency (kidney failure) and anxiety disorder. The MDS also identified Resident #1 required substantial/maximal staff assistance with toileting and repositioning and required partial/moderate staff assistance with showering, lower body dressing, putting on and removing footwear. The MDS also identified Resident #1 with two venous and arterial wounds present with applications of non-surgical dressings and medications to the wounds.On 9/16/25, the Care Plan identified Resident #1 with the problem of an actual skin impairment, venous ulcers, to his left lower leg and directed staff to monitor him weekly for and document/report to his physician as needed any changes in skin status; appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth)On 10/2/25, the Care Plan identified Resident #1 with the problem of an actual skin impairment, venous ulcers, to his right lower leg. (previous one healed out 10/2/25) and directed staff to monitor me weekly for and document/report to my MD PRN changes in skin status; appearance, color, wound healing, s/s of infection, wound size (length X width X depth)On 10/20/25, the Care Plan identified Resident #1 with the problem of the need for contact isolation as he has ESBL (Extended-Spectrum Beta-Lactamase) in his urine from a urinary tract infection and directed staff to utilize Contact Precautions involve gown and glove use during high-contact resident care activities, follow facility's infection control policies/procedures when cleaning/disinfecting room, handling soiled linen, disinfecting equipment, etc. High contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. Precautions are intended to be in place for the duration of a resident's course of antibiotic treatment.In an interview on 10/20/25 at 8:11 AM, Resident #1's family member reported an observation on 10/17/25 during the day shift when she observed Staff A, RN changing Resident #1's dressing at the nurse's station. She did not clean the wound and did not wash her hands in between. After she put the tape on the dressing, she put all the items she used in the medication cart along with the scissors without disinfecting the scissors. She did not wash her hands afterward.During an observation of wound care on 10/20/25 starting at 11:16 AM, Staff B, Registered Nurse (RN) donned isolation gown and gloves and removed the dressings from the right lower leg and removed her scissors from her pocket and cut through the soiled dressings and removed the collagen dressings and kerlix dressings. Staff B then removed her gloves, put the scissors in her pocket and while wearing the isolation gown left the room to get more supplies. At 11:27 AM, AM Staff B sprayed wound cleanser to wounds on Resident #1's right leg, and used the same gauze to cleanse each wound. The wounds and surrounding skin appear dark purple in color without edema noted and had a large amount of serous drainage noted on dressings. Staff B then left the room wearing the isolation gown, and without washing her hands. At 11:32 AM, Staff B returned to stand outside the room (while Resident #1 used the urinal) and donned a new isolation gown and gloves. Staff B dried the 3 wounds on Resident #1 right lower shin with the same gauze. Without a glove change or washing her hands, Staff B opened three new collagen dressing packets and applied them to the wound. At 11:42 AM, Staff B, RN removed the scissors from her pocket and without disinfecting them cut the dressing from Resident #1's left lower leg. The dressings were dated 10/19 and saturated with wound drainage. At 11:45 AM, Staff B, cleansed the wounds on the residents left lower leg with the same gauze. At 11:47 AM, Staff B, without a change of gloves or completing hand hygiene, opened 3 new collagen dressing packets and then picked dead skin from one of the wounds. Staff B removed her gloves, and without completing hand hygiene donned new gloves.At 11:52 AM, Staff B, without a change of gloves, cleansed the wound to the left second toe.At 11:57 AM Staff B picked up items that had been dropped on the floor, without a change of gloves she proceeded to place new dressing supplies in a drawer by the sink. Staff B also placed the scissors in the drawer, without first disinfecting them. During an interview on 10/20/25 at 1:01 PM, Staff A, RN reported the following: after removing soiled dressings or touching any other surfaces, after cleansing the wound, she would need to change her gloves, disinfect the scissors before and after cutting through the dressing. She would always disinfect them afterward. She also reported when she worked on 10/17/25, she was wearing gloves when she changed Resident #1's dressings at the nurse's station. She did not take him to his room as she was worried his wounds were draining so much it would cause his pants to stick to his skin. She also reported she did cleanse the wounds and placed the soiled dressings in a clear bag which she took outside to the dumpster. She may not have had gloves on when she taped the dressing in place.During an interview on 10/20/25 at 2:17 PM, Staff B RN, reported the following: dressing changes should be completed in the resident's room, she would need to change gloves any time she would touch anything dirty, she would disinfect the scissors after every wound care, between wounds and after use. She admitted she forgot to disinfect the scissors after wound care and did not know why she forgot. When asked what the proper way was to clean the wounds, she reported up and down and away from the wound. During an interview on 10/21/25 at 12:02 PM, the Director of Nursing reported she would expect nurses to complete the following during wound care for a resident in Enhanced Barrier Precautions: complete wound care in the resident's room, don and doff an isolation gown and gloves in the resident's room, cleanse wounds from the center and work outward and disinfect the scissors before and after dressing changes.A review of the Facility Policy titled: Wound Care Guidelines dated June 2025, directed:1. Wash and dry hands thoroughly.2. Apply disposable gloves, loosen the tape and remove dressings.3. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly.4. Put on disposable gloves.5. Cleanse the wound (the policy failed to document the direction the nurse should take when cleansing).6. Apply treatments and dressings as ordered.7. Wipe reusable supplies (ie: scissors) with alcohol as indicated.A review of the Facility Policy titled: Standard Precautions dated October 2024, directed: 1. Prior to cares, don an isolation gown2. Remove the gown and perform hand hygiene before leaving the resident's room.

Based on observation, clinical record review, and staff and resident interviews, the facility failed to maintain an effective pest control program that kept the facility free of ants and vermin. The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 4/18/25 revealed Resident #2 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. The assessment indicated Resident #2 did not have symptoms of delirium or hallucinations. During an interview on 5/14/25 at 10:33 a.m., Resident #2 stated there had been ants in her room that were observed over the last month. She stated the ants were under the night stand and along that wall, and she learned from staff that there was an ant problem in the room next to hers. Resident #2 identified Resident #5 as the occupant of the room. Observations in the resident's room at that time revealed 4 insulated types of cups and handled mugs with lids and straws located on top of the night stand, food not observed on the night stand, and a package of approximately 20 containers of bottled water on the floor near the night stand and next to the wall. Ants were not observed in the area, however, there was an approximate 5 millimeter (mm) long by 1 mm wide black colored piece of debris that looked similar to mouse droppings, located on the floor between the wall and the night stand. The resident had a 2nd night stand in her room located in the center of her room and positioned next to where she sat in a Broda chair (wheelchair that reclines). There was a clear plastic bag of red grapes that also contained a banana, located on top of that night stand. The resident stated around a month ago there was a mouse in her bed that had 5 baby mice, and she had notified staff of that. 2. The MDS Assessment tool dated 4/30/25 revealed Resident #5 scored 13 out of 15 on the BIMS cognitive assessment, which indicated intact cognition. The assessment indicated Resident #5 did not have symptoms of delirium or hallucinations. During an interview on 5/14/25 at 3:17 p.m., Resident #5 stated he had not seen any ants in his room, but their had been a mouse, and pointed to a mouse-trap located along the exterior wall beneath the wall heating system in his room. During an interview on 5/14/25 at 8:56 a.m., Staff A, Certified Nursing Assistant (CNA) stated she heard that some residents said they saw ants in their rooms, but she had not seen any, and there had been times when their were mice in the facility, usually in rooms of residents that kept food in their rooms. Staff A stated she had not seen any mice. During an interview on 5/14/25 at 1:28 p.m., Staff B, CNA, stated they had some mice in the building in the past, had not seen any mice recently, and was not aware of any ant problems. During an interview on 5/14/25 at 3:03 p.m., Staff C, CNA, stated she was not aware of any ants or mice in the facility, she had not seen any. During an interview on 5/14/25 at 2:20 p.m., the facility Administrator stated the facility had a contract for pest control that provided monthly services until 12/24/24. She'd received invoices for monthly services and forwarded them to the management. The Administrator stated she had thought the Pest Control provider continued services. The Administrator stated she was unaware the last serve was on 12/24/24 until she contacted the provider on 5/14/25 and learned the bill had not been paid. The Administrator stated she had already contacted a different pest control company known to her that said they would come to the facility later on 5/14/25 or on 5/15/25 and initiate pest control services. During an interview on 5/14/25 at 4:05 p.m., the Administrator stated Resident #2 had history of delusions, she received a call from the nurse on duty when Resident #2 said there was a mouse with babies in her bed, the nurse said there were no mice in her bed, the resident was having delusions at the time. The Administrator stated there was a resident in the room next door to Resident #2, that hoarded food in his room and was an ongoing problem (Resident #9 who passed away on 4/13/25) and there was an associated history of ants and mice in his room in the past associated with that, treated by their pest control service provider. The facility's Pest Control F 925 policy dated 10/2024 directed staff: 1. This community maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. 2. Maintenance Services assists, when appropriate and necessary, in providing pest control services.

Based on observation, clinical record review, wound care provider and facility staff interviews, the facility failed to notify the physician of pressure ulcer deterioration and implement nutritional orders in an effort to promote healing for 1 of 3 residents (Resident #3) reviewed for pressure ulcers. The facility reported a census of 36 residents. Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Slough tissue is defined as a layer of dead skin cells and debris that forms on the surface of a wound. It can be yellow, white, tan, or cream in color, and can be moist, stringy, or fibrinous. Slough can occur in both acute and chronic wounds. Eschar is defined as a dry, dark scab usually adherent to healthy underlying tissue, and might require chemical or mechanical debridement if the tissue does not fall away from the underlying tissue naturally. Findings include: Review of Resident #3 Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status, which indicated the resident had severely impaired cognition. The list of diagnoses included; hip fracture, arthritis, asthma and encephalopathy (a change in brain function caused by various conditions such as infection, metabolic disorders, toxins or trauma). The assessment identified Resident #3 had a Foley catheter, and always incontinent of bowel. The MDS revealed Resident #3 required substantial staff assistance to roll left and right, and had not attempted sit to stand, or chair/bed-to-chair transfers due to medical conditions. The MDS indicated Resident #3 required substantial staff assistance for toileting hygiene, shower/bathe self, and personal hygiene. Resident #3 Height and Weight documented as 65 inches (5 ft 5 inches) and 107 pounds. The MDS documented on admission Resident #3 had a surgical incision wound, and skin tears. The Risk of Pressure Ulcer/Injuries question Is this resident at risk of developing pressure ulcers/injuries? answered with a 0 (code for No). The Unhealed Pressure Ulcers/Injuries question Does this resident have one or more unhealed pressure ulcers/injuries? Answered with a 0. Review of hospital records faxed to the facility on [DATE] revealed the Assessment/Plan included, in part: protein calorie malnutrition, with dietician consulted, have added high-protein supplementation 3 times daily. The Admission Assessment, dated 12/23/24 at 8:45 PM documented Resident #3 had the following wounds present at admission: a. Left inner forearm - skin tear b. Right anterior elbow - skin tear c. Left lateral thigh - surgical wound The Admission Assessment Care Planning section did not indicate a Focus, Goal or Interventions for any of the 42 care areas listed. Wound management was on of the care area options. A N Adv - Braden Scale for Predicting Pressure Ulcer Risk Evaluation completed on 12/23/24 at 9:40 PM indicated a score of 13.0. Per the Braden Evaluation Scoring, A score of 13 puts a resident at moderate risk for pressure ulcers. A score of 10-12 is considered a high risk. A Health Status Note dated 12/31/24 at 4:25 PM: Noted new skin issues upon skin rounds. MASD (moisture associated skin damage) to coccyx and skin tear to the upper L (left) back, new orders received for wound care and entered. Will continue to monitor. The N Adv - Skin Check note entered at 4:57 PM documented #012: New skin issue. Location: Right gluteus. Laterality/Orientation: Medial (towards the middle of body). Issue type: Skin tear .Length (cm - centimeters) 6.3 Width (cm) 6.4 Area (cm2) 0.1. Epithelial (area of new formed skin cells) 30%. Slough (area of wound covered by dead tissue, appearing yellow or white) 0%. Eschar (area of hard, dry, dark crust on the surface of wound often black or brown): 50%. Exudate (discharge) amount: Moderate. Exudate type: Sanguineous: Indicates active bleeding, typically bright red .Dressing saturation: None. A Dietary Progress Note, dated 1/3/25 at 5:43 PM for RD (Registered Dietician) Nutrition Assessment: DX (diagnosis) of PCM (protein calorie malnutrition) .Diet: regular, regular textures .Poor po (oral) intake <-50% of meal intake; averaging <25% .Braden 13; high risk for PI (pressure injury) .Nutrition DX: Agree with hospital DX of PCM. Meets criteria for moderate PCM of acute on chronic illness AEB (as evidenced by) inadequate oral intake <25% of meals >30 days with elevated nutritional needs .High risk for wt. (weight loss) and skin breakdown, poor wound healing .Recommendations: 1. Add nutritional shake 1 carton (120 ml) with lunch and dinner. 2. Offer House supplement 90 ml TID (three times daily) between meals. 3. Vit C 500 mg BID. 4. Weekly Weights for 4 weeks. 5. RD following as warranted and remains available as needed. A N Adv Skilled Evaluation note, dated 1/7/25 at 1:04 PM documented #008: Skin issue has been evaluated. Location: Right gluteus. Laterality/Orientation: Medial. Issue type: Skin tear .Length (cm) 13.5 Width (cm) 9 Area (cm2) 0.2. Epithelial: 10%. Slough: 30%. Eschar: 60%. Exudate amount: Moderate. Exudate: Serosanguineous: mixture of serum and blood .Dressing Saturation: Heavy >75%. Documentation of physician notification of the change in wound size, and heavy saturation of dressing not indicated in the Skilled Evaluation note. A Dietary Progress Note, dated 1/7/25 at 1:07 PM for RD Progress note r/t wounds: RD contacted by facility nurse to update on wounds. Buttocks/sacrum area of concern. Surgical site for repair of left femur fx (fracture). Improved from 9 skin tears to one. POC (Plan of Care): 1. Add liquid protein 30 ml QD (once daily). 2. RD following as warranted and remains available PRN (as needed). A N Adv - Skin Check note, dated 1/10/25 at 12:17 PM documented #001 Skin issue has been evaluated. Location: Right gluteus. Laterality/Orientation: Medial. Issue type: Pressure ulcer/injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 3 Pressure Ulcer/injury - full thickness skin loss. Wound acquired in house. Exact date: 12/31/24 .Staged by: In-house nursing. Length (cm) 16 Width (cm) 10.5: 1.2. Undermining (a condition where the edges of the wound separate from the underlying tissue, creating a cavity or pocket beneath the wound service): Yes. Undermining = 2 instances .Epithelial: 10%. Granulation (moist, pink or red tissue that forms in the wound bed during the healing process): 20% Slough: 20%. Eschar: 50%. Exudate amount: Heavy. Seropurulent: mixture of purulent (thick, opaque fluid that is typically yellow, green or white in color. It is a sign of infection .Dressing Saturation: Heavy >75% . A Health Status Note, dated 1/10/25 at 12:59 PM documented Received order for referral to [provider name redacted] wound clinic from MD and call placed to [provider name redacted] wound clinic for appt (appointment). Scheduler on another call at the time of call and message left for [name redacted] to call back to schedule this appt. DON (Director of Nursing) aware of the referral and call made to schedule. Called son to let him know of the referral to wound clinic due to deteriorating wound to coccyx. A N Adv Skilled Evaluation, dated 1/11/25 at 2:46 PM documented #011 Skin issue has not been evaluated. Location: Right Gluteus. Laterality/Orientation: Medial . A Health Status Note, dated 1/13/25 at 1:10 AM, documented Went into the resident's room earlier in the night and resident told this RN to get out of her room and don't touch me .Dressing to her buttocks area soaked with BM (bowel movement). Changed dressing as ordered . A Health Status Note, dated 1/13/25 at 8:55 AM documented Nurse went to resident room to preform wound care, and noted R (right) buttock wound has deteriorated over the weekend, and how has a significant depth, with continued breakdown. MD here in house rounding and called into room to assess the wound, and order to send out to hospital for further evaluation and treatment. A Health Status Note, dated 1/13/25 at 5:37 PM documented Call placed to follow up on resident and resident was admitted to the hospital for UTI (urinary tract infection), and ortho (orthopedic) consulted and resident will undergo surgery . Review of the Care Plan, Date Initiated: 1/14/25, Revised: 1/28/25 revealed a Focus area to address I have a Stage 3 pressure ulcer to my rt(right) buttock r/t (related to) immobility. Interventions, initiated on 1/14/25 included, in part: a. Administer Medications as ordered. Monitor/document for side effects and effectiveness. b. Administer treatments as ordered and monitor for effectiveness. c. Assess/record/monitor wound healing Measure length, width, and depth where possible. Assess and document status of wound perimeter wound bed and healing progress. Report improvements and declines to the MD (medical doctor). d. Follow facility policies/protocols for the prevention/treatment of skin breakdown. e. Monitor nutritional status. Serve diet as ordered, monitor intake and record. f. Monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs or symptoms of infection, wound size (length, width, depth), stage. g. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. h. The resident needs monitoring to turn/reposition at least every 2 hours, more often as needed or requested. i. The resident requires the bed as flat as possible to reduce shear. j. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. The Care Plan, Date Initiated: 1/17/25 also had a Focus area to address I am incontinent of Bowel. Interventions, initiated on 1/17/25, included: a. Apply barrier cream as ordered. b. Ask encourage resident to use call system& report need to use BR (bathroom). c. Check resident AC (before meals), PC (after meals), HS (bedtime) & provide incontinence care as needed. d. Monitor for excoriation/skin breakdown. The Care Plan did not include a Focus area to address protein calorie malnutrition. Hospital discharge (on 1/17/25) instructions for visit date 1/13/25 diagnoses listed included: Wound infection - complicated; complicated UTI .sacral decubitus ulcer (pressure ulcer) .Instructions from your Doctor . for coccyx - Irrigate with saline. Gently tuck Dakin's (a solution used to treat and prevent infections in wounds) 0.125% moistened gauze into wound depth and undermining and cover with ABD (abdominal pad), secure with tape. Perform daily and as needed. Additional orders included: reposition every 2 hours/repositioning wedges/bilateral heel boots, and Follow up with wound clinic upon discharge. A review of Physicians Orders revealed an order to start on 1/18/25 for Dakin's (1/4 strength or 0.125%) apply to coccyx topically one time a day for wound care. A review of the January 2025 Medication Administration Record (MAR) revealed a 9 documented on 1/18/25, and 1/19/25. No documentation of administration noted on 1/20/25. Per the MAR Charts Codes, a 9 =Other/See Nurse Notes. A review of the Nurse Notes in the electronic record revealed a lack of documentation to explain the Chart Code used on 1/18/25 and 1/19/25. The review of Physician Orders revealed a lack of orders for: repositioning every 2 hours, use of repositioning wedges and bilateral heel boots. And the RD orders for Mighty Shakes, house supplement, and Pro-stat were not re-ordered. A N Adv-Skin Check note, dated 1/17/25 at 1:59 PM documented #001: Skin Issue has been evaluated. Location: Right Gluteus. Laterality/Orientation: Medial. Issue type: Pressure ulcer/injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure Ulcer staging: Stage 3 Pressure Ulcer/injury -full thickness. Wound acquired in-house. Exact date: 12/31/24. Staged by: In- house nursing. Length (cm): 6 Width (cm) 10.5 Depth (cm) 1. Epithelial: 10%. Slough: 30%. Eschar: 40%. Exudate amount: Heavy. Seropurulent. Dressing saturation: Heavy >75%. A review of the electronic health record revealed a lack of assessment information for the right gluteus Stage 3 pressure ulcer on 1/18/25, 1/19/25, and 1/20/25. A N Adv-Skin check note, dated 1/21/25 at 2:46 PM documented #002: Skin Issue has been evaluated. Location: Right Gluteus. Laterality/Orientation: Medial. Issue type: Pressure ulcer/injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure Ulcer staging: Stage 3 Pressure Ulcer/injury -full thickness. Wound acquired in-house. Exact date: 12/31/24. Staged by: In- house nursing. Length (cm): 10 Width (cm) 8.5 Depth (cm) 1.2 . Epithelial: 10%. Granulation:40%. Slough: 20%. Eschar: 0%. Exudate amount: Heavy. Seropurulent. Dressing saturation: Heavy >75%. A follow up Wound Clinic visit note, dated 1/23/25 noted Wound #2 Coccyx, pressure ulcer measured 10.9 cm x 8.2 cm x 1.9 cm. Wound status: not healed. The visit discharge information assessed Resident #3 Stable. The Wound Clinic discharge orders for the 1/23/25 visit included: a. Cleanse sacral pressure sore with NS, apply slightly moistened Hydrofera Blue (an antimicrobial dressing), cover with ABD gauze or Optifoam/sacral pad and tape, change daily and PRN. b. Increase protein in diet to at least 1 Gram per pound of ideal body weight a day. c. Add 20 Grams of collagen peptides BID. d. Add 20 Grams of whey protein BID. e. At least 2 protein shakes a day of facility choice. f. Return to the Wound Center in 1 week, scheduled 1/30/25 at 8:45 a.m. A review of the January 2025 MAR revealed the wound care orders implemented. The MAR lacked orders for an increase in protein, the addition of collagen peptides, whey protein and at least 2 protein shakes a day. During an interview on 2/7/25 at 11:51 a.m., Staff A, Licensed Practical Nurse (LPN) stated she transcribed the resident's physician orders from the Wound Center on 1/23/25. Staff A stated she did not transcribe the orders to increase the resident's protein intake, add whey protein, collagen peptides, and protein shakes. Staff A stated the RD recommendations that were ordered prior to the resident being in the hospital were not restarted. She explained the recommendations were not on the hospital discharge orders. A review of the electronic health record revealed a lack of wound assessments on 1/25/25, 1/26/25, and 1/27/25. A Dietary Progress Note, dated 1/27/25 at 8:40 AM, documented Resident in bed this AM, and food was taken to the resident room for resident to eat. Resident woke up and looked at the sandwich and said I don't want to eat that just bring me some milk. Milk was brought to the resident and resident drank 1/2 cup of milk and then went back to sleep. Will continue to monitor. A N Adv -Skin Check note, dated 1/28/25 at 4:57 PM documented #001: Skin Issue has been evaluated. Location: Right Gluteus. Laterality/Orientation: Medial. Issue type: Pressure ulcer/injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure Ulcer staging: Stage 3 Pressure Ulcer/injury -full thickness. Wound acquired in-house. Exact date: 12/31/24. Staged by: In- house nursing. Length (cm): 14 Width (cm) 10 Depth (cm) 0.8 . Epithelial: 10%. Slough: 30%. Eschar: 50%. Exudate amount: Moderate. Seropurulent. Dressing saturation: Moderate 26-75%. The note did not indicate physician notification of the increase in size of wound. A follow up Wound Clinic visit note, dated 1/30/25 did not document measurements or status for Wound #2 Coccyx. The visit discharge information documented Resident #3 Discharge Condition: Unstable, Discharge Destination: ER (emergency room ). During an interview on 2/5/25 at 9:55 AM, the Wound Clinic nurse stated when the resident returned for a follow up appointment on 1/30/25, the sacral pressure sore had deteriorated. She stated the physician contacted the facility to inquire about the orders given at the 1/23/25 appointment. She stated the facility staff were unable to answer the physician's questions. Hospital ED (Emergency Department) Physician Notes, dated 1/30/25 at 10:49 AM documented Chief Complaint - pt (patient) arrives with c/o (complaint of) growing wound on coccyx. Pt lives at aspire and sees wound clinic for her skin. She has a wound on her coccyx that has grown by around 40% 1 week. Pt states she is in pain . The hospital History and Physical Documentation dated 1/30/25 revealed, in part .Patient presented to the ED once again on 1/13/25 with a worsening wound at the coccyx area. She was discharged to the facility on [DATE]. The coccyx wound was reported to be 8 cm x10 cm at that time and is now 16cm x12 cm. Resident #3 discharged from the hospital and returned to the facility on [DATE]. Discharge orders included: a. Wound care to the sacral pressure sore, cleanse with NS, apply silver alginate to the wound bed and cover with silicone foam dressing daily and PRN. b. Foam wedges for positioning resident. c. Heel boots on while in bed. During an interview on 2/7/25 at 3:25 PM, the Director of Nursing (DON) and Corporate Nurse stated the RD recommendation should have been reviewed with the physician for continuation when Resident #3 discharged back to the facility on [DATE]. The DON stated staff should transcribe physician orders as written, unless contraindicated or changes required, and should clarify the order with the physician and transcribe the order as directed. During an interview on 2/10/25 at 9:03 AM, the Administrator stated a new process had been put into place on 2/7/25. After the nurse on duty transcribed new physician orders, they would be double checked by the following nurse (nurse on the next shift), and then triple checked by the DON to ensure all physician orders were implemented as directed. During an observation on 2/10/25 at 10:18 AM, Resident #3 in her room, in bed. An air mattress overlay on the bed, resident positioned on her left side, with her head positioned near the head of the bed, heel boots not on, resident did not have her call light. Resident #3 stated she was not comfortable due to her head position. Staff A, LPN asked to assess the resident's position. Staff A assisted the resident, and placed the heel boots on the resident. During an observation on 2/11/25 at 8:24 AM, Resident #3 positioned in bed on her left side, heel boots on, head of bed elevated approximately 10 degrees. Resident's hip appeared low. The facility Corporate Nurse stated the air mattress on the bed had a hole/was leaking. The Administrator stated she would contact the company and get a replacement air mattress, she should be able to have a new air mattress later that day. At 10:21 AM, the resident had been moved to another bed, pending replacement of the air mattress.

Based on observations, clinical record review, Registered Dietician, staff and resident interviews, the facility failed to provide food that met the individual preferences of 1 of 7 residents reviewed (Resident #4). The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment. dated 8/7/24, revealed Resident #4 scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS listed diagnoses included diabetes, congestive heart failure, peripheral vascular disease and anxiety. The MDS assessed Resident #4 required substantial staff assistance to reposition in bed, transfer to and from bed and chair, for dressing, toileting and bathing, and limited staff assistance required for eating. A review of Physician Orders revealed: a. Consistent/Controlled Carbohydrate diet (CCHO, common diet order for people with diabetes), regular texture, thin consistency liquids, ordered 5/31/22. b. Lantus SoloStar (long acting insulin) Solution Pen-injector 100 unit/ml (milliliter) (Insulin Glargine). Inject 53 units subcutaneously two times a day for DM2 (diabetes mellitus type 2). Start Date: 10/22/24. c. Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 7 units subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA. Start Date: 9/23/24 d. Trulicity Subcutaneous Solution Pen-Injector 1/5 MG (milligrams)/0.5ML (Dulaglutide - generic name). Inject 1/5 mg subcutaneously in the morning every Fri (Friday) related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA q Friday. Start Date: 4/12/24 The Care Plan, Created on: 4/21/22, Revision on: 11/14/23 Focus area I have Diabetes Mellitus and take insulin. Interventions included: Encourage me to practice good health practices; lose weight if overweight, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care. The Care Plan, Date Initiated: 7/18/22, Revision on: 1/8/24 Focus area I have a nutritional problem r/t (related to) Class 3 obesity. I receive a therapeutic diabetic diet for bgl (blood glucose) & wt (weight) control. My obesity and urine incontinence places me at risk for skin breakdown. I am able to feed myself and make my needs and preferences known. I prefer to eat meals in my room. I am non-compliant with my current diet. Interventions included: Document % (percent) eaten of each meal and offer meal alternative consistent with diet order if meal is refused or <50% consumed. Encourage dietary compliance with CCHO diet order for healthy weight control and blood glucose regulation. Explain and reinforce the importance of maintaining the diet ordered. Provide and serve diet as ordered. The facility policy, dated October 2023, titled Nutrition & Weight Management, Diet Ordering Standard indicated All residents' diets shall be served according to the physician's order. During an observation on 10/23/24 at 10:20 a.m. a whiteboard in the facility dining room contained a hand written menu for the noon meal: chicken tetrazini, green beans, roll, and chilled fruit. An alternate menu written on a piece of paper, posted on the wall near the whiteboard listed a hot dog as the alternate for the 10/23/24 noon meal. The alternate menu did not have an authorization/signature of a Registered Dietician (RD). During an observation on 10/23/24 at 12:14 p.m, Resident #4 received a room tray with a hot dog on a bun, and a saucer of fruit cocktail. During an interview on 10/23/24 at 2:11 p.m., Resident $4 stated staff brought her a hot dog for lunch. She stated she told the staff member she didn't care for hot dogs, and asked if she could have a peanut butter and jelly sandwich. Resident stated she received the sandwich about 20 minutes later. She stated she preferred a vegetarian diet, would eat meat if absolutely necessary but preferred not to, staff usually provided a peanut butter and jelly sandwich when she asked for it, it wasn't the best choice but about the only one consistent with her preferences. Resident #4 stated staff have not provided the sandwich when she asked, she couldn't estimate how often this had happened. She explained the other night she received a supper tray with beef, she asked for a substitution but staff didn't provide anything else for her to eat, so she covered the food with a napkin and didn't eat anything until breakfast the following morning. During an interview on 10/24/24 at 10:03 a.m., Staff A, the interim off-site RD stated she worked remotely from another state and had not been in the facility or met with any of the resident's. She stated was not aware Resident #4 preferred a vegetarian diet and was concerned the resident went without a meal due to her preferences, as she was an insulin dependent diabetic, and had other conditions that also required consideration. Staff A stated she would speak to the Dietary Manager and the facility Administrator to come up with some menu alternatives that would be appropriate for the resident, and would also discuss an Always Available alternative menu with them. During an interview on 10/24/24 at 10:28 a.m., the Administrator stated she was going to have a conference phone call with the resident, the Dietary Manager and Staff A, RD after the lunch meal today. The Administrator stated there were some additional items usually available in the kitchen besides the list that they had, that included tomato, chicken noodle and vegetable soups, deli meats for sandwiches, and could provide some type of vegetable salad/cottage cheese combination and would discuss this with Staff A. On 10/24/24 at 1:25 p.m., the Administrator provided an Alternates Available Menu, signed by the RD. The list included: hot dog, hamburger, chicken nuggets, polish sausage, grilled cheese, soup, peanut butter and jelly, and lunch meat sandwich A Progress Note, transcribed by Staff A, RD, on 10/24/24 at 1:59 p.m. stated: Resident [Resident #4] expressing desire to eat more vegetarian meals. Reports she is not fully a vegetarian, however is not liking meats as much as she had previously. Registered Dietitian, Dietary Manager, and Administrator met with resident to discuss her new food preferences. Weekly menus were provided to resident, however resident reports being blind in one eye and poor vision in the other. The Dietary Manager read menu selections to resident and reviewed menu selection with her. Dietary preferences were obtained for meal/food preferences, ensuring adequate protein to be received. Dietary Manager stated self or dietary aid will visit with resident daily to review and obtain new food preferences for the day for meal substitutions from regular menu. Food items that the facility does not have in inventory was discussed with Administrator and Dietary Manager for adding foods to the food purchase order and sources of obtainment. Resident expressed pleasure that the staff will support her for her new food preferences to promote adequate nutrition status and personal pleasure and contentment. RD remains available to continue to review resident's selections with Dietary Manager and facility staff as warranted. RD available as needed.

Based on clinical record review, facility assessment review, and staff interviews the facility failed to employ sufficient numbers of staff to meet resident needs. The facility reported a census of 36 residents. Findings include: 1. A review of the Facility Assessment, updated 8/01/24 revealed the facility needed 3 (three) Certified Nursing Assistants (CNA) for first and second shift if the census was 30 or more in order to meet resident needs. A review of the staff schedules from 8/01/24-9/02/24 revealed there were two CNA's for either partial or whole shifts 8 (eight) times on first shift and 13 times on second shift. During an interview 9/04/24 at 12:27 p.m., Staff C, Certified Medication Aide (CMA) acknowledged there are staff who come in late or oversleep, which leaves too few staff on the floor. During an interview on 9/04/24 at 12:36 p.m., Staff B, CNA noted she did not feel they had enough staff on the floor. She noted it depended on who she worked with if she could get everything done in a shift. She explained right now there were just 2 (two) CNA's as the third one took a resident to an appointment. She noted they don't often have call-ins or no shows, they just don't have enough staff scheduled. During an interview on 9/04/24 at 12:46 p.m., Staff A, CNA exclaimed right now no, they do not have enough staff. There have been only 2 (two) CNA's this day. Two is not enough. This past weekend it was only two of them [CNA's]. She was not sure if they just schedule two or if there were call-ins. Duties carry over to the next shift if there are only two working. She noted 3 (three) CNA's would be better. During an interview on 9/05/24 at 11:57 a.m., the Administrator explained she usually started the scheduling but the Assistant Director of Nursing (ADON) and Director of Nursing (DON) help with call-ins and scheduling also. They have several office staff that are CNA/CMA's that they can ask to help out if they are short on the floor during first shift. CMA's get pulled from medication duty to work the floor as well. In the afternoons they usually run 2 (two)CNA's but they are hiring more. They could usually ask someone to come in early or stay late. She explained staff called in 2-3 times per week and there was a lot of staff turnover. She noted staffing is based on census. Typically there were 2 (two) CNA's per shift on the weekends and they just hired more. There was also a policy where staff could be held over on their shift. She reported 3 (three) staff members quit recently because of this. They do borrow from other buildings at times if needed, and try to keep agency staff out. She expected all staff to answer a call light, no matter their title or job duties. 35434 2. The Minimum Data Set(MDS) assessment tool, dated 4/3/24, listed diagnoses for Resident #16 which included depression, chronic pain, and chronic obstructive pulmonary disease. The MDS stated the resident was dependent on staff for toileting hygiene, showering, dressing, personal hygiene, and transferring and listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility Freedom of Abuse Neglect and Exploitation Policy revised 8/2020, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. The policy stated the facility had zero tolerance for abuse of any type or manner and would address accordingly. A handwritten statement, dated 5/6/24, by Staff H Registered Nurse(RN) stated she heard screaming down the hall and Staff F Certified Nursing Assistant(CNA) stated she could not take these residents cursing them out and complaining while she cared for them. Staff H stated Resident #16 called the Staff F a b--h and Staff F took a box of gloves and threw it at the resident from the doorway and it hit the resident indirectly in the head(it hit the bed mattress before it hit patient). During an interview on 9/3/24 at 2:20 p.m. Staff H Registered Nurse(RN) stated on the night in question, the facility was understaffed and staff were pretty stressed out and Resident #16 got the worst end of it. She stated she heard screaming from the other end of the building and she arrived near Resident #16's room and Staff F stated she was the one doing the screaming. Staff H stated the resident and Staff F were yelling at each other. The resident called her names and said she was a bad a-- b---- and Staff F said she would show him. Staff F grabbed a box of gloves which was not empty and whipped it at him with all of her strength. Staff H stated the gloves landed in the bed. She believed the gloves hit the resident but she could not say where. She stated when she threw the gloves, it had force behind it. She stated after this happened the resident was shook up. During an interview on 9/4/24 at 3:06 p.m., Staff F CNA stated on the day in question [5/6/2024], they were short staffed. She stated on 5/6/24, those who worked in the building consisted of: herself, Staff H RN and Staff N CNA. She stated they were the only 3 in the building. She stated after supper she needed to assist Resident #16 into bed and he had no sling under him for the mechanical lift. She stated Staff N was there but she was pregnant and was spotting so she could not have her lift. The resident stated he did not care and directed them to just get me into bed. She stated Staff N said she could help and they both picked him up and they all three fell into bed. The resident then told Staff F not to manhandle him and was then pissed and yelling. Staff F said he was verbally abusing her and he said something and she just snapped and said I don't give a f--*. Staff F stated f--k you and no one appreciates me. Staff F stated she knocked over the wheelchair and left the room. At this time Staff H arrived and the resident then said oh f--* that b---h and Staff F stated she took a box of gloves and threw it directly into the room at the wall. She stated the box did not hit the resident. She stated she did not throw any washcloths or threaten anyone. Staff F stated she was angry and went out the front door and cried. She said she would not return down that hall and then went to another hall and assisted another resident when Staff G came into the room and told her she had to go. About a week prior to the incident on 4/29/24, she stated she had a mental breakdown. She came into the building for the second shift and every resident was soiled and she could not take it anymore. She stated other workers did not show up for work and she was completing sit to stand lifts by herself. She stated she understood her exploding was not ok but the facility put a lot on her. She went out to her car and started screaming and crying. The Administrator, Staff J RN and her mother(who worked in laundry) came out to her car also and were looking at her She told them to get away and she was embarrassed. Staff F punched her car window and cracked it and she threw a 40 ounce soda on her mother. She stated as she tried to reverse in her car, an ambulance and police car arrived. After speaking to the police, she went home. She stated this was around 5:00 p.m. She stated the Administrator texted her to see if she was ok but then asked her that night if she could come in at 10:00 p.m She did not end up coming back that night. The Daily Staff Assignment sheet for 5/6/24 displayed the following staff for the evening shift: Staff N CNA Staff F CNA until 8:30 p.m. Day charge nurse Staff H RN During an interview on 9/9/24 at 12:47 p.m., the Administrator was queried regarding ways she monitored and handled staff burnout. She stated she tried really hard to keep the facility staffed and tried to limit the amount of overtime. She stated she could tell by a staff member's energy, how they responded to residents, and their attitudes if they were getting burned out. She stated if they were clearly burned out, she would start filling the hours with other staff if she had them available. 25855 During an interview 9/4/24 at 1:42 PM, Staff A, CNA stated with a census of 36 resident, the facility is usually staffed with one nurse, one med aide and 2 or 3 CNAs. She stated there have been one or two days she arrived to work and was the only CNA scheduled to work During an interview on 9/4/24 at 2:02 PM, Staff B, CNA stated with a census of 36 resident, the facility is usually staffed with one nurse, one med aide and 2 or 3 CNAs. She added there are 9 (nine) residents that require transfers with a mechanical lift which requires 2 (two)staff to assist During an interview on 9/4/24 at 2:19 PM, Staff C, CMA stated she has been the only aide to come in to work at least once a month when people call in sick. During an interview on 9/5/24 at 9:01 AM, Staff D, LPN stated the facility usually is staffed with one nurse, one med aide and 2 (two) CNAs. She stated there have been 2 or 3 times she arrived to work and only one CNA was scheduled to work

Based on previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 36 residents. Findings include: Per review of the dia-hfd.iowa.gov website, the following deficiency had been previously identified per a Recertification Survey conducted from 2/19/23 to 2/16/2. The deficiency also cited during a Recertification Survey and Complaint Survey conducted from 9/3/2024 to 9/9/24: a. F725 - Sufficient Nursing Staff. Review of the Recertification Survey, and Complaint Survey conducted 11/13/23 to 11/21/23 revealed the following deficient practices, which also were identified during the Recertification Survey, and Complaint Survey conducted from 9/3/24 to 9/9/24: a. F677 - ADL Care Provided for Dependent Residents b. F684 - Quality of Care c. F804 - Nutritive Value/Appearance, Palatable/Preferred Temperature d. F812 - Food Procurement, Store/Prepare/Serve - Sanitary f. F880 - Infection Prevention & Control During an interview on 9/09/24 at 3:44 p.m., the Administrator explained the QAPI team meets at least quarterly and try to meet monthly to discuss issues. Data is collected via an online program and resident or employee complaints. The facility takes the top three issues to work on at a time and intend to follow it for one calendar year. The deficiencies from a survey are considered high priority. She acknowledged there was no plan in place for improvement of the previous survey deficiencies when she took the position as Administrator. She noted she was not surprised they had repeat deficiencies this survey. A review of the facility QAPI Management Plan, revised 1/2024 revealed, Once a Plan of Improvement has been implemented by the facility, the QAPI Committee should monitor the progress of the Plan. Should the issue continue to be a concern to staff, residents or facility customers, additional Resident Grievance/Concern/Complaint Reports should be submitted to the QAPI Committee for further review. Duties and responsibilities of the QAPI Committee included, but are not limited to: a. Reviewing and approving written policies that guide and limit the activities and decisions of the staff as they fulfill the objectives of the facility. b. Establishing and enforcing policies to ensure that specific duties or functions are performed accurately and uniformly. c. Prioritizing areas of concern and identifying QAPI projects. d. Appointing Special Project Teams to investigate matters of concern and recommend Plans of Improvement to the QAPI Committee. e. Monitoring and evaluating the results of the Plans of Improvement and determining follow-up activities, if needed. f. Establishing benchmarks and data collection methodology for evaluating Plans of Improvement g. Review of clinical/operational results

Based on record review, staff interview, and policy review the facility failed to ensure the Dietary Manager met the minimum qualification of having a national certification for food service management and safety in the required timeframe. The facility reported a census of 36 residents. Findings include: The facility lacked record of the Dietary Manager's education or certification. They were unable to produce a schedule for the Dietician. The facility Employee Name Report, dated 9/3/24, indicated the Dietary Manger date of hire as 6/21/22. During an interview on 9/04/24 at 4:55 p.m., the Administrator stated the Dietary Manager had scheduled to take her certification test the previous week but the test was shut off in the middle of her taking it. The test rescheduled for this Tuesday [9/3/24] but she was called in to work due to a cook cancellation. She was rescheduling the test for next week [week of 9/9/2024]. During an interview on 9/05/24 at 9:25 a.m., the Administrator explained the dietician works remotely. She is never on site. She acknowledged the Dietary Manager not having her certificate was an issue. During an interview on 9/05/24 at 12:35 p.m., the Dietary Manger explained she had several years working as a Dietary Supervisor but did not take the necessary classes to qualify until this April. She noted she had to reschedule her certification test yet again. The facility lacked a policy indicating the necessary certification for Dietary Managers.

Based on record review, observations, resident and staff interviews, and policy review the facility failed to serve at the safe temperature, and palatable. The facility reported a census of 36 residents. Findings include: A review of the Resident Council Minutes from May 2024 revealed documented complaints of food sometimes being cold. During an interview on 9/03/24 at 10:45 a.m., Resident #6 described the vegetables as overcooked and the hamburger tasted like sandpaper. He noted the food was not warm when it gets to his room on a room tray. During an observation on 9/03/24 at 1:05 p.m., a requested test tray food items temperature results: a. Mashed potatoes - 135.5 degrees Fahrenheit (F) b. Boiled carrots - 125.0 F c. Roast beef - 120.5 F When tasted, the carrots noted to be lukewarm and have a mushy consistency. The roast beef noted to be lukewarm. During an interview on 9/05/24 at 12:35 p.m., the Dietary Manager explained she expected food holding temperatures to be around 145 F. She expressed other steps may need to be put in place to keep the room trays warm. The facility undated manual, titled HACCP (Hazard Analysis and Critical Control Points) Procedures Manual, noted the minimum acceptable holding temperature for all hot foods to be 135 F. The manual directed staff to prevent soggy, overcooked vegetables.

Based on record review, observation, staff interview, and policy review the facility failed to assure food was properly prepared and appropriate to meet resident needs. The facility reported a census of 36 residents. Findings include: The facility menu titled Spring/Summer 2024 provided by the facility for 9/03/24 designated the following serving sizes to be given to residents with a pureed diet: a. Pot roast- #8 scoop size (4-5 ounces (oz.)) b. Gravy- 2 oz. c. Potatoes and onions- #10 scoop size (3-4 oz.) d. Carrots and celery- #16 scoop (2 1/4 oz.) e. Apple crisp- #10 scoop f. Wheat roll- #12 scoop (2 1/2-3 oz.) During an observation of the puree preparation on 9/03/24 at 1:28 p.m., the Dietary Manager (DM) failed to measure the beef and placed four chunks into the blender for four residents. Beef juice was added and the DM failed to measure the resulting puree before it was poured into a serving container. A 3 oz. scoop was used to serve the meat. Five #8 scoops of carrots with added juice was then measured, blended, and the volume not measured afterward before being placed in a serving container. An #8 scoop was used to serve the carrots. Seven (7) chocolate chip cookies and an unknown quantity of milk was blended, not measured, and poured directly into dessert bowls. Bread was not pureed or served and gravy was not made for the meal. During an interview on 9/05/24 at 12:35 p.m., the DM explained different managers trained her over the years and showed her two different ways to puree. One of the managers taught her to use a total volume chart to measure the amount at the end of pureeing and find the corresponding scoop size for the number of servings prepared. The other did not. She does not use it. An undated facility policy, titled Pureed Food Preparation, directed staff to portion out the number of pureed items needed to prepare pureed meals for all residents prior to blending. Only nutritive liquids are to be added for consistency. The policy failed to provide direction on measuring foods after blending to ensure adequate serving sizes.

Based on observations, policy review, and staff interview the facility failed to prevent the potential for cross contamination due to lack of hand hygiene during preparation and plating of meals, proper storage of opened food items, uncovered garbage cans, and a lack of adequate chemical concentration in cleaning buckets. The facility reported a census of 36 residents. Findings include: During an observation of the kitchen on 9/03/24 at 10:12 a.m, the cleaning buckets were tested and lacked the appropriate chemical concentration for sanitizing surfaces. During the observation the following items were found in the freezer opened, unsealed, and undated: a. Cookie dough b. Chicken nuggets c. Ravioli d. Pizza crust e. Sausage patties f. Sausage links The dry goods pantry revealed almond extract with the lid broken off, unsealed and undated on the shelf. A continuous observation of meal preparation, and plating on 9/03/24 at 11:50 a.m., revealed: a. A garbage can found under the food prep counter with no lid, and a second can under the dish sink with no lid. b. Staff L, [NAME] wore gloves and grabbed two stacks of plates, touched a pan and a spatula, and failed to change gloves prior to plating cookies by hand. c. Staff M, [NAME] washed dirty dishes, failed to perform hand hygiene, and proceeded to whisk powdered drink mix and water together for meal service. d. Staff L wore gloves to handle plates, plate covers, and tongs, and failed to change gloves and plated 4 buns by hand. The tong handles for the meat fell into the pan and touched the food. The tongs used to plate meat, and the food then served to residents. During an observation on 9/04/24 at 10:40 a.m., the Dietary Manager re-tested the cleaning bucket solution, and the the test strip remained negative. During an interview on 9/05/24 at 12:35 p.m., the Dietary Manger explained she expected and educated staff not to wear gloves and touch items other than food. She further explained the facility was supposed to get the garbage lids as they knew that was an issue last survey and but they still haven't. An undated policy, titled HACCP Procedures Manual, directed staff to use proper hand washing for safe food preparation. Some food items, such as bread and rolls, should be handled with utensils or plastic gloves to decrease potential of infections. Staff must change gloves if handling different food items. The policy lacked direction regarding covering garbage cans, chemical sanitization, and food storage of opened items, labeling and dating of said items.

Based on clinical record review, policy review, and staff interviews, the facility failed to carry out assessments and interventions to promote healing of an existing pressure ulcer, resulting in an infection and hospitalization for 1 of 5 residents reviewed for pressure ulcers (Resident #20). The facility reported a census of 25 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 12/21/21, listed an admitted [DATE] for Resident #20 and included the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident required limited assistance of 1 staff for bed mobility, extensive assistance of 1 staff for transfers, dressing, toilet use, and personal hygiene, and depended completely on 1 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating moderately impaired cognition. The MDS identified the resident was at risk for developing pressure ulcers and had 2 Stage 2 (partial thickness loss of skin) pressure ulcers and 1 Stage 3 pressure ulcer (full thickness tissue loss). A 12/14/21 document entitled Instructions from your Doctor directed staff to cleanse the coccyx with saline and apply the wound vac at a pressure of 125 mm (millimeters)/Hg (mercury), low intensity, change 2-3 times weekly. The document directed staff to cleanse the right and left buttock with saline and cover with Xeroform(a protective dressing) and cover with silicone bordered foam pad, change daily and as needed. The document documented the resident should follow up with the Wound Clinic. Wound/Skin Healing Records, dated 12/14/22, charted the resident had a Stage 2 right buttock wound measuring 2.5 centimeters (cm) x 1.0 cm x 0.1 cm (length x width x depth), a Stage 2 left buttock wound measuring 1.5 cm x 1.2 cm x 0.1 cm, and a Stage 3 coccyx wound. The record did not include a measurement for the coccyx wound and stated the resident had a wound vac (a dressing which pulls fluid from a wound to reduce swelling and assist in cleaning the wound and removing bacteria) in place. The clinical record lacked documentation of further skin assessments from the resident's admission on 12/14/21 until the resident's discharge on 1/3/22. A 12/20/21 Care Plan entry stated the resident had multiple Stage 2 pressure ulcers to the buttocks and coccyx and utilized a wound vac. The December 2021 and January 2022 Treatment Records listed the following orders: a. Cleanse the coccyx with saline, apply wound vac black foam to wound bed, bridge to hip, pressure at 125 mm/hg, low intensity, change 2-3 times weekly. The entries for 12/31/21, 1/1/22, 1/2/22, and 1/3/22 were blank and lacked initials to indicate the completion of the treatment. b. Cleanse the right and left buttocks with saline and apply a layer of Xeroform and cover with silicone bordered foam pad, change daily and as needed. The 1/1/22 entry was blank and lacked initials to indicate the completion of the treatment. Progress Notes revealed the following entries: a. On 12/29/21 11:19 a.m., entry stated the facility placed a call to the Wound Clinic regarding the wound vac not sticking and denuded (loss of skin) surrounding skin. b. On 12/29/21 3:30 p.m., an entry stated the facility received a call from the Wound Clinic and they would discuss with the Physician on Thursday (12/30/21) and call back with new orders. c. On 12/30/21 7:46 a.m., an entry stated the facility called the Wound Clinic regarding the wound vac and left a message for a call back. d. On 1/1/22 5:10 p.m., an entry stated the wound vac was found off the resident and at bedside during the morning assessment at approximately 8:00 a.m. and the wound without a dressing and was left open to air with the wound vac left off for an unknown time of at least two hours. The nurse cleaned the wound and placed a wet to dry dressing on the area. The wound is on the coccyx is approximately quarter size and is tunneled. The resident's buttocks were excoriated with several small superficial breaks in the skin and the resident reported a pain level (on a scale of 1-10) of 8/10(burning) with the cleaning of the skin. The nurse washed with warm soapy water, dried thoroughly and applied [MEDICATION(S)] Cream (used to treat skin concerns). The nurse would pass this information to the Night Nurse and the aide to pass on information to keep the buttocks as dry as possible with frequent checks. A 1/3/22 10:37 a.m., a Progress Note stated the resident was shaky and complained of increased pain to the wound and that the wound vac was again off at this time. The wound had a foul odor with visible clots. The facility received an order to send the resident to the emergency room (ER). The facility lacked additional Wound Assessments including measurements and characteristics of the wound from 12/14/21-1/3/22 and lacked documentation Nursing Staff followed up with the Wound Clinic regarding the wound vac not working properly. The facility lacked documentation the resident attended a Wound Clinic appointment during her stay. A 1/8/22 Hospital Consultation Note stated the resident presented to theER on [DATE] for a possible wound infection. The note stated the resident had a sacral wound vac which was removed 3 days prior to admission due to it not functioning well. The resident had [CONDITION(S)] bacteremia and the source was felt to be from her wound. The resident required intravenous antibiotics. A 1/17/22 hospital Discharge Summary stated the resident required an Incision and Drainage (I and D) procedure during her stay. The facility policy Skin Management Standard, dated August 2021, directed staff to complete Skin Assessments weekly and to notify the Physician if there was a change in the condition of the wound. The policy directed Nursing Staff to inspect wound vac dressing sites frequently. During an interview on 9/13/22 at 9:49 a.m., the Director of Nursing (DON) stated she was not at the facility when the resident was so she did not know the details. The DON stated, expected Nursing Staff should document treatments and complete skin assessments every 7 days. She stated if the wound vac was not working, they should notify the Physician and find an alternative treatment. The DON stated she would expect staff to follow up on calls to the Wound Clinic. She stated nursing follow-ups was something they were working on currently. During an interview on 9/14/22 at 10:25 a.m., with regard to the resident not attending a Wound Clinic appointment, the DON stated it could have been a transportation issue as that had been a concern in the past.

Based on record review, resident and staff interviews, the facility failed to ensure the intervention(s) were implemented/followed to provide adequate supervision to prevent falls resulting in major injuries for one of four residents (Resident #1). The facility reported a census of 34 residents. Finding include: According the MDS (Minimum data set) assessment tool with a reference date of 06/19/14, Resident #1 ' s [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 3 out of 15, identified Resident #1 with severe cognitive impairment. The MDS identified Resident #1 required extensive assistance of two staff members to physically assist with transfers, bed mobility, Toilet use, ambulation in the resident's room, and personal hygiene, and assist of one staff member for dressing. The MDS documented the resident normally used mobility devices of a walker and wheelchair for mobility. The MDS indicated Resident #1unsteady with balance during transitions and walking but able to stabilize with staff assistance. The MDS indicated the resident to have functional limitation in range of motion on one side of their lower extremity that interfered with daily functions or placed the resident at risk of injury. The MDS documented the resident had no falls since prior assessment being completed. The Care Plan with an initiated date of 05/20/13, identified the resident is at risk for falls related to history of dementia and history of falls as evidence by fall risk assessment. The Care Plan listed interventions that directed staff to: 1. Resident uses low bed. 2. Staff encourage resident to ask for assistance as needed. 3. Staff encourage resident to participate in activities that promote exercise, physical activity for strengthen and improved mobility. 4. Staff clear resident's environment of unnecessary objects that may cause injury. 5. Staff toilet the resident upon arising, before/after meals, at bed time and as needed. 6. Staff assure resident has non-skid, well-fitting footwear. 7. Staff assists Resident#1 with walk to dine. 8. Staff apply bed alarm to bed when Resident #1 in bed. 9. Staff ambulates with assist of two, gait belt and walker (revision on 6/25/14). 10. Staff applies the chair alarm to chair when sitting. 11. Staff to provide resident# 1's items within reach. 12. If fall occurs, staff to assess for injury and notify physician. 13. Staff assures Resident# 1's call light is within reach. 14. Staff are to transfer with assist of two, gait belt and walker (revision on 6/25/14) 15. Staff to use wheelchair for mobility of resident, initiated on 6/25/14. 16. Staff assures Resident#1 ' s floor alarm in place, initiated on 6/25/14. 17. Resident to have low bed, dated 6/19/14. (Restated on the care plan). Review of the facility's Un-witnessed Report dated 7/27/14 at 3:25 p.m., revealed the nurse summoned to the resident's room by CNA due to resident fall in room. Resident observed on the floor at foot of bed half lying and half seated on left side. The resident holding right lower extremity and crying. Right lower extremity obviously contracted and resident complained of pain to right groin/hip area. Resident#1's alarm noted to be under the resident's pillow and sounding. Resident and family contacted and resident sent to the emergency room for further evaluation and treatment. Review of the Facility's Un-witnessed Incident Report (fall) dated 7/13/14 at 7:30 a.m., revealed the resident scooting on bottom down hallway toward dining room The resident stated he/she wanted to get to their wheelchair and go to breakfast. The resident's bed and chair alarm sounding. Staff to move the resident to a room closer to common area. Review of the Facility's Un-witnessed Incident Report (fall) of resident dated 7/11/14 at 8:38 a.m. Revealed at 7:30 a.m. resident on the floor in hallway outside the resident's room door. Bed alarm and floor mat alarm had both been sounding, bed in low position. No injuries noted, staff to put floor mat beside low bed. Review of the Facility's Un-witnessed Incident (fall) of resident dated 6/17/14 at 4:10 p.m., revealed the resident was seated on the side of the bed and staff asked the resident to wait for help to transfer to toilet. The staff went to get wheelchair and the resident in the interim scooted self on floor several feet toward bathroom. No injuries noted, staff education/counseling and physical therapy started on 6/20/14. Review of the Facility's Un-witnessed Incident (fall) of resident dated 6/11/14 at 8:30 p.m. revealed the staff observed the resident seated upright in the hallway, walker nearby, alarm sounding on bed. The resident stated going to the hospital due to knee pain. No injuries noted, resident assisted back to bed and staff recommended to have physical therapy screen. Review of the resident's Progress Notes dated 7/27/14 reviewed the resident had a fall at 3:25 p.m. The resident found to be lying on floor of room at foot of bed, half sitting and half lying on left side, resident holding/guarding right lower extremity and crying. The resident assessed by nurse and the resident's physician notified and order received to send the resident to the emergency room . The facility received notification from the hospital that Resident #1 had surgery scheduled on 7/28/14 for a right hip replacement. Review of the resident's Progress Restorative Note dated 7/25/14 at 12:28 p.m. revealed Resident #1 as noncompliant this week waiting for staff assist with transfers multiple times. Resident #1 found standing alone in room with no staff, staff encouraged Resident #1 to use the call light and encourage the resident to come out of room for activities, alarms remain in place. Review of the resident's Progress Behavior Notes dated 7/24/14 at 9:18 a.m. revealed the resident to be noncompliant, transferring self and getting up walking around by self constantly. Review of the History and Physical dated with admitted [DATE] revealed the resident presented with a right femoral fracture, resident most likely got out of bed and fell when trying to walk, staff found her lying on the floor in closet. The discharge date of [DATE]. Review of statement from the facility indicated the resident made it through surgery on Monday (7/28/14) per family report, however the resident had difficult time coming out or anesthesia and passed away on Tuesday (7/29/14). Review of the Daily Resident Alarm Checklist 6-2 shift for the July indicated the facility did not have any alarm checklist for residents alarm being checked for placement and functioning for 6 days out of 31 days. Review of August Alarm Checklist on 8/12/14, revealed 3 of 12 days of residents alarms not being checked. The facility when questioned failed to produce the missing daily sheets of resident alarms being checked and indicated they have no policy or procedure for alarm checks. Review of the Daily Resident Alarm Checklist dated 7/12/14 lacked indication of the time alarms checked. The sheet documented that Resident #1's floor alarm not working at this time, staff called on-call staff, may use bed alarm on floor until Monday morning when staff can re-evaluate. Interview on 8/12/14, 8/13/14 at 11:17 a.m., and 8/13/14 at 4:56 p.m. with the DON. The DON stated Resident's floor mat still in use and took surveyor to the room where the DON identified the short alarm mat is the one Resident #1 had in place at the time of the fall on 7/27/14. The DON demonstrated the alarm function and alarm box noted to not have the safety guard in place on side of alarm box where the on off switch is located, alarm after it had to be turned on did function, no resident had been in bed during this time. The DON did indicate the resident has a history of messing with alarm boxes such as turning them off and placing the box under her pillow if the alarm box placed in reach of the resident. The DON reported that on 7/12/14 staff put a bed pressure alarm in place due to the long floor mat not working and that would be ok for staff to place a pressure bed alarm on the resident's floor by bed. The DON stated she is not sure what happened to the resident's long floor mat, maybe Staff E changed it, there is no documentation of what happened to alarm, or if it got repaired, no follow-up done on alarm. The DON then stated during interview on 8/13/14 the resident did have a long floor mat in place when he/she fell and that the DON found the alarm floor mat rolled and in corner of room. The DON stated she checked the floor mat alarm and it worked. The DON stated Staff D, LPN, stated she reviews the alarm checklist on all days, they are placed in her box in medication room and she gets them and reviews them and files them in her office. The DON stated no facility system in place for non-functioning equipment just expected staff not to use it. The DON stated she expects staff to take any equipment out of use, get it tested , and replace it. The DON stated she checked on the floor alarm mat on 7/12/14 and just now found out that staff kept it in place because they tried it a couple more times and it worked so they kept the floor mat in place. Interview on 8/12/14 at 11:40 a.m. and 8/13/14 at 10:04 a.m. with Staff E, LPN (Licensed Practical Nurse) restorative nurse. Staff E stated resident#1's alarm floor mat that she implemented for resident safety had been a long floor mat and not the short one due to the resident having a history of climbing out of the top and bottom of bed and the long mat covered both of these areas. Staff E stated he/she prefers the long floor mat for all resident's versus the short mats. Staff E stated she/he had not been aware that the resident's alarm floor mat not working on 7/12/14, that no one shared this information. Staff E stated the alarm check list are done by the nurse on the weekend and placed in the DON'S (Director of Nursing) in box and the DON picks them up on Monday morning. Staff E indicated that she/he does the alarm check list Monday through Friday and then places it into the DON ' s box. Staff E indicated when she/he came in on Monday following 7/12/14 and the resident did not have a bed alarm on the floor, as this would not be appropriate to place this type of alarm on the floor, but had the long mat in place when Staff E did the alarm checks. Staff E stated she/he had not been informed the long floor mat did not work appropriately on 7/12/14. Staff E stated that Resident #1 has a known history of messing with the bed alarm and attempting to walk around the floor mat alarm so it will no sound. Staff E reported that if the resident's alarm box to the bed alarm is placed under the resident's bed and the bed lowered to low position this prevents the resident from getting to the alarm box. Staff E stated on Friday 7/25/14 prior to resident's fall she/he checked the alarms and the resident had the long mat in place and functioning. Staff E stated on Monday 7/28/14 when he/she came into work the long mat had been rolled up in the closet and in the resident's room Staff E noted a short mat. Staff E stated he/she never questioned anyone about why the mat had been placed in the restorative closet and nothing was said to Staff E regarding the floor mat. Interview on 8/13/14 at 9:32 a.m. with Staff D, LPN, revealed he/she worked on 7/27/14 on the day shift and had been assigned to care for the resident. Staff D stated along with Staff F, CNA (Certified Nurse Aide) assisted the resident to bed right before 2 PM. Staff F stated the resident did not want to use the bathroom prior to lying down and Staff D reported after assisting with the transfer Staff D left the room. Staff D stated she did see the long floor mat in place by the side of the bed and soft yoga pad on the other side of the bed. Staff D stated she did not check the alarms prior to leaving the resident's room as Staff F still with resident completing cares. Staff D stated it would have been Staff F to check the alarms prior to leaving the room. Interview on 8/13/14 at 1:47 p.m. with Staff F, CNA, revealed he/she worked on 7/27/14 on the day shift. Staff F stated he/she assisted Staff D lay the resident down, the resident refused toileting prior to lying down around 1:45 p.m. Staff F stated after resident on bed Staff F left the room and Staff F assisted Resident #1 to a lying position and removed the resident's shoes, the resident had pants and shirt on, did not want blanket so put blanket at foot of bed. Staff F stated the long floor mat alarm in place and activated as well as the bed alarm, bed in low position, and call light in reach. Staff F stated usually puts the bed alarm box under the bed and then lower the bed so the resident cannot reach the alarm box as the resident does have behaviors of doing so. Staff F stated he/she does not recall if he/she placed the alarm box under the bed or not. Staff F states if the alarm box is not put completely under the bed and placed at side of bed the resident can reach it. Staff F stated this is not wrote any place, he/she had been trained on this for this resident. Interview on 8/12/14 at 1:46 p.m. with Staff B, RN (Registered Nurse) revealed he/she worked 2nd shift on 7/27/14. Staff B stated staff from day shift reported just toileted the resident and the 2nd shift staff laid the resident down in bed. Staff B stated the first time he/she the resident that day had been around 3:30 p.m. when summoned to the resident's room and found the resident on the floor half sitting and half lying on the floor holding top of body up with left elbow, crying, and guarding right groin/hip area. Staff B indicated she called the resident's physician and received an order to send the resident to the emergency room for an evaluation. Staff B indicated the alarm fall mat placed on top of soft yoga mat but not sounding and resident not on an alarm on the floor. Staff B indicated finding the bed alarm box under Resident #1 ' s pillow and sounding but muffled. Staff B stated Staff C, CNA reported hearing Resident #1 crying from the common area and went to the resident's room and apparently the resident had the door closed. Staff B stated the resident needs the bed alarm placed under the bed and out of reach as the resident has a history of taking the alarm box and putting it in the trash can or under pillows of the bed. Interview on 8/12/14 at 2:25 p.m. with Staff A, CNA, revealed he/she worked 2nd shift on 7/27/14. Staff A identified Resident #1 in common area at 2 p.m. when she came into work and appeared agitated. Staff A stated that Staff A and Staff C, CNA, toileted and laid Resident#1 down in bed shortly after coming into work. Staff A stated the staff members placed the bed alarm under the bed and put the bed in low position then situated the floor mat in place and activated following Staff A testing the mat for proper operation. Staff A stated Resident #1's alarm always needs positioned under the bed and bed lowered so the resident could not reach it. Staff A reported she did not see Resident#1 until the ambulance arrived to transfer the resident to the hospital. Interview on 8/13/14 at 3:14 p.m. with Staff C, CNA. Staff C stated she came in at 1:45 p.m. on 7/27/14 and noted the resident sitting outside with family. Staff C indicated Staff C and Staff A, CNA, assisted the resident to the bathroom and laid Resident #1 down in bed. Staff C reported the bed alarm box placed under the bed and bed placed in low position and floor mat in place and functioning, no other floor mats on the floor. Staff C stated staff members are instructed to always place the resident's bed alarm under the bed and lower the bed. Staff C stated the resident is known to have behaviors of taking the alarm box and placing it under pillow or just messing with it. Staff C stated the placement of the alarm box is not wrote on the care card in the resident's room or care plan. Staff C stated around 3:30 p.m. Staff C and another staff member heard the resident crying from the common area. Staff C stated she/he went to the resident's room and found the door shut and when Staff C pushed the door open found a shoe behind the door. Staff C stated she/he found the resident sitting and leaning to left side at the end of the bed. Staff C stated the resident crying out, bed alarm box sounding very faintly under the resident's pillow. Staff C indicated the resident had one shoe on, socks, pants and shirt on, floor dry and not cluttered. Staff C summoned for the nurse. Staff C indicated resident not touching floor mat alarm pad when she found the resident and the floor mat alarm not sounding. Review of the death certificate information revealed the date of death as 7/29/14 at 3:38 p.m. The medical cause of death listed as Acute Cardiac Arrythmia related to hypertensive heart disease and other significant conditions identified as surgical repair of right hip fracture on 7/29/14 after fall related injury occurring on 7/27/14 at the nursing home. Manner of death listed as Accident.

Based on clinical record review, resident and staff interviews, the facility failed to ensure staff utilized a sit to stand lift transfer device as planned for one of four resident reviewed resulting in the resident sustaining a fracture (Resident #3). The facility census was 36 residents. Findings include: The Admission Record revealed Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 that indicates the resident had moderately impaired cognitive status and required extensive assistance of 2 staff with bed mobility, transfers and toilet use. The Care Sign dated 5/6/14, directed staff to use the sit-to-stand lift for all transfers with the assistance of 2 staff. The Therapy Recommendation dated 4/11/14 directed staff to utilize a mechanical Sara lift with two staff member assist for transfers. Progress Notes dated 6/15/14 at 7:20 p.m., revealed the nurse aide informed the charge nurse Resident #3's ankle appeared to be swollen and the resident complained of pain. The nurse noted some edema, bruising and tenderness with palpation to the entire circumference of the left ankle. At 7:38 p.m., the nurse received an order for [REDACTED].#3 to the emergency department for evaluation if x-ray showed a fracture. Progress Note dated 6/16/14 at 12:30 a.m., revealed an ambulance transported the resident to the emergency room for evaluation of the fractured ankle. An X-ray Report dated 6/15/14, revealed the resident had a mildly displaced fracture of the distal fibula metadiaphysis and moderate osteoporosis and mild degenerative arthritis. The hospital radiology report dated 6/16/14 revealed bimalleolar (ankle) fracture. The order was for the ankle fracture to be treated with an orthopedic boot. Nursing notes dated 6/16/14 revealed the facility was notified by the emergency room Nurse that Resident #3 was admitted to the hospital for treatment. During interview on 7/17/14 10:16 a.m., Staff A (Agency Staff), certified nurse aide, (CNA) reported the morning of 6/15/14 they assisted the resident with the sit to stand lift out of bed for breakfast and back to bed after lunch with Staff B. Staff A denied any incident. Staff A did not know why Staff B and the resident reported Staff A failed to use the lift to transfer Resident #3 that morning. During interview on 7/10 14 at 1:03 p.m., Staff B, CNA reported he/she was present in the room when Staff A transferred the resident from the wheelchair to the bed with the sit to stand lift. Staff B reported finishing cares for the roommate then walked to Resident #3's side of the room. Staff B had transferred the resident from the wheelchair to the bed without other staff assistance. Staff B observed the resident's left ankle/foot was internally rotated. Staff B told Staff A to tell the nurse about the resident's ankle. During a second interview on 7/15/14 at 9:07 a.m., Staff B reported he/she was not honest about what happened during the transfer of Resident #3 by Staff A due to fear and intimidation from Staff A. Staff B reported Staff A (Agency Staff) transferred Resident #3 failing to utilize the lift as ordered and Staff B did not assist with the transfer or observe the transfer. Staff B saw the resident sitting on the edge of the bed and Resident #3's left ankle was externally rotated. Staff A noticed the resident's ankle and told Staff B to just tell other staff that Staff A and Staff B used the lift. Staff B reported when Staff A and Staff B went back in the room to get Resident #3 up for lunch he/she noticed the resident's ankle was extremely swollen. Staff B thought Staff A told the nurse. Staff A and Staff B transferred the resident with the sit to stand lift to the wheelchair for lunch. Staff B reported the resident complained of ankle pain after the transfer. Staff B reported he/she was scared and told the Director of Nurses after the incident that the lift was used but that was not the case. During interview on 7/10/14 at 12:35 p.m., Staff D, registered nurse, RN visited Resident #3 at the hospital. The resident reported the Agency Staff (Staff A) lifted him/her alone and without the lift. The resident reported the same Staff A lifted him/her like that before. The resident reported it hurt right away and he/she knew something was wrong. During interview on 7/10/14 at 9:12 a.m., the resident reported the Agency Staff (Staff A) thought she could move Resident #3 without the machine. The resident reported the Agency Staff (Staff A) put a belt around his/her waist and his/her leg got caught during the transfer. Resident #3 reported his/her leg hurt right away. The resident did not tell anyone what happened because he/she did not want to get anyone in trouble.

Based on observation, record review and staff and physician interviews, the facility failed to prevent an avoidable pressure ulcer and properly identify the stage of the pressure ulcer for 1 of 3 resident's identified with pressure ulcers acquired at the facility (Resident #1) . The facility identified a census of 36 residents. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) 14 day assessment, with a reference date of 2/28/14. The MDS identified the resident had no pressure ulcers present but at risk of developing a pressure ulcer. Resident's #1 had a Minimum Data Set (MDS) assessment with a reference date of 3/14/14 which identified [DIAGNOSES REDACTED]. The MDS dated [DATE] (30 day assessment) documented the resident required total assistance with all cares, did not ambulate, and had impairment with range of motion for the upper and lower extremities on one side of the body. The documentation reflected the resident at risk for developing pressure sores and did have 1 unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar which measured 4 centimeters (cm.) by 3 cm. The Braden Skin assessment dated [DATE] reflected a score of 12. A score of 12 identified the resident at a moderate risk for the development of a pressure ulcer. On 2/21/14, the Braden Skin Assessment determined the score to be 13 which is also a moderate risk for a pressure ulcer to develop. The resident's Admission Nursing assessment dated [DATE] documented the left side of the body as flaccid. The Transfer Form dated 2/14/14 from the hospital identified skin intact. The Transfer Form did not identify Prafo Boots in order to prevent pressure ulcers of the feet. The Physician's Order Statement dated 2/17/14 did not direct the staff to apply any Prafo boots for the resident. The Physician's Telephone Order dated 3/5/14 directed staff to apply Prafo boots to the resident while in bed. The February 2014 Treatment Record failed to document any Prafo boots or heel protectors applied to the resident ' s feet. The March 2014 Treatment Record documented staff applied Prafo boots (blue) to the resident starting 3/5/14. Resident #1's Care Plan dated 2/28/14 documented the resident with an unstageable pressure sore to the left heel related to immobility,[MEDICAL CONDITION](stroke) and incontinence. The interventions for the pressure ulcer included to treat as ordered and assess weekly. Observation on 3/18/14 at 9:45 a.m., revealed the resident in bed wearing small heel pads with one Velcro strap across the top of each foot. Heel pads are not Prafro boots which were ordered on [DATE]. Observation on 3/19/14 at 10:20 a.m., revealed the resident in a wheelchair wearing large, soft, blue foam heel protectors. Observation on 3/19/14 at 12:21 p.m., Staff E, Consultant Registered Nurse, removed the resident's large blue heel protectors. The medial side of the left heel revealed a large eschar, approximately 4 cm. by 3 cm. dark brown and dark red in color. Staff E acknowledged it was a pressure ulcer and the resident did not have it prior to admission. Staff E believed Prafo boots contained a brace with the boot. Record review of the Physical Therapy Evaluation and Plan of Treatment documented the resident's risk factors as contractors, decrease in level of mobility, decreased skin integrity, [MEDICAL CONDITION] and limited out- of- bed activity. The evaluation failed to address any braces to the resident's lower extremities. Record review of the resident's Physical Therapy Treatment Encounter Note dated 3/7/14 showed the Physical Therapist Assistant identified a large blister on the left lower extremity medial side of the heel and notified Nursing immediately. The facility's record for Weekly Pressure Ulcer Healing Record documented the following for a description of stages for a pressure ulcer: Stage 1: An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperatures, tissue consistency, sensation and or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Stage 2: Partial thickness of skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous that may extend down to, but not through, underlying fascia. The ulcer clinically presents as a deep crater with or without undermining of adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers. Record Review of the resident's Weekly Pressure Ulcer Healing Record documented the onset date of the resident's left heel pressure ulcer on 3/7/14. The description noted the blister as unstageable and 3 cm. round. (The blister per facility's skin description should be a stage 2.) Record Review of the resident's Weekly Pressure Ulcer Healing Record dated 3/14/14 documented the unstageable ulcer with measurement soft 4 cm. by 3 cm. intact blister, soft to touch and dark blue in color. Record Review of the resident's Weekly Pressure Ulcer Healing Record dated 3/15/14 documented a stage 2 pressure ulcer measuring 3 cm. by 4 cm. with unknown depth. The comment identified the blister as intact. Record review of the physician's orders, facsimile (fax) or telephone before 3/5/14 identified no orders for braces or Prafo boots. Record review of the Nurse's Notes dated 2/15/14 at 6:35 p.m. identified documentation of braces on both of the resident's lower extremities. Record review of the Nurse's Notes dated 2/16/14 at 9:52 a.m. identified documentation of braces on both the resident's lower extremities. Record review of the Nurse's Notes dated 2/26/14 at 7:55 p.m. revealed documentation of 1 plus [MEDICAL CONDITION] (swelling) to the resident's left foot. Record review of the Nurse's Notes dated 3/8/14 at 6:45 a.m. and 3/9/14 at 6:45 a.m. identified documentation of 2 plus [MEDICAL CONDITION] to the resident's left foot. Record review of the Nurse's Notes dated 3/10/14 at 12:20 a.m. identified documentation of 1 to 2 [MEDICAL CONDITION] to the resident's left foot. Record review of the Nurse's Notes dated 3/14/14 at 12:24 p.m. revealed documentation of 1 plus [MEDICAL CONDITION] to the resident's left foot. On 3/19/14 at 2:10 p.m., Staff G, Licensed Practical Nurse, was interviewed and revealed of not ever seeing the pressure ulcer but noted the resident always wore heel protectors. On 3/19/14 at 4:08 p.m., Staff A, Registered Nurse, was interviewed and stated had received an order for [REDACTED]. On 3/19/14 at 4:15 p.m., Staff B, Registered Nurse, noted the resident always wore something on the lower extremities, but was unsure if they were braces or heel protectors. Staff B stated the resident did wear braces when first arrived at the facility. On 3/19/14 at 4:22 p.m., Staff C and D, both Residential Care Technicians (Nursing Aides) agreed the resident wore something on the lower extremities but were unsure if they were braces or heel protectors. Both staff noted of changing the resident's position every 2 hours from side to side and would float the resident's heels. On 3/19/14 at 4:30 p.m., Staff F, Licensed Practical Nurse, assessed the resident's left heel on 3/14/14. Staff F stated the blister was intact, not sac-filled with fluid but flat, soft to touch and blue in color. On 3/19/14 at 4:40 p.m., the Administrator, Registered Nurse, had heard from the staff that the boots the resident wore caused a pressure ulcer. The Administrator revealed the gray, fuzzy braced boots in the closet. The boots came with the resident from the hospital and was worn by the resident in bed. The gray, fuzzy, braced boots went from the bottom of the foot, up toward the mid-calf area. There was a hard plastic brace-like that ran on the bottom of the foot, open circled around the each side of the heel and up the back. The braced boots contained the label which stated "Ankle Contractors". The Administrator agreed the open area of the plastic looked like the circled area of the pressure sore on the lateral left heel. The Administrator noted of being under the impression from staff the resident's foot slipped upward into the brace. On 3/19/14 at 4:50 p.m., the Director of Nursing (DON), Registered Nurse, was interviewed and stated was unaware which boots the resident wore. The DON checked with the Physical Therapy Department and stated all the boots the resident wore are considered Prafo boots, just a different brand name. The gray, fuzzy, braced boots from the closet are also considered Prafo boots. The DON stated the facility did not have a designated wound nurse, but was in the process to train someone. On 3/19/14 at 4:53 p.m., Staff F, Licensed Practical Nurse, was interviewed and stated she was unsure which boots the resident wore. Staff F stated the braced boots in the closet were probably from the hospital and were probably the boots the resident wore until the appearance of the pressure sore. Staff F stated the resident now wears the big, soft, foam boots. On 3/20/14 at 8:48 a.m., the MDS Coordinator was interviewed and stated there was not a physician's order for the Prafo boots and the resident came with them from the hospital. On 3/20/14 at 10:27 a.m., Staff H, Registered Nurse, noted the resident wore some kind of braces or boots from the hospital. Staff showed the Weekly Pressure Ulcer Healing Process written on 3/15/14 and stated it was a blister, fluid filled. Staff H stated whoever discovers then will assess a pressure ulcer. On 3/19/14 at 10:43 a.m., Staff I, Licensed Practical Nurse was interviewed and stated she assessed the pressure ulcer after being informed by the Physical Therapist Aide (PTA) on 3/5/14. The resident's left heel contained a fluid filled blister. The physician was notified. Staff I removed the gray, fuzzy boots, braced boots and placed the big , soft, blue foam boots, which Staff I stated were also called Prafo boots. Staff I stated the staff changes the resident ' s positions from side to side as residents do not lie on their backside. The gray, fuzzy, braced boots would be used if the resident laid on his/her back to prevent foot drop, so the resident would not need those braces. Staff I noted there was no physician's orders for the braces or Prafo boots but decided to wait till after an evaluation from the Physical Therapist. Staff I did not follow up after the Physical Therapy's initial evaluation. Staff I believed of sending a fax to the physician to get an order for [REDACTED]. Staff I noted there was a difference between braces and heel protectors. Staff I stated a physician's order is required for resident's to wear Prafo boots. On 3/19/14 at 2:10 p.m., the Physical Therapist Assistant was interviewed and stated the boots from the hospital ("Ankle Contractors") are mainly used for residents who lie on their backs. The PTA also noted all the boots could be called Prafo boots. Prafo was the name of a brand of boots that could be used. The PTA stated the resident wore the gray, fuzzy, braced boots every time they met for a therapy session. On 3/19/14 at 2:20 p.m., the Consultant Nurse (Staff E) was interviewed and stated staff did not need a physician ' s order for Prafo boots. On 3/20/14 at 1:30 p.m., the facility Medical Director was interviewed and stated if a resident's foot had [MEDICAL CONDITION] and was flaccid, then a splint or brace would not be recommended. The Physician stated he would expect the facility staff to call to ask for an order for [REDACTED].