Every finding on record at Ruthven Community Care Center

Based on clinical record review, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accidents for 1 of 3 residents reviewed (Resident #5) for falls. Findings include: Resident #5's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. The MDS identified Resident #5 required substantial/maximal assistance with bed mobility, transfers and ambulation. Resident #5's MDS included diagnoses of schizophrenia, depression, anxiety, unsteadiness on feet, and history of falling. The Care Plan dated 2/12/15 documented Resident #5 required assistance with activities of daily living and was at risk for falls. The Care Plan directed the following interventions with dates:-Staff to transfer Resident #5 with assistance of 2 staff members- 7/19/25-Staff to ambulate Resident #5 in hallway, distance as tolerated with front wheeled walker, gait belt, wheelchair to follow with assistance of 2 staff members- 3/28/25- Staff reeducated to utilized 2 staff members with all transfers- 8/1/25Resident #5's Fall Risk Assessments documented the following scores and fall risk:6/25/25=22-High Risk8/1/25= 18- High [NAME] Progress Note titled Fall dated 6/25/25 at 2:42 AM documented Resident #5 walked into the bathroom with the Certified Nursing Assistants (CNA's) and once in the bathroom before Resident #5 made it to the toilet, he started to sit and the CNA's lowered him to the floor. The note documented the intervention for the fall was re-educating staff on using a gait belt at all times for transfers or using a wheelchair if not comfortable with walking the resident. The clinical record lacked documentation that the family/resident representative was notified regarding the fall.The facility forms titled Corrective Action Notice dated 6/26/25 for Staff B, CNA and Staff C, CNA documented verbal coaching completed by the Director of Nursing (DON) via phone due to the CNA's transferred Resident #5 without a gait belt and lowered him to the floor.A Progress Note titled Fall dated 8/1/25 at 8:55 PM documented Resident #5 was being transferred into the recliner chair when he began sitting too soon. The CNA who was assisting with the transfer was unable to fully support Resident #5's weight and lowered him to the floor. The note documented the intervention for the fall was to re-educate the staff to utilize 2 staff members with every transfer.On 10/1/25 at 1:12 PM, Staff D, Registered Nurse (RN) reported on 8/1/25 Staff E, CNA attempted to transfer Resident #5 to the recliner by herself. Staff D said there was another aide present standing in front of Resident #5's walker but was not providing any assistance. She said Staff D was the only aide that had physical hands on Resident #5. On 10/1/25 at 2:00 PM, the DON agreed it was an expectation for the staff to follow the care plan regarding assistance levels and use a gait belt with all transfers.A facility policy titled Gait Belt Usage dated 2025 documented all employees providing direct resident care are required to utilize a gait belt whenever hands on assistance was needed for resident transfer and/or ambulation unless otherwise contraindicated.A facility policy titled Accident and Supervision dated 2025 documented the resident environment would remain free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. In addition, the policy documented the facility would implement interventions to try to reduce resident's risk from hazards in the environment and ensure that the interventions are put into action, implemented correctly and consistently.

Based on observation, staff interviews, pharmacist interview, manufacturer's instructions and policy review, the facility failed to administer insulin medication appropriately and discard the insulin pen 28 days after opened for 1 out of 1 resident (Resident #8) reviewed for insulin administration. The facility reported a census of 43 residents.Findings include: Resident #8's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 11, indicating moderately impaired cognition. The MDS included diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar levels). The MDS identified Resident #8 received insulin injections for 7 days during the look back period.A Physician Order dated 6/12/25 directed staff to administer Lispro (rapid acting insulin) 6 units subcutaneously (fatty tissue layer beneath the skin) one time a day via a KwikPen for diabetes.On 9/30/25 at 11:00 AM, observed Staff A, Registered Nurse (RN) obtain Resident #8's Lispro insulin pen from the medication cart. The insulin pen was labeled opened as of 8/27/25. When the surveyor asked the RN how long the pen was good for after opening, the RN said she was not sure and would need to check on it. The RN proceeded to administer 6 units of Lispro insulin via pen with an open date as of 8/27/25.On 9/30/25 at 11:34 AM, Staff A, RN verified the Lispro insulin pen was good for 28 days after opening. She acknowledged the insulin pen was dated opened as of 8/27/25 and should have not been given. On 9/30/25 at 11:37 AM, the Director of Clinical Services reported the RN should have gotten a new insulin pen out. On 9/30/25 at 12:09 PM, the Pharmacist verified the Lispro insulin pen was good for 28 days after being removed from the refrigerator and opened. She said the manufacturer would question the strength of the insulin after 28 days. She said the insulin may be less potent and less likely to control the blood sugar.The Instructions for Use for Insulin Lispro revised July 2023 documented not to use the insulin pen and to discard it after 28 days of usage, even if the pen still had insulin left in it.The facility Medication Management Policy dated 2025 directed staff to check expiration date on package/container.

Based on clinical record review, staff interviews, pharmacy interviews and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 12 residents reviewed (Residents #6). The facility failed to implement a physician order for a new treatment of Epsom salt foot soaks. The facility reported a census of 29 residents. Findings include: Resident #6's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #6 was independent with bed mobility transfers and ambulation. Resident #6's MDS included diagnoses of hypertension (high blood pressure), cerebral palsy, pain in the right foot, and localized edema. A Progress Note dated 7/10/24 documented Resident #6 saw the Podiatrist, received a new order to apply TAO (triple antibiotic ointment) to the right great toe daily and to call the clinic the following morning to schedule an appointment to have the right great toenail removed. A Progress Note dated 7/15/24 documented Resident #6 returned with post procedure instructions directing staff to soak the right great toe two times daily and then cover with TAO and bandaid. A Progress Note dated 7/29/24 documented Resident #6 returned to the facility from appointment and the right great toenail removal progressing as expected. New orders received to discontinue soaks and twice a day bandaid changes to the right great toe. Apply bandaid and TAO to the right great toe nail bed once daily until healed. A Progress Note dated 9/5/24 at 8:17 AM documented a note text to the Physician reporting Resident #6 had an appointment on Monday to be seen for the right great toe. The note revealed Resident #6's right great toe was red, inflamed and causing resident pain and discomfort. The note requested an order to soak the right great toe in Epsom salt twice a day for 1 week. A Progress Note dated 9/5/24 at 5:07 PM documented the Physician responded yes to the Epsom salt soaks and okay to set up telehealth if an antibiotic needed to be started. The clinical record lacked documentation the Pharmacy was notified of the order for the Epsom salts and lacked follow up documentation regarding the need for the telehealth visit. A Progress Note dated 9/5/24 at 9:29 PM documented Resident #6 had complaints of pain and discomfort to the right big toe. The toe appeared edematous and reddened. The note documented the toe was being dressed twice daily with a bandaid. Review of the September Treatment Administration Record (TAR) 2024 starting on 9/6/24 directed staff to soak Resident #6's right foot in a warm Epsom salt bath twice a day for 7 days for inflammation and pain. A Progress Note dated 9/6/24 at 5:53 AM documented Epsom salt had not been delivered by Pharmacy. A Progress Note dated 9/7/24 at 8:55 PM documented Epsom salt unavailable at this time. A Progress Note dated 9/8/24 at 9:42 AM documented no Epsom salt on hand. A Progress Note dated 9/8/24 at 9:31 PM documented awaiting on Epsom salts. A Progress Note dated 9/9/24 at 5:13 AM documented awaiting on Epsom salts. A Progress Note dated 9/9/24 at 1:16 PM documented Resident #6 returned from appointment with new orders for right great toe infection. The new orders directed staff to soak the right great toe in Epsom salt, apply TAO and cover with bandaid dressing twice a day for 10 days and start Cephalexin (oral antibiotic) 500 mg (milligrams) three times a day for 10 days. A Progress Note dated 9/9/24 at 11:35 PM documented Resident #6's right great toe was reddened and tender. A Progress Note dated 9/9/24 at 11:37 PM documented Epsom salt not available this evening. A Progress Note dated 9/10/24 at 11:35 AM documented Resident #6 continued to complain of soreness to the right great toe and the area remained pink. The note documented a call to the pharmacy to follow up on delivery of the Epsom salt for ordered treatment with delivery planned for that evening. Review of the clinical record from 9/5/24 to the morning of 9/10/24 lacked documentation regarding the follow up on the delivery of the Epsom salt. On 9/19/24 at 9:00 AM, the Director of Nursing (DON) reported the facility had waited on the pharmacy to deliver the Epsom salt. She stated she was not aware of what the hold up was. She stated she had called the pharmacy herself regarding the Epsom salts. The DON acknowledged the clinical record did not reflect the follow up call. The DON reported she was not responsible for ordering the supplies. She verified she would expect the facility to look at other options or ways of obtaining the treatment supply. On 9/19/24 at 9:40 AM, the DON reported she had talked to the Pharmacy. The DON stated the pharmacy did not have the Epsom salts in stock when it was ordered and had to wait for it to come in. When asked if she expected the staff to follow Physician orders, she stated Absolutely. On 9/19/24 at 9:53 AM, a Pharmacy employee reported the facility was billed for Epsom salt on 9/9/24 and it was delivered on 9/10/24. She stated the Epsom Salt was sent out as a stock item and was not on the resident profile. The Pharmacy employee reported she had gone through the refill requests and hard copies and could not locate an order for Epsom salt for Resident #6 on 9/5/24. On 9/19/24 at 10:07 AM, the Pharmacy Manager reported she had gone through faxes, emails, hard copies, deleted emails/faxes for 9/5/24 and 9/6/24 and could not locate an order for Epsom salt for Resident #6. She stated the pharmacy received an order for Epsom salt on 9/9/24. She stated if the facility had called with a verbal request/order, those orders would be written down and scanned in. An undated facility policy titled Physician orders for Medications and Treatments documented all medications would be administered as ordered by a healthcare professional authorized by the state to order medications.

Based on personnel file reviews, facility policy review and staff interview, the facility failed to provide dependent adult abuse recertification training within 3 years for 1 of 5 employees reviewed (Staff A). The facility identified a census of 29 residents. Findings include: The personnel file for Staff A, LPN (Licensed Practical Nurse) documented a hired date of 1/12/24 . Review of the Dependent Adult Abuse Mandatory Reporter Training Certificate documented Staff A completed the 2 hour dependent adult abuse training on 8/17/21. Review of facility policy titled Abuse Policy dated 2023 revealed each employee shall be required to take a 1 hour recertification training within 3 years of the initial 2 hour training and every three years thereafter. On 9/17/24 at 1:33 PM, the Director of Nursing (DON) acknowledged and verified Staff A's Dependent Adult Abuse Mandatory Training was overdue. The DON stated Staff A would be taking the recertification training on 9/17/24.

Based on observations and staff interviews the facility failed to ensure food was labeled with dates after opening, labeled with product after removing from original package and discarded after product expiration date. The facility identified a census of 35 residents. Findings include: An initial kitchen tour conducted on 06/19/23 at 9:22 a.m., the following items were stored in the kitchens refrigerator ready for service: a. Individual serving of potato salad in a styrofoam bowl uncovered and not labeled. b. Individual serving of potato salad covered in a styrofoam bowl with no label. c. 2 bottles of salad dressings in a container unlabeled and lacked a date opened. d. Open bottle of honey thickened cranberry juice with an open date of 4/22/23. Label reads discard unused portion after 10 days. Review of the facility provided policy tilted Food Service dated 2023 revealed all foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Interview on 06/19/23 at 9:43 a.m. with the Dietary Manager (DM) revealed she expected the items to be labeled. The DM discarded the items immediately.

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to provide restorative therapy for 1 of 2 residents reviewed (Resident #15). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points indicating intact cognition. The MDS revealed the resident had diagnoses to include dislocation of left hip, osteoarthritis in left hip, and pain in left hip. The MDS revealed the resident required extensive assistance of 1 staff with bed mobility, transfers, and toileting. The MDS revealed the resident had occupational therapy 4 days out of the past 7 days and physical therapy for 2 days out of the past 7 days; the resident did not receive restorative therapy. The Rehab Communication form dated 11/2/22 signed by an Occupational Therapist directed staff to walk patient in the hallway 1-3 times per day with gait belt, FWW, and immobilizer with assist of 2 staff with wheelchair to follow. Distance to patient tolerance. The Restorative Nursing Recommendations form dated 4/24/23 signed by an Occupational Therapist directed staff as follows: 1. NuStep for 9 minutes at a level of 1-2. 2. 1 times per day for 3 days per week: Please stand patient at the sink with front wheeled walker, gait belt, and wheelchair behind for completion of hand hygiene and combing hair. 3. Please encourage group exercise class. 4. Patient is independent with bilateral upper extremity exercises for home exercise program with 1 pound dumbbell while seated in her chair. The Care Plan for Resident #15 listed an intervention dated 11/2/22 directing staff to walk the resident in the hallway 1-3 times per day with a gait belt, front wheeled walker (FWW) and immobilizer with assist of 2 and wheelchair to follow. Distance to resident tolerance. The Care Plan lacked any documentation of any other restorative exercise program. In an interview on 6/19/23 at 10:46 AM, the resident reported that she recently ended physical therapy, that she had exercises to do on her own, and would like to have individual assistance with exercises. The Clinical Record lacked documentation that the resident received NuStep exercise or the handwashing and hair combing activity. The facility Restorative Activities of Daily Living Services policy, undated, documented the following: Policy: Residents of this facility will achieve and maintain the highest practicable level functionality with all Activities of Daily Living. Documentation: The Restorative Flow Sheet will address the goals and interventions in addition to documentation of staff implementation of planned interventions. In an interview on 6/20/23 at 1:35 PM, the Director of Nursing (DON), with Staff A, Registered Nurse (RN), and the Administrator present, reported that it was discovered that the tasks for walking in the hallway, handwashing with hair combing were entered into the clinical record as prn (as needed). This did not trigger staff to document these activities and no other documentation was available for review.

Based on observation, record review, and staff interview, the facility failed to provide adequate assessment and timely intervention for impaired skin integrity for 2 of 2 residents reviewed (Resident #32 and #24). The facility reported a census of 30 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #32 scored 8 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required supervision for transfer and walking in the corridor, limited assistance with toilet use and personal hygiene, and independent with ambulation in the room. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan initiated 6/16/17 identified the resident had a potential for alteration in skin integrity. The interventions included encouraging the resident to not pick at her skin, monitoring the resident's skin with cares, alerting the nurse of any red/open area, so she could contact the physician, and encouraging her to change her position frequently. The Client Episode Coordination Notes Report (hospice) documented the following: On 8/26/21 The resident's family member called to ask them to make sure to check and change the resident often that night. The triage nurse called the facility they assured them that they would make sure the resident was dry and comfortable. On 8/27/21 The family member called with concerns about her mother. She believed the resident's pain was due to having a raw bottom and possible hemorrhoids. The writer discussed educating the facility on the use of repositioning every two hours as well as using barrier cream. On 8/27/21 The Hospice nurse visited and documented the resident's coccyx and buttocks reddened with no openings. On 9/1/21 The Hospice nurse visited and the resident's bottom was reddened and starting to open. Skin barrier cream continued to be applied by the facility staff. The physician would like for Vaseline to be applied. On 9/3/21 The Hospice nurse assisted facility staff turn and reposition the resident. The resident had a large loose stool, peri cares completed and the patient had a reddened area from her coccyx to her groin area, not open but very red and the resident complained of pain. Discussed peri cares with facility staff, not using an incontinent brief, and putting on a chucks only. The facility clinical record lacked any assessment of the resident's sore coccyx and perineum. A Hospice Physicians Order dated 9/1/21 notified the Physician the resident's coccyx and perineum reddened and starting to show further breakdown and questioned if they could apply Vaseline to the affected area three times a day and as needed until healed. The Physician responded yes. The Treatment Administration Record (TAR) for August 2021 lacked any treatment to the resident's coccyx/perineal area. The TAR for September 2021 showed they were to apply Vaseline to the resident's coccyx/perineum 3 times a day (TID) until healed, initiated 9/3/21. On 3/30/22 at 2:16 p.m. Staff B CNA stated the resident's bottom was sore for a long time. They repositioned and used a cushion in the chair. On 3/30/22 at 2:35 p.m. Staff A CNA stated the resident did have a sore bottom but they found that the family was coming in and putting stuff on her skin that she was allergic to and that caused irritation. On 4/4/22 at 9:04 a.m. the Director of Nursing (DON) stated the family had brought in some ointment that had sulfa in it and according to the resident's records she was allergic to it and that inflamed her bottom really bad. She thought the previous DON would document on what had happened. The family told them they had brought the ointment in and that they had applied it. On 4/4/22 at 9:56 a.m. the Care Plan Coordinator (CPC) stated the previous QA Nurse (no longer worked at the facility) talked with the Hospice Nurse about a cream they found in the resident's room. They weren't sure if they should throw it away or what they should do with it and they decided that they should keep it. She said she talked to the staff who were working and asked them if they had ever used the cream on the resident and they said no they had not. They believe the family brought in the cream and they put it on the resident and that she was allergic to it. The clinical record lacked any documentation of the family applying something to the resident's perineal/coccyx area the resident may have been allergic to, or notification of the physician of a possible allergic reaction to something they believed had been applied. The facility Skin Impairment Assessment/Documentation Process reviewed and updated 11/9/18 documented all skin conditions were to be assessed and documented weekly on a skin sheet. The description of any skin condition must be completed including notification of the physician and responsible party (family). The care plan would be updated, and CNA's updated for education providing the quality care to heal and attempt to prevent further skin issues. 2) According to the MDS assessment dated [DATE] Resident #24 scored 11 on the BIMS indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Care Plan revised 7/15/20 identified on readmission from the hospital, the resident had an unstageable pressure area to left heel. The interventions included completing the treatment as ordered by the physician, encouraging the resident to wear his [NAME] boot on his right lower extremity (RLE), monitoring skin with cares, alerting the nurse of any red/open areas, so she could contact the physician, and notifying the physician if his skin condition worsened. A Non-Pressure Skin Condition Report dated 12/8/21 documented the resident's left heel measured 1 by 0.7 centimeters (cm), the wound bed had black/brown eschar and the surrounding skin normal for skin. The next documentation of the area dated 1/26/22 documented the area measured 0.4 by 0.2 cm and the wound bed normal for skin . The comments included the area had resolved with a small calloused area. They were doing [MEDICATION(S)] and 2 by 2 dressing. A Physician/Nursing communication form dated 1/21/22 notified the physician the resident had an area to his left great toe that had scabbed and questioned if they could discontinue the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The area to the resident's left heel resolved with a small callous area. They were doing [MEDICATION(S)] and a 2 by 2 dressing. The communication questioned if they could have orders to DC and leave open to air. The resident had [NAME] boots that he wore all the time. The physician agreed. The form included documentation they would monitor 1 time a week for 4 weeks on the TAR. The clinical record lacked any further documentation of an assessment of the areas. During observation on 3/31/22 at 3:22 p.m. with the Quality Assurance (QA) nurse the resident's left heel area had a dark area towards the lateral left heel. The resident denied any discomfort and no drainage noted. He had a protective boot he wore on the left foot and leg. The left great toe had a crusted area at the tip. On 3/31/22 at 3:58 p.m. the Director of Nursing (DON) stated the resident's foot had that area since the wound nurse determined it healed and they did watch it but at this point they are not doing anything with it. On 4/6/22 at 8:24 a.m. the DON stated she could not find the skin sheets between 12/8/21 and 1/26/22. On 4/6/22 at 10:21 a.m. the DON, Staff H Licensed Practical Nurse (LPN), and the Nurse Consultant observed the resident's left foot. The foot had a black area of the lateral heel. The DON and the LPN stated it had been like that for 3 years. The DON stated the area that healed on the heel was more central and it did appear to be a calloused area. She said the black area was a callous, she would find something about it.They acknowledged the area on the right great toe. The Nurse Consultant thought it may be a fungus. At the time of the exit conference on 4/7/22 at 3 p.m. the facility had provided no additional information regarding the areas on the left foot. The facility policy Skin Impairment Assessment/Documentation Process reviewed and updated on 11/9/18 documented the standard included providing weekly assessment of all skin conditions including pressure sores, to help prevent infection and other complications for skin [CONDITION(S)], and providing documentation of skin impairments. The process included all skin conditions such as skin tears, rashes, bruises, open areas, pressure sores or stasis ulcers would be assessed and documented on a weekly skin sheet.

Based on record review, staff interview, and policy review, the facility failed to assure residents maintained acceptable parameters of nutritional status, such as usual body weight unless a resident's clinical condition demonstrated that it was not possible for 1 of 5 resident's reviewed (Resident #32). The resident had the same weight documented 8 consecutive times, then showed a 37.5 pound, 24% loss in 11 days. Staff were documenting the previous weight and not weighing the resident. The facility reported a census of 30 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #32 scored 8 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required limited assistance with eating. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident weighed 156 pounds (#) and did not have a significant weight loss described as a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The Care Plan identified the resident had diabetes initiated 6/16/17, with the goal for continuing to eat the foods of the resident's choice, and feeding without a significant change in weight. The interventions included offering the resident supplements as the Dietitian recommended, telling the resident food placement when serving her, serving a general, regular diet with ground meats and small portions, taking the resident's order at meals, and weighing the resident as ordered. The Weight Summary documented the resident weighed: 5/22/21 at 9:24 p.m. 156#. 5/26/21 at 8:01 p.m. 155#. 6/5/21 at 9:59 p.m. 155.5#. 6/9/21 at 9:02 p.m. 155.5#. 6/19/21 at 5:52 p.m. 155.5#. 6/23/21 at 7:34 p.m. 155.5#. 6/30/21 at 5:08 p.m. 155.5# 7/3/21 at 8:09 p.m. 155.5#. 7/14/21 at 9:52 p.m. 155.5#. 8/14/21 at 9:59 p.m. 155.5#. 8/25/21 at 1:48 p.m. 118#, a 37.5# and 24% weight loss. The Progress Notes dated 8/25/21 at 3:56 p.m. documented the Director of Nursing (DON) and the the Nurse spoke with the resident regarding Hospice Services due to a physical decline, weight loss, and pain. The resident wanted comfort cares and wanted staff to visit with her family for agreement. The Progress Notes dated 8/26/21 at 11:14 a.m. documented the resident has had an overall physical and mental decline. The resident had a previous fall, significant weight loss and not eating. Conversations were had with family and they would like resident to Hospice. On 3/30/22 at 2:36 p.m. Staff B Certified Nursing Assistant (CNA) stated the resident wasn't eating as much and appeared to be losing weight. They did go down to the resident's room and assisted her with eating. The resident didn't care to go out to the dining room to eat her meals. On 3/30/22 at 2:35 p.m. Staff A CNA stated she remembered working with the resident and she could not see very well and that's why she didn't like to go out to the dining room. On 4/4/22 at 9:04 a.m. the DON stated the family not really involved with the resident until the end when she got so much worse. The resident stopped eating and had a really big decline. She could not account for such a big weight loss in two weeks. But said that she had just basically stopped eating. On 4/4/22 at 9:40 a.m. Staff C CNA stated for awhile the resident complained about the food being cold when they got it to her room. She said they had to check it right before they took it down to her to make sure it was warm enough before it left the kitchen. She just got to the point where she just really didn't want to eat or she picked at food. One time she sat with the resident and fed her and she did eat some. She had difficulty seeing but if they sat it up for her and told her where each thing sat she knew where the food was and she could also see shapes. She did not go to the dining room and that had been a long term thing with her. She didn't know when, but she definitely noted the resident had lost a lot of weight and even commented to her about the weight loss. On 4/5/22 at 8:45 a.m. the DON stated she did not feel the resident could have lost that much weight in 11 days. She said towards the end the resident only had bed baths so they may not have taken her down for weights. They may have just written down the previous weight. She did not feel the resident's weight would have been exactly the same for eight consecutive documentations. On 4/5/22 at 9:56 a.m. the QA Nurse stated she had talked to Staff E CNA and she had written down previous weights and not weighed the resident when the resident wanted a bed bath instead of a whirlpool. On 4/5/22 at 11:20 a.m. the QA Nurse talked to the staff who documented the resident's weight on 8/14/22 (Staff A CNA) and she stated she had documented the resident's previous weight and not actually weighed her. On 4/5/22 at 3:23 p.m. the Dietician stated if the resident had a significant weight loss she would have assessed the situation and recommended interventions to help maintain or even gain weight. When she did the last assessment on the resident she had admitted to hospice and hardly ate. The facilities undated weight policy documented for the best accuracy and consistency, residents should be weighed in the morning before breakfast unless otherwise specified. Re weights would be done if there was a 3 pound or more weight gain or loss from the previous weight. If an extreme weight change were noted or a resident had poor nutrition intakes at meals the Dietitian may recommend the resident be reweighed weekly.

Based on record review, observation and staff interview, the facility failed to ensure dishwashing temperatures and sanitizing solutions were maintained at safe, sanitizing levels. Findings include: 1. A review of the Dishmachine Log revealed only one temperature recorded daily, beginning 2/28/22 thru 3/29/22, for a total of 30 days. A single daily entry consisted of the notation over 160 degrees with a yellow test strip attached with a blackened mark, indicating the correct temperature had been achieved. A joint review of the dishmachine with the Dietary Manager (DM) liquid additives revealed 2 components were attached to the machine. One labeled detergent and one labeled rinse additive. The DM stated the machine is operated as a high temperature sanitizer and does not utilize chemical sanitizing. A review of the manufacturer's attached labeling instructed that during the wash stage, a minimum of 155 degrees F (Fahrenheit), for a minimum of 45 seconds was required for proper operations and sanitizing. The labelling also instructed that a minimum of 180 degrees F for a minimum of 7 seconds, with a dwell time (time spent in the same stage of a process) of 20 seconds was required for proper operations and sanitizing during the rinse stage. A review of the yellow test stripes attached to the daily temperature log revealed the temperature range was marked as obtaining a temperature of 160 degrees F. A review of the undated facility policy titled 'Dish Machine Temperature Log' , directs that staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. It further directs the food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures. It outlines the temperatures for a 'High Temperature Dishwasher' as a wash cycle obtaining 150-165 degrees F and a final rinse temperature for sanitization as 180 degrees F. On 3/29/22 at 10:30 AM, a joint review was conducted with the DM of the red cleaning buckets filled with Multi-QUAT (sanitizing solution). The product is used for the 3-compartment sink sanitizing of large cookware and to refill and replenish buckets of sanitizer for staff to utilize on food contact surfaces and equipment. Testing of the bucket revealed a measurement of 150 ppm. The ECOLAB signage posted over the wash sinks, instructs the user to monitor the solution with a test strip. The test strip indicates a color change when dipped into the solution, to indicate if the solution meets the required range of 150-400 ppm (parts per million) for safe and effective sanitizing. The DM acknowledged this documentation of testing for proper sanitizing levels of product is not documented or monitored on any log, throughout the day. On 3/29/22 at 11:00 AM, an interview with the DM, stated they have never documented the dishmachine temperatures more than once daily, and typically this occurs at the breakfast meal She stated they have never documented the ppm of the Multi-QUAT solution used to sanitize food surfaces and equipment. Stated she believed the kitchen in the assisted living facility did utilize a log that documents those processes. The DM acknowledged a log documenting the dishmachine operating temperatures after each meal and the monitoring of the sanitizing solution strength, would demonstrate safe practices for the kitchen. Stated she plans to implement the new log this week.

Based on clinical record review, observation, staff interview, and resident interview, the facility failed to treat a resident in a respectful, dignified manner during wound care (Resident #14). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS revealed the resident required the extensive physical assistance of 2 persons for transfers, bed mobility and personal hygiene. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan last revised on 2/16/22 showed Resident #14 deficit in activities of daily living (ADL) due to a right ankle fracture, and a wound to the right ankle from a past surgical procedure. The Care Plan informed staff the resident was non-weight bearing and required a hoyer lift for transfers. The Treatment Record dated March 2022 showed Staff I, Registered Nurse (RN), performed dressing changes to Resident #14's right ankle on 3/19/222 and 3/20/22. In an interview on 3/30/22 at 11:30 AM, Staff F, Certified Nursing Assistant (CNA), explained Staff I changed the right ankle dressing of Resident #14 while she sat on the bedpan. When Staff I lifted the resident's leg, the resident responded, ouch. I can lift my leg if you can wait for me to get off the bedpan. Then without warning Staff I released the resident's leg and allowed it to drop onto the bed. Staff I then told the resident, stop whining. I have a job to do. In an interview on 4/4/22 at 9:18 AM, Resident #14 stated, I was on the bedpan when Staff I started to change the bandage. Everyone knew I could lift my own leg but she just grabbed it. It hurt so bad. I told her that I could lift my leg, then she just dropped it, told me to stop being a [NAME]. The Respect and Dignity Policy dated 4/7/22 documented the resident has the right to be treated with respect and dignity including the following: The right to treat each resident with respect and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident individuality.The facility must protect and promote the rights of the residents. In an interview on 4/6/22 at 3:40 PM, the Administrator voiced he expected all employees to treat residents with absolute respect and dignity. The Administrator added this employee or any other employee that is disrespectful or would bring harm of any kind does not belong at this facility.

Based on record review and staff interview, the facility failed to notify the family of a fall for 1 of 4 residents reviewed (Resident #32). The facility reported a census of 30 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 scored 8 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required supervision for transfer and walking in the corridor, limited assistance with toilet use, and personal hygiene, and independent with ambulation in the room. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Notes dated 2/26/21 at 4:02 p.m. documented the Nurse was called to the resident's room by housekeeping. The resident sat on the floor, with her feet directly in front of her and her back leaning against her recliner. Staff faxed the Physician and informed the family. The residents Clinical Resident Profile listed three family member contacts. The Progress Notes dated 7/26/21 at 11:58 a.m. documented the Nurse was called to the resident's room by a Certified Nursing Assistant (CNA). The resident laid on the floor on her back with her legs straight out in front of her. The resident stated she walked to the bath room in a hurry when she lost her balance and fell backwards. She stated she did hit her head but it did not hurt. She did have pain in her mid back. Neuros and vitals were assessed and within normal limits (WNL). No open wounds were noted. The resident did state having pain in her mid back but okay. The resident assisted to a standing position with 2 and a gait belt with out incident. The resident denied pain once brought to a standing position. Reminded the resident to take her time when walking. Staff notified the Physician, and the resident was her own power of attorney (POA) and she understood the situation. The clinical record lacked any documentation the facility notified the family of the fall. On 3/30/22 at 9:13 a.m. the resident's family member stated the facility did not notify them of the fall. She thought they should have notified them of that. On 4/6/22 at 8:24 a.m. the Director of Nursing (DON) stated she thought the resident was her own POA and didn't want her family notified. She did not know if they had any documentation. She did not know when that stopped. The facility policy reviewed and updated 11/9/18 regarding Condition Changes/Managing directed the licensed nurse would notify the Physician and the family or responsible party .

Based on clinical record review, observation, staff interview, and resident interview, the facility failed to follow policy and protocol when staff failed to report allegations of misconduct to responsible parties. The facility also failed to follow investigative protocols when allegations were reported for 1 out 3 residents reviewed (Resident #4). Findings: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS revealed the resident required no assistance for transfers, bed mobility and dressing and eating. The resident required setup assistance and the help of one staff member for toilet use and personal hygiene. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 3/30/22 at 9:37 AM, Resident #4 stated Staff A, Certified Nurses Aide (CNA), asked to borrow $40 because she was broke. Resident #4 further stated, I never did see it back. It happened late last winter. In an interview on 3/30/22 at 10:55 AM, the Director of Nursing (DON), reported the facility did not conduct an investigation that involved an employee asking residents for money. In an interview on 4/4/22 at 1:50 PM, Staff J, Certified Nurses Aide (CNA), stated Resident #4 told me that he borrowed money to Staff A last year. She commented, I don't know how much. I don't remember if I reported it. In an interview on 4/4/22 at 1:51 PM, Staff G, Certified Nurses Aide (CNA), stated Resident #4 told me that he borrowed Staff A money. She stated, I had already heard about it and thought everyone knew so I didn't report it. It was a while ago. In an interview on 4/4/22 at 3:27 PM, the Administrator stated, I had no knowledge of any employee that loaned money from residents. Nothing was reported to me otherwise I would have followed up. I take that kind of thing seriously whether it is employee to resident or resident to resident. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy (undated) documented all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. In an interview on 4/6/22 at 3:44 PM, the Administrator stated he expected employees to follow policy and immediately report allegations. We will reeducate everyone on reporting abuse. 2. In an interview on 3/30/22 at 9:37 AM, Resident #4 stated, the kitchen staff poured water on my head. The resident explained, she said it was a joke, but I thought it was inappropriate. I'm very jumpy and used to have seizures. She would poke my ribs too. I asked her to stop, but she didn't. I moved places, so she couldn't do it so easily. Resident #4 stated, the kitchen staff tell me they are joking and having fun but it feels like they're picking on me. I reported it but as far as I know nothing was done. In an interview on 3/30/22 at 10:55 AM, the DON reported that she knew of this incident. The DON stated, Resident #4 likes to joke. His personality changes. One minute he will joke with the girls and the next he doesn't like it. I didn't take it further than that.The DON failed to initiate an investigation. In an interview on 3/30/22 at 12:51 PM, the Dietary Supervisor stated, yeah I dripped water on Resident #4's head. I did it. I dripped 2 drops and then wiped it off. The Dietary Supervisor explained, Resident #4 told others and thought it was funny, but then about 5-7 days later he reported it. He didn't eat in the dining room for a month after that. The Nursing Facility Abuse Prevention, Idenfiication, Investigation and Reporting Policy (undated) instructed should an incident of suspected resident abuse be reported or observed, the Administrator or he/her will designate a member of management to investigate the alleged incident. In an interview on 4/6/22 at 3:46 PM, the Administrator stated that he expected the DON to initiate an investigation when she became aware that Resident #4 felt the interaction with staff was no longer a joke.

Based on record review and staff interview, the facility failed to notify the resident or their representative of the bed hold option for 1 out of 2 residents reviewed for hospitalization s (Resident #1). The facility reported a census of 31 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] for Resident #1 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Nurse's Progress Note dated 2/20/22 documented the resident was transported to the emergency room and returned to the facility on [DATE], was transported to the doctor's office on 3/3/22 and returned to the facility on [DATE]. Documentation of notification of resident or their representative regarding the bed hold policy was absent from the resident's health record. The Bed Hold and Transfer Notice, undated documented upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative will provide information concerning our bed hold policy. When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed hold policy within 24 hours of such transfer. In an interview on 4/4/22 at 10:48 AM, the Director of Clinical Services stated the bed hold notifications did not get done. The same Nurse worked both times the bed hold notifications needed to be done, she didn't know she was supposed to do them. In an interview on 4/6/22 at 3:36 PM, the Administrator stated he expected employees to follow policy and that bed hold notifications should be completed as required.

Based on observation, record review and staff interview, the facility failed to assure care plan interventions were in place to prevent 1 resident from falling (Resident #24) and failed to provide adequate supervision to prevent 2 residents from having altercations (Resident #10 and #31), 5 residents reviewed. The facility reported a census of 30 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #24 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident's diagnoses included [CONDITION(S)] and diabetes. The current Care Plan identified the resident at risk for falls due to general weakness dated 2/10/20. The interventions included the resident had a tab alarm to be on at all times due to falls and self transferring for the resident's safety, initiated 10/14/21. The Progress Notes dated 12/1/21 at 4:03 p.m. documented a housekeeper called the nurse to the resident's room because she heard him fall to the floor. When the nurse entered the room, the resident laid on his right side face down, next to the dresser, with blood coming out of his nose and forehead. After cleaning the resident's face noted a skin tear to his forehead measuring 1.5 centimeters and the bridge of his nose measuring 1 centimeter. He also had an abrasion on the right side area measuring 5.5 centimeters by 4.5 centimeters. The right greater knuckle looked swollen and bruised but the resident denied pain and could move it without issues . The resident complained of his face hurting but no other pain. He moved all extremities within normal limits per his usual. He received acetaminophen for a headache. The resident's family member called and notified and requested he be sent to the emergency room (ER). The intervention initiated at the time of the fall: staff and resident education, the alarm not on at the time of the fall. On 3/31/22 at 3:22 p.m. the resident sat in the wheelchair with the personal alarm attached to the back of his shirt. On 4/4/22 at 9:04 a.m. the Director of Nursing (DON) stated if the resident's Care Plan called for an alarm it should have been on at the time of the incident on 12/1/21. On 4/6/22 at 8:24 a.m. the DON stated all staff working the afternoon of 12/1/21 were written up because the resident did not have the alarm on. 2) According to the MDS assessment dated [DATE] Resident #10 had long and short term memory impairment and severely impaired skills for daily decision making. The resident exibited no behaviors. The resident required limited assistance for ambulation and locomotion. The resident's diagnoses included senile dementia of the brain and a cerebral vascular accident (stroke). According to the MDS assessment dated [DATE] Resident #10 scored 00 on the BIMS indicating severe cognitive impairment. The resident exibited no behaviors. The resident required extensive assistance for ambulation and locomotion. The Care Plan revised 4/22/21 identified the resident had confusion due to dementia. The resident got restless and had difficulty sleeping. The interventions included heart, hands, health (HHH) program instructions located inside of the resident's closet, he enjoyed using the fidget blanket and tool sensory board, visiting with his wife on the phone, watching the Hallmark Channel, CMT and Smokie and the Bandit movies. He preferred quiet settings/individual activities. He usually declined group activitivities. They monitored his behavior and redirected as needed. The Progress Notes dated 9/16/21 at 9:52 a.m. documented the nurse on the phone heard Resident #31 yelling out. The nurse turned around and saw Resident #10 had ahold of Resident #31's wrist.The nurse immediately directed the Certified Medication Aide (CMA) to separate the resident's from each other. The Progress Notes dated 9/16/21 at 4:58 p.m. documented the nurse in the copy room heard Resident #31 scream. She ran out of copy room to see Resident #10 backed up by a CNA in his wheelchair. Resident #31 said he deserved that. The CNA explained she saw Resident #10 had a hold of Resident #31's wrists. Resident #31 stepped back and open handedly smacked Resident #10 in the face. Resident #31 believed Resident #10 was her husband. She often tried to talk to him, and he was not very verbal and it caused her to become very upset. Resident #10 became very upset when Resident #31 touched him as he knew she was not his wife and it made him uncomfortable. The Progress Notes dated 10/1/21 at 3:10 p.m. documented the nurse heard Resident #31 yelling, and the nurse rushed around the desk to the TV room to see what was going on. Upon getting to Resident #10 and Resident #31 a CNA had also ran to see and had already separated them. The nurse asked Resident #10 where Resident #31 grabbed him and he said his neck. The nurse completed a full head to toe assessment of the resident and obtained vital signs. No new skin areas noted and the resident denied any pain. The Progress Notes dated 10/7/21 at 1:29 p.m. documented the nurse called the resident's wife and informed her of another episode in the dining room, between Resident #10 and another resident. The other female resident, who believed Resident #10 was her husband, grabbed his wrist and started yelling that he was hitting her. Resident #10 never laid a hand on her and a CNA witnessed the episode. There were no injuries to either party. The Progress Notes dated 11/25/21 at 12:11 p.m. documented Resident #10 grabbed Resident #31 by the wrist as she walked past. Resident #10 then squeezed and tried to turn Resident #31's wrist in attempt to harm her. They have had incidents in the past where she believed he was her husband. This caused him to be fearful of her. The residents were separated immediately. 3) According to the MDS assessment dated [DATE] Resident #31 scored 4 on the BIMS indicating moderate cognitive impairment. The resident ambulated independently. The resident's diagnoses included non-Alzheimer's dementia. The resident exibited behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 to 3 days. The identified symptoms significantly disrupted care or the living environment, impacting others. Wandering occured daily but did not significantly intrude on the privacy or activities of others. The Care Plan initiated 9/15/21 identified the resident had Alzheimer's and delusions. She often thought others were her family. She had a history of wandering without clothing on and had physical aggression towards another resident in the past, with a goal of trying not to hit, undress or hug/touch other residents that she thought were her family. Interventions included assisting the resident with dressing as needed, she liked to feel helpful, please set her up with a folding towel activity, assembling snacks , and she also had a baby doll that she liked to take care of. Offer the resident activities that she can do on her own or in small groups, and occupational therapy to evaluate and treat with a heart hands health program. Tell the resident your name and that you were going to take care of her, the resident had an admission to hope harbor for behaviors and family was looking looking into moving her into an Alzheimer's unit. Redirect with reminiscing, remind the resident that her family was not in the building when she searched for them and assist with using the phone to call her family. When the resident showed signs of aggression give one to one and assist her to another area away from others and offer an activity. The Progress Notes dated 9/16/21 at 9:52 a.m. documented the nurse on the phone heard heard a resident yelling out. The nurse turned around and saw that Resident #10 had ahold of Resident #31's wrist. The nurse immediately directed the Certified Medication Aide (CMA) to separate the resident's from each other. (Staff) performed a full skin assessment, and no skin conditions noted related to the incident. The Progress Notes dated 9/16/21 at 4:58 p.m. documented the nurse in the copy room heard Resident #31 scream. She ran out of copy room to see Resident #10 being backed up by a CNA in his wheelchair. Resident #31 said he deserved that.The CNA explained she saw Resident #10 had ahold of Resident #31's wrists. Resident #31 stepped back and open handedly smacked Resident #10 in the face. Resident #31 believed Resident #10 was her husband. She often tried to talk to him. Resident #10 was not very verbal and this caused Resident #31 to become very upset. Resident #10 became very upset when Resident #31 touched him because he knew she was not his wife and it made him uncomfortable. The Progress Notes dated 10/1/21 at 3:10 p.m. documented the nurse heard Resident #31 yelling, and rushed around the desk to the TV room to see what was going on. Upon getting to Resident #10 and Resident #31, a CNA had also ran to see what was going on and had already separated them. The Progress Notes dated 10/7/21 at 2:35 p.m. documented a CNA in the dining room witnessed Resident #31 grab Resident #10's wrist and started yelling that he was hitting her. It was witnessed that Resident #10 did not lay a hand on Resident #31. The resident's were separated immediately and the male resident was taken to the Administrator's office, as he was afraid of Resident #31. The Progress notes dated 11/25/21 at 1 p.m. documented the nurse was in the TV area talking with two residents. She heard Resident #31 scream out in pain. She looked up to see CNA's separating Resident #10 and #31. Upon speaking with the CNA's they said Resident #31 walked by Resident #10 and he got a mean look on his face and reached out and grabbed her hand and squeezed. Resident #31 had a small bruise present (0.5x 0.4 cm) on her dorsal hand,unsure if related or not. On 4/4/22 at 9:48 a.m. Staff C Certified Nursing Assistant (CNA) stated that Resident #31 thought Resident #10 was her husband. One time she called him sweetie and he wouldn't talk to her so she roll up a newspaper and said she would whack him in the back of the head. Staff C stopped this and redirected Resident #31 away. She said this happened before the first altercation they had. She said one of the interventions was that they would not be in the same room. So Resident #31 sat in the small dining room and Resident #10 sat in the large dining room and they didn't walk them in or out or go in and out where they would be in close proximity to each other. Resident #10 was very uncomfortable when Resident #31 would try to talk to him or get close to him. They tried to keep them separated. Resident #10 started staying in his room more and sitting in his recliner, and Resident #31 continued to wander. On 4/4/22 at 9:56 a.m. the Care Plan Coordinator (CPC) stated she updated the care plans when info came in. She never witnessed any of the events between Resident #10 and Resident #31. She did look at the care plan and was not sure when it was updated but on 10/25 she found one intervention on the care plan but she could not find any others. So she could not say what specific interventions were put in place. She could see that the care plan was revised on 12/10 but also cancelled on 12/10. She did say that Resident #31 was aggressive toward her spouse at home prior to coming into the facility, and that Resident #31 and Resident #10 knew each other before the home. The CPC stated that sometimes if she could see that Resident #31 was exit seeking or restless she would have her come in and visit with her and reminisce, and that would keep her occupied for some time. On 4/4/22 at 10:51 a.m. the Activity Director (AD) stated she averted an interaction right after the resident returned from the hospital stay. She said they had to have someone with Resident #31 if she was out and about and Resident #10 was also out. She said Resident #31 could walk quite fast so she could get to Resident #10 quickly. She said for awhile after Resident #31 returned from the hospital she wasn't walking as well and required assistance of two. She said one of the interventions they did was they both couldn't come out to the same activity they would ask Resident #31 and if she didn't want to come then they would ask Resident #10. If Resident #31 wanted to come out they would ask Resident #10 to come to the later activity. She said she thought that intervention initiated sometime before Halloween so sometime in October. On 4/4/22 at 11:13 a.m. the Administrator stated Resident #31 would visit in his office. Shee had a baby doll that they would give to her and that would take up some of her time. He said they tried to keep the two residents separated. He would bring the other resident in his office he did not like the sound of Resident #31's voice, it agitated him. He the MDS Coordinator, the Quality Assurance nurse, and the DON discussed it and decided they had to do some kind of an intervention, and that was sending her somewhere. The other resident was in a wheelchair and Resident #31 was freely mobile throughout the facility. They did the hearts, hand, health program through occupational therapy as one thing they tried. He said if they didn't get it documented on the care plan the interventions we're a priority, not getting it written down somewhere. Resident #31 transferred to a facility that had a dementia unit. On 4/4/22 at 11:39 a.m. Staff F CNA stated she saw Resident #31 and Resident #10 going to have an altercation and someone intervened and stopped it. They started putting Resident #10 in his recliner in his room instead of in the TV room. They observed the residents to try and assure that they weren't in a position that they could have an altercation. The other resident would come out to the TV room when Resident #31 was gone. Staff F didn't see any of the altercations herself. She said the other resident was kind of grabby anyway. They tried to keep Resident #31 busy. On 4/4/22 at 11:47 a.m. Staff G CNA stated once she saw Resident #31 smack the other resident with her hand and she also had seen the other resident pinch Resident #31's hand on another occasion. She said one of the things they would do would be to keep the other resident in his room and they would keep a close eye on the residents when they were both out of their room. On 4/4/22 at 11:56 a.m. Staff D CNA stated Resident #31 would go up to Resident #10 and one or the other would get aggressive. Resident #31 slapped Resident #10 at least two times. Some of the younger staff would put them too close together and not realize the problems that they'd have. She would say no they cannot be together. They took Resident #10 to his room instead of the TV room to sit in his recliner, so that Resident #31 wouldn't see him out there and start something. She said Resident #31 didn't seem to care if he sat out in the TV room or sat in his room. They put him in the TV room if there's something going on and he couldn't sleep, then he wouldn't miss it. The facility policy Care Plan Frequent Update reviewed and updated 11/9/18 documented the resident care plan would be updated whenever there was a change in the plan of care. The process included whenever a change in physician orders and or nursing interventions occurred the care plan would be reviewed. The care plan would be reviewed to determine which section of the care plan addressed the concern and or problem that the change affected. The update/change to the care plan would be communicated to appropriate staff.

Based on record review and staff interview, the facility failed to assure staff treated each resident with respect and dignity and cared for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 12 on the Brief Interview for Mental Status (BIMS) indicating some cognitive impairment. The resident had behavioral symptoms not directed toward others, daily. The resident depended on staff for transfer and locomotion. The current Care Plan revised 10/30/14 identified the resident had [MEDICAL CONDITIONS] disorder and dementia which could affect thought processes. The interventions included the resident followed by psyche for behavioral treatment/management. Behaviors managed well with 1 to 1 visits with staff. Staff used TLC, 1 to 1, etc . for behavior, inappropriate comments, etc . If staff had problems redirecting or managing they were to refer to the social worker, designee, charge nurse or Director of Nursing (DON). The resident often yelled out for help in addition to using the call light. Staff reminded her she didn't need to yell and she did not always know what she wanted. The Care Plan identified the resident had a level 2 Preadmission Screening and Record Review (PASRR) related to mental illness initiated 6/22/16. The interventions included the resident had a tendency to yell for help, and to please remain calm when she did this initiated 3/15/19. The Care Plan identified the resident's behaviors included screaming for help instead of using the call light. The interventions included approaching in a calm caring manner, if the resident angry or critical of others, do not react in a way that escalated her behavior. Please watch words and tone of voice, initiated 5/31/17. During an interview on 10/14/20 at 2:17 p.m. Staff B Certified Nursing Assistant (CNA) stated on 5/16/20 after lunch someone took the resident to her room and gave her the call light. She could hear the resident calling out for help. Staff B stated Staff C CNA walked by and said let's go help the resident. Staff B stated she had been talking to someone, and when she arrived at the room, Staff C talked to the resident, telling her she should not yell like that. They were transferring the resident in the total mechanical lift when Staff C called the resident a fat, lazy, piece of[***] Staff B stated she hoped the resident had not heard that. After they got her in bed, they were preparing to remove the lift sling when Staff C ripped it out from behind her back. Staff B thought it hurt the resident because she reacted and tried to hit when Staff C did this. During an interview on 10/15/20 at 9:31 a.m. Staff D Housekeeping stated on 5/16/20 she worked across the hall when she heard Staff C called the resident fat and said all she did was eat. She said Staff B had left the room. She said when Staff C left the resident's room she slammed the door. Staff D stated she had heard Staff C being unkind to another resident before. A typed report documented the Administrator received a call at 8:30 a.m. on 5/17/20 about an incident. He went to the facility and talked with Staff B. At 12:50 p.m. he talked with the resident and asked if Staff C had said anything mean to her. The resident said Staff C was always mean to her, but did not remember exactly what she said, but she told her before she needed to go on a diet. The Administrator had the nurse do a head to toe assessment and no new injuries were noted. The Administrator called Staff C at 4:15 p.m. and informed her she would no longer be an employee of the facility. During an interview on 10/15/20 at 8:20 a.m. Staff E Registered Nurse (RN) stated Staff C could get short tempered, but she never witnessed anything she thought abusive. She said Staff C worked a lot, they called her in constantly. Staff C had 1 day a week off. She worked too much. She said the resident did not like Staff C, so Staff C could not be in the room unless she had another staff member with her. That last day she worked (5/16/20) Staff C chose to assist with the resident instead of letting the other 2 CNA's do it. During an interview on 10/15/20 at 12:30 p.m. the resident stated she never liked Staff C, but she didn't recall what she said to her. She said Staff C treated her roughly 1 time and she never liked her after that. She could not elaborate. During an interview on 10/15/20 at 1:30 p.m. Staff F CNA stated she worked Staff C's last day (5/16/20). She stated she did hear Staff C yelling in another resident's room, but could not make out the words. When Staff C came out of the room she said I can't even with him anymore. Staff F said Staff C was loud and had an attitude with staff. She had been talked to about it. Staff F said the resident did not like Staff C, citing she was a [***] to her and too rough. During an interview on 10/15/20 at 9:57 a.m. the Administrator (at the time of the incident) stated he received a message he should come in and talk to some staff. He interviewed Staff B and felt if what she said was accurate it would be verbal abuse. He also talked with Staff D who also heard Staff C say something inappropriate. The resident stated Staff C was mean to her. He felt they had enough corroboration to terminate Staff C. The Administrator thought Staff C may be burnt out, working 6 or 7 days a week and had another part time job. He had talked to her previously about being rude to staff several times. He said a previous housekeeper had reported something about another resident and Staff C's approach, and he talked to Staff C about it.

Based on observation, record review, and staff interview, the facility failed to provide privacy during personal care for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 12 on the Brief Interview for Mental Status (BIMS) indicating some cognitive impairment. The resident required extensive assistance with toilet use and personal hygiene. The resident had an indwelling urinary catheter and an ostomy (for bowel), and [DIAGNOSES REDACTED]. During an observation on 10/19/20 at 9:32 a.m. Staff A Certified Nursing Assistant obtained a basin with water and washcloths and brought to the bedside and placed on the resident's bedside table. Staff pulled the resident's incontinent pad back and exposed the genital area. The door to the resident's room remained wide open. Staff A used a washcloth from the basin to wipe the resident's lower abdomen and bilateral groins. Staff A put the same washcloth back in the basin, wrung it out and used it to clean the genital area, including the catheter insertion site. Staff A asked the resident to roll to his left and washed his buttocks with a different washcloth from the basin. Another staff member closed the resident's door. During an interview on 10/19/20 at 9:58 a.m. Staff A confirmed she had not closed the door to the room prior to providing care for the resident. During an interview on 10/19/20 at 2:30 p.m. the Director of Nursing stated closing the door to the room when providing care was basic protocol. The Infection Preventionist stated another staff member had reported to her about Staff A leaving the door open when providing care. The Infection Control Manual revised 5/24/17 regarding Catheter Care directed to provide privacy.

Based on observation, record review, and staff interview, the facility failed to provide appropriate infection control practices including the removal of gloves when contaminated, before touching non-contaminated and environmental surfaces, and performing hand hygiene when indicated for 2 of 4 residents reviewed (Resident #2 and #3) to mitigate the risk of the spread of infection during a Covid-19 outbreak. The facility reported a census of 32 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 12 on the Brief Interview for Mental Status (BIMS) indicating some cognitive impairment. The resident required extensive assistance with toilet use and personal hygiene. The resident had an indwelling urinary catheter and an ostomy (for bowel), and [DIAGNOSES REDACTED]. The resident's orders record showed the resident received treatment for [REDACTED]. a.[MEDICATION NAME] 500 mg by mouth two times a day for UTI for 14 Days initiated 4/7/20 and completed 4/21/20. b. [MEDICATION NAME] Capsule 10 mg by mouth two times a day for complicated [MEDICATION NAME] (type of UTI) for 10 Days initiated 5/15/20 and completed 5/25/20. c.[MEDICATION NAME] 500 mg 1 tablet by mouth two times a day for UTI for 14 days initiated 8/5/20 and completed 8/19/20. d. [MEDICATION NAME] inject 1 gram intramuscularly (IM) for UTI 8/5/20. e. [MEDICATION NAME] inject 1 gram for UTI for 1 Day 8/25/20. f. Bactrim DS Tablet 800-160 mg 1 tablet by mouth two times a day for acute [MEDICATION NAME] for 10 days until finished initiated 9/24/20 and completeed 10/4/20. The current Care Plan identified the resident with history of UTI initiated 4/8/20. Interventions included monitoring/documenting/reporting to the physician as needed (PRN) for signs/symptoms of UTI. The Care Plan identified the resident diagnosed with [REDACTED]. The interventions included housekeeping deep cleaned the resident's room daily. The resident would be allowed to wander per usual, but staff to assist him with frequent handwashing. The resident's laundry red bagged. The resident's urine contained in catheter bag, bowel contained in my colotomy bag. Staff education and education of the resident on importance of hand hygiene, sanitation and contact precautions. When emptying the resident's catheter and [MEDICAL CONDITION], staff to performe high level of sanitation of toilet and all areas of high touch. During an observation on 10/19/20 at 9:32 a.m. Staff A Certified Nursing Assistant donned gown, gloves and shoe covers to enter the resident's room. Staff A already wore a mask and shield. Staff obtained a basin with water and washcloths, brought to the bedside and placed on the resident's bedside table. Staff pulled the resident's pullup back and exposed the genital area. Staff A used a washcloth from the basin to wipe the resident's lower abdomen and bilateral groins. Staff A put the same washcloth back in the basin, wrung it out and used it to clean the genital area, including the catheter insertion site. Staff asked the resident to roll to his left and washed his buttocks with a different washcloth from the basin. Staff A went to the bathroom wearing the same gloves and obtained a new incontinent pad and placed it. She then went to the bathroom and obtained barrier cream (wearing the same contaminated gloves) and wore the same gloves while applying to the resident's groins, fastened the incontinent pad, and pulled up his pants. Staff obtained a graduate still wearing the same gloves and placed it on the floor under the catheter bag without a barrier. She had her left knee on the floor and got up placing her left gloved hand directly on the floor. She looked for more alcohol wipes and called on the walkie for someone to bring them. She got down on her knee again and started opening the catheter drain, when staff knocked on the door. Staff A got up touching the floor with her closed gloved hand. After receiving the alcohol wipes she went back and emptied the catheter bag in the graduate, handling the catheter bag and drain with both gloved hands. When finished emptying the graduate she gathered the garbage and wascloths and placed in red bags, removed PPE including gloves, and placed them in a receptacle by the inside of the door. She walked across the hall to the utility room, went inside, then did hand hygiene with alcohol based hand rub (ABHR) from the dispenser on the wall. During an interview on 10/19/20 at 9:58 a.m. Staff A confirmed she did not change her gloves (at any time) while providing care for the resident. During an interview on 10/19/20 at 2:30 p.m. the Director of Nursing stated staff should use a new cloth, not put the (used) cloth back in the water and wring it out. She said gloves should be removed after providing incontinent care with hand hygiene, and staff should assure clean gloves when emptying the catheter. The facility Infection Control Manual revised 5/24/17 regarding Standard Precautions directed washing hands after touching blood, body fluids, secretions and contaminated items, whether or not gloves were worn, after gloves were removed, between resident contacts and any other time necessary, such as between tasks or procedures on the same resident. Glove use included wearing gloves when touching blood, body fluids, secretions, excretions and contaminated items, putting on clean gloves just before touching mucous membranes and non-intact skin, and removing gloves promptly after use and before touching non-contaminated and environmental surfaces. According to the Centers for Disease Control (CDC) and Prevention multiple opportunities for hand hygiene may occur during a single care episode. The clinical indications for hand hygiene included immediately after glove removal. The CDC document reads: Always clean your hands after removing gloves. Dirty gloves can soil hands. It is important to change your gloves if moving from contaminated body site to clean body site. 2) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with toilet use and personal hygiene. The resident had occasional bladder incontinence. [DIAGNOSES REDACTED]. During an observation on 10/19/20 at 12:10 p.m. Resident #3 was sitting on the toliet, Staff A put a gaitbelt around the residents waist and assisted her to stand. Wearing gloves, Staff A used a washcloth from a wash basin and cleansed the resident front then back and removed gloves. She pulled up the resident's incontinent pad and pants with no hand hygiene, then pulled her mask back to talk to the resident, and did not perform hand hygiene. She assisted the resident to her recliner and made her comfortable before she performed hand hygiene. During an interview on 10/19/20 at 3:10 p.m. the DON stated staff should not expose their mouth or nose when talking to a resident, and should wash their hands after touching their mask. The CDC Strategies for Optimizing the Supply of Facemask's revised 6/28/20 documented the extended use of facemask's is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters. HCP should take care not to touch their facemask. If touched or adjusted they must immediately perform hand hygiene.

Based on record review and staff interview, the facility failed to resubmit for Preadmission Screening and Resident Review (PASRR) when a a resident remained in the facility beyond a convalescent stay for 1 of 3 residents reviewed (Resident #19). The facility reported a census of 27 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #19 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's [DIAGNOSES REDACTED]. A Notice of PASRR Convalescent Approval dated 12/10/19 documented the resident could be admitted to a Medicaid certified nursing home for up to 60 calendar days. If the stay went beyond 60 calendar days, a facility representative must submit a status change level 1 to Ascend. A PASRR resident review would be required. The report documented a limited approval. The facility must submit a status change level 1 if residence in the facility expected to extend longer than the number of approved days and no later than 5 days before the conclusion of the approved stay. The rationale included should more than the approved days be needed the nursing facility must submit a status change to Ascend 7 days prior to the end (2/8/20) of the authorization and a level 2 would be initiated. The current Care Plan initiated 12/18/19, identified the resident had a 60 day Convalescence Approval. If not discharged by 2-8-19, the nursing home must submit a new PASRR at least one week prior to expiration of authorization. The goals included the convalescence approvals were time limited so the nursing facility would work with the resident to ensure that rehabilitative and recovery goals were met and submit a new PASRR prior to expiration of the exemption if not ready for discharge by that time. During an interview on 2/12/20 at 10:01 a.m. the MDS Coordinator stated they did not resubmit for level 2 when they were aware the resident would stay beyond the 60 day convalescent stay.

Based on clinical record review, observation, resident interview, and staff interview, the facility failed to complete restorative maintenance programs as recommended by the therapy department for 2 of 3 residents reviewed with restorative programs (Resident #17 and #18). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 17 identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required limited staff assistance for ADL's (activities of daily living), without range of motion (ROM) impairment,and had a history of [REDACTED]. The resident's Care Plan revealed the resident had an ADL deficit due to poor balance and frequent falls and directed staff to encourage and assist with a restorative nursing program, date started 8/14/19. A Restorative Nursing Program, dated 8/19/19, directed staff to walk with the resident 2 to 3 times daily and to provide lower body exercises 1 to 3 times a week that included the Nustep for 10 to 15 minutes, standing hip flexion and marching, hip abduction and extension, and squats. The Nursing Rehab sheet for January 2020 revealed the resident received restorative service 1 time on 1/4/20. The Nursing Rehab sheet for February 2020 revealed the resident received restorative service 1 time on 2/9/20 between 2/1/20 and 2/12/20. During an interview on 2/12/20 at 9:27 a.m., Staff D, CNA (Certified Nursing ssistant)/Restorative Aide, stated she worked at the facility on Tuesdays, Wednesdays, Saturdays, and Sundays. Staff D stated the resident had refused restorative services a few days when ill, restorative not completed on 2/5/20 due to a therapy evaluation done that day, the resident refused on 1/29/20. Staff D stated no other CNA's assisting residents with restorative at this time. During an interview on 2/12/20 at 2:36 p.m., the DON (Director of Nursing) verified no lower body restorative program provided to the resident before January of 2020. The DON stated the resident received restorative exercises twice in January 2020 and 1 time in February 2020. The DON state the previous restorative aide left last summer and the CNA's instructed to provide restorative services when time allowed. During an interview on 2/13/20 at 8:55 a.m. the DON stated the December 2019 Nursing Rehab sheet lacked an area for staff to document the lower body exercises and staff added the lower body exercises to the January 2020 rehab sheet. The DON stated the peddler the resident had in her room was there for the resident to use on her own, with staff assistance to help get her feet in the pedals with the straps. During an interview on 2/13/20 at 9:30 a.m., the contracted PTA (Physical Therapy Assistant) stated 3 days a week was the minimum goal for restorative services frequency. The PTA stated she she had a leave of absence when the resident's program written for 1 to 3 days a week and the 1 day minimum may have been a way to get the resident started on a restorative exercise program. During an interview on 2/13/20 at 9:50 a.m., the resident stated she had not done lower body exercises in January and February 2020 because the staff had not had time. 2. The MDS assessment dated [DATE], documented Resident #18 with a BIMS of 15 indicating intact cognition. The resident required total staff assistance for ADL's, unable to walk, and had bilateral upper and lower body range of motion impairment. The resident's [DIAGNOSES REDACTED]. The resident's Care Plan documented the resident had an ADL deficit, required the assistance of 2 staff for cares, and directed staff to assist with a maintenance nursing program as directed, start date 1/10/20. A Restorative Nursing Program program, dated 1/11/20, directed staff to provide the resident with passive upper and lower body range of motion exercises, 15 repetitions, 2 to 5 days weekly. The resident's record lacked a restorative nursing sheet for January 2020. A February 2020 rehab sheet revealed the resident had not received any restorative services in February through 2/12/20. During an interview on 2/12/20 at 12:26 p.m., Staff D, restorative aide, stated she had not started the resident's restorative program yet, had completed range of motion exercises with the resident 1 time and the resident enjoyed the exercises. During an interview on 2/12/20 at 2:40 p.m., the DON stated Staff D said the resident had refused restorative exercises the last 3 times offered and Staff D had not documented the refusal.

Based on observation, record review and staff interview, the facility failed to provide appropriate incontinent care to prevent infections for 1 of 4 residents reviewed (Resident #25). The facility reported a census of 27 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #25 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with toilet use and personal hygiene. The resident had frequent urine incontinence, and [DIAGNOSES REDACTED]. The Progress Notes dated 12/1/19 at 3:07 p.m. documented the resident stated increasing pain to her lower abdomen, with urine cloudy, dark in color, and odorous. The resident yelled out in pain when voiding. The MAR for December 2019 showed the resident received antibiotic 12/3-10/19 for UTI. The Progress Notes dated 1/9/20 at 12:56 p.m. documented the resident experienced pain and pressure with the start of voiding and at the end of voiding. The resident had urinary frequency and yelled out. The resident's urine appeared cloudy, dark in color, and odorous. The MAR for January 2020 showed the resident received antibiotic for UTI 1/10-21/20 indicating the (1/15/20 MDS inaccurately reflected the resident's infection status). The current Care Plan initiated 8/6/16, identified the resident with an activity of daily living (ADL) deficit due to forgetfulness. The interventions included the resident needed assistance of 1 to 2 with toileting, peri care, and dressing. The Care Plan lacked identification of the resident's history of UTI's. During an observation on 2/11/20 at 7:10 a.m. Staff B, Certified Nursing Assistant (CNA) and the MDS Coordinator took the resident to the shower/tub room. Staff transferred the resident with the sit to stand lift to the toilet. Staff had washcloths in the sink and partially filled with water. Staff B removed the washcloths and washed her hands in the sink. She refilled the sink with water and put a washcloth and disposable cloths in the sink. While (the cloths) were in the sink the MDS Coordinator rinsed the resident's glasses (over the sink) to clean them. Then staff used the cloths and washcloth for perineal care. Staff B wiped the resident under her abdominal folds while she sat on the toilet. Staff raised the resident with the mechanical lift and Staff B wiped with a disposable cloth with return of bowel movement (bm) 4 times, each time with a new cloth. Staff B then took a washcloth wearing the same gloves and wiped in the genital area, folding the cloth several times and wiping. During an interview on 2/12/20 at 7:20 a.m. Staff B stated she had the washcloths in the sink the previous day. She admitted they should not put the washcloths in the sink. She confirmed the previous day after she cleaned the anal area (of bm) with disposable wipes she used a blue washcloth and reached through the residents legs to wipe the genital area. During an interview on 2/12/20 at 3:45 p.m. the Infection Control Nurse stated after cleaning a resident of bm, she would expect staff to change gloves and perform hand hygiene before cleaning the genital area. She would expect staff to place washcloths in a basin rather than the sink if using them for the resident's hygiene.

Based on record review, observation, interviews with staff & resident, and policy review, the failed to provide adequate nursing supervision to protect 2 of 11 residents from injury/physical environmental hazards. (Residents #4 & #3) The facility identified a census of 34 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 15 which indicated intact cognition. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The care plan dated 12/28/16 directed staff to do the following due to risk for injury for very fragile leg skin: a. A pad placed along the frame of my bed to help protect legs from injury. b. Educated to take care when motating in room to avoid bumping self on furniture and nursing stand in room repositioned. c. Educated to take care when rubbing and itching at self to prevent skin areas. d. Follow provider orders with care of legs and overall skin. e. Educated to pay attention to clean and dry areas well and soft cloths provided. f. Staff changed shoes worn. g. Educated to lotion extremities well to maximize elasticity-refuses geri arms. h. Ace wraps to lower legs to help decrease/prevent edema. i. Educated by the dietary manager on the importance of extra protein at meals, please remind and encourage extra protein intake at meals as allows. j. Educated to move with care and to try to wear sturdy footwear whenever possible. k. Instructed to pay attention to what she is doing to prevent trauma. l. Juven per dietitians orders, m. Notify medical doctor if any concern regarding skin arise. Review of the Fall Risk assessment dated [DATE] revealed the resident had a score of 15 which indicated the resident a moderate risk for falls. Review of the Points Of Care dated 11/14/17 posted in the resident's bathroom directed staff to do the following: a. Use bed pan for toileting and use a turn sheet under her to turn her only. Do not roll her from side to side using your hands. Review of the MAR dated 11/1/17 through 11/30/17 revealed the resident received Coumadin 5 mg (milligram) daily 11/1/17 through 11/5/17. Review of the Physician/Nursing Communications dated 11/6/17 revealed the resident's INR was 6.4. The order revealed to hold Coumadin 2 days and then restart at 4 mg (milligrams) daily. a.) Review of the Progress Notes dated 11/8/17 at 12:05 AM regarding the 11/7/17 incident revealed 2 CNAs were in the residents room attempting to take her to the toilet. The resident had the belt one for use with the EZ- stand lift. The CNAs were attempting to lift the resident up in the lift when 1 of them said blood had been dripping onto the stand from the left leg. This nurse walked into the room with the treatments for her legs as the CNAs lowered her back into the wheelchair. Staff lifted the pant leg to see an approximate 5 to 6 inch, deep skin tear to the outer left calf that had been squirting blood out and direct pressure had been applied using a blue towel. The CNA held pressure while the nurse went to the medication room to get bandage supplies to bandage the wound. A decision made to have the resident go to the hospital due to continued bleeding and 911 called at 9:12 PM. At 9:20 PM family notified. At 9:25 PM the ambulance arrived at the facility and transported the resident to the hospital at 9:40 PM. The resident returned to the facility at 11:40 PM and stated she wound start telling staff to make sure and take her foot pedals off the wheelchair before they try and move her. The resident's leg rubbed up against the top of the foot peddle where it connected to the chair and caused the skin tear. Orders included: change dressing daily, Bacitracin, Telfa and pressure dressing times 7 days. An INR at the hospital had been 5.5. Coumadin on hold due to past Coumadin readings. No incident report presented for the incident on 11/7/17. Review of the ED (emergency department) note dated 11/7/17 revealed the resident presented with a lower extremity left skin avulsion. The injury occurred when the resident struck her leg on the furniture. A pressure dressing with Bacitracin and Telfa applied and orders to dress daily until healed. The area measured 7 cm (centimeter) linear avulsion separated by 2 cm gap. The depth less than 2 mm (millimeters). During an interview with Staff O, CNA on 11/16/17 at 10:30 AM she stated she assisted the resident to transfer with another CNA (11/7/17). She further stated they forgot to take the wheelchair pedals off the wheelchair. The resident mentioned it as they were lifting her. They saw a large amount of blood and lowered her back to the wheelchair. The resident did not have the ace wraps on due to she just had a bath. Staff tried to stop the bleeding and the nurse called 911. b. ) Review of the Incident report dated 11/8/17 revealed the nurse called to the resident's room. The resident lying on the floor with wheelchair tipped on her, legs in footrest. A large pool of blood had been under her legs. Staff put towels under and around the leg and applied pressure and bleeding appeared to stop. Staff placed a pillow under her head and noticed a large bump on her forehead. The resident alert and oriented the entire time. Review of the Progress Notes dated 11/8/17 at 9:03 PM revealed the skin note at 9:03 PM the nurse called to the resident's room. The resident had been lying on the floor with the wheelchair tipped on her and the legs were in the foot rests. A large pool of blood had been gathering under her leg. Staff were unable to see where the blood had been coming from. Staff placed towels under and around the leg to apply pressure and the bleeding appeared to stop. Staff placed a pillow under her head and noted a large bump on her forehead. The resident remained alert and oriented through out. The ambulance called due to the blood loss and head injury. The resident transported to the emergency room at approximately 9:50 PM. Review of the ED Note dated 11/8/17 revealed the resident fell at the facility. She had been waiting to get assistance to void and lost her balance. The following injuries identified: a. Yesterday's laceration about 4 cm long, not bleeding. 14 cm by 7 cm oval skin tear, not bleeding over left knee, no depth, basically a second degree burn. b. 7 cm laceration, linear, mid left shin, transversely oriented. c. 7 cm laceration, linear, anterior proximal right thigh, transversely oriented. d. 14 cm by 7 cm gaping laceration, deep with large defect, over right knee, not to periosteum but close to bone depth. No joint exposed. e. Large hematoma above the right eye on the forehead measured 8 cm by 3.5 cm. f. Left ankle bruising, swelling. During the hospitalization the resident received blood transfusion and underwent surgical repair of lacerations. During an interview with Staff H, CNA on 11/15/17 at 11:30 AM she stated she had worked on 11/8/17 and had been on break around 6:30 to 7:00 PM. She went to break around 6:30 PM to 7:00 PM and the nurse called for assistance for another resident outside. She went to assist. Staff M went to assist and had told Staff H the resident had used the call light and asked to use the restroom and she had told her she could not with 1 staff and she would have to wait. Staff M stayed with the other resident and I stayed on the floor to answer call lights. She saw the resident's light come on and had forgotten she had it on earlier to request toileting so went to the room right away. She found the resident on the floor on her stomach and the call light string by her hand. Blood had been slowly running on the floor. The wheelchair had been tipped forward and both pedals were under her shins. Her calves were holding the wheelchair up so it did not fall on her. She called for assistance and slid a pillow under her head. The nurse tried to find the bleeding spot to apply pressure. She further stated only 2 CNAs and 1 nurse on duty and normally have 3 CNAs. Additional Interviews: During an interview with Resident # 4 on 11/15/17 at 12:00 p.m., she reported waiting for staff to come help her and stated it took staff forever. Resident #4 reported 1 hour must have passed and the next thing she knew, she was on the floor. During an interview with the ER Physician on 11/28/17 at 110 AM she stated the resident had so many wounds and had been seen in the ER the night(11/7/17) before for a wound you have to ask why. She stated she had a concern of the communication and never had a report of the etiology of the wounds. The facility only reported a fall and this had not been a simple fall. She has a concern with the facilities process. During an interview with the resident's Physician on 12/1/17 at 11:30 AM he stated the resident had risk factors prior to the accident of age, fragile skin and on Coumadin. She now has skin failure and on hospice. There is still a chance for the wounds to heal but now the resident bed ridden and continues to have the risk factors. Review of the Major Injury Determination Form dated 11/15/17 revealed the Physician believed the injury sustained is a major injury pursuant to the Iowa Administrative Code. During an interview with Staff M, CNA on 11/16/17 at 6:00 AM she stated she assisted with a transfer using the EZ stand lift (11/7/17). She stated 1 wheelchair pedal had still been on and must have caught the residents leg. They saw bleed and stopped immediately. She grabbed a washcloth and applied pressure. She continued to applied pressure until the EMTs came. The other CNA had stated it should be OK to leave the wheelchair pedal on. She further stated she was on duty on 11/8/17. She assisted another resident that had gone out the front door and into Assisted living. She heard a call for the residents room and ran to the resident's room. The resident had been face down on the floor. Staff placed a pillow under her head and her legs were tangled in the wheelchair pedals. She helped get the wheelchair out and the resident had been bleeding. They could not see the injuries. She stayed with the resident and talked to her until the ambulance came and they then rolled her onto a sling. The ambulance personnel cut the resident's pants off and she saw the injuries. She further stated the resident had put the call light on to toilet and she had told her she had to go get some help. She did not know how long it had been prior to the fall. During an interview with Staff P, RN on 11/16/17 at 2:00 PM she stated she heard the resident's call light so went in to do the treatment to the leg (11/7/17). She walked into her room and she was bleeding and in the EZ stand and staff were putting her back into the wheelchair. She pulled up the pant leg and she was bleeding all over. She had the CNA put pressure on the area and went to get bandage supplies. After pressure applied, it still did not stop and she sent the resident to the hospital. She did see the wheelchair pedals on during the transfer. She further stated wheelchair pedals should be taken off prior to transfers. She stated the resident had told her she the CNAs had told her it would be fine to leave the pedals on. Observation on 11/15/17 at revealed Staff I, CNA and Staff F, CNA assisted the resident with toilet use. Staff assisted the resident onto the bed pan. No turn sheet under the resident to assist in turning. An incontinent pad had been under the resident but out of reach for staff. Staff handled the resident to assist turning to her side and placed their hands on the resident's shirt and unclothed hip. Staff did use the palm of their hands when handling the resident. 2. According to the MDS (minimum data set) dated 8/30/17 Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 11 which indicated moderate cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers and toilet use and limited assistance with ambulation. The MDS identified the resident had 1 fall with no injury since the prior assessment. The care plan updated on 9/22/17 to include string on alarm shortened to allow it to activate in the event the attempt to self transfer. The care plan did not include personal alarm prior to 9/22/17. The fall risk assessment dated [DATE] revealed the resident had a total score of 18 which indicated a high risk for falls. Review of the incident report dated 9/22/17 revealed the Activities Director yelled down the hallway for help. The resident in the bathroom and lowered to the floor per staff. Alarm attached and call light within reach. The resident had proper footwear on and moved all extremities times 4 with no injury noted. The resident transferred with the assist of 3 and Hoyer lift. Review of the Hospital History of Present Illness report dated 9/22/17 revealed the resident had a right distal fibular fracture, closed, minimally displaced. The resident admitted for a urinary tract infection. Review of the Major Injury Determination Form dated 9/22/17 revealed the injury sustained is not a major injury. Review of the Progress Notes dated 9/22/17 at 11:40 AM revealed staff arrived in the resident's room quickly after Activities director summoned for help. The resident had been squatting in the corner of the bathroom with both feet angled under her buttocks not touching the floor. The resident had been holding onto the railing angled from the corners of the bathroom. Her alarm was on and intact. Staff attempted to lift her but unable and lowered her to the ground. The resident had complaints of pain in the right ankle/foot area. A reddened area noted on the right elbow and turned ankle to staff. The resident stretched out to allow her legs to stretch. The pained facial expressions and noises subsided and she indicated she was no longer having discomfort. The resident assisted into her wheelchair by a Hoyer lift with 3 staff. The resident choose to go to the dining room for lunch. No facial grimacing noted and no longer moaning. On 9/23/17 at 2:38 PM staff documented the resident returned to the facility at 11:30 AM via wheelchair van with staff driver. Review of the medical record revealed the facility failed to document further assessment of the resident following the fall or transfer to the facility. During an interview with the Activity Director on 11/15/17 at 10:10 AM she stated she had been in her office and the resident's roommate told her the resident needed help. She went to the residents room and the resident in the bathroom holding on to the bar and her left leg turned under her. She yelled for help and staff came to the room. She went to get more help and the Hoyer lift. At some time, after noon, she saw the resident in her recliner and she denied pain. When she saw the resident the alarm box had been on the resident's wheelchair and the string remained in tact clipped to her clothing. The alarm had a long string and did not activate to sound. During an interview with the Nurse Manager on 11/15/17 at 8:30 AM she stated she went to the resident's room and the resident had been lowered to the floor. She complained of general discomfort and her body was sore. The transferred the resident to the wheelchair and staff administered Tylenol with the noon medications. The resident then ate lunch. During an interview with Staff G, CNA (certified nursing assistant) on 11/15/17 at 10:45 AM she stated she went to the residents room and she had been in the bathroom holding onto the bar. The resident had been way down, to her knees and her right ankle twisted under her. They tried to lift her but were unable and lowered her to the floor. She did not complain of ankle pain. The transferred her to the wheelchair with a lift. The alarm box still on the wheelchair and intact. She further stated she had seen the resident transfer before and the string just long enough to not activate sound. Review of the Policy and Procedure titled Fall Risk Assessment and Prevention dated 2/20/16 directed staff to do the following: a. During resident assessment, the fall risk will be determined, If resident's risk is high, resident considered at risk for falls. b. After fall risk determined, the nurse will review resident's condition and put appropriate interventions into place and update the care plan. c. The care plan will be monitored for effectiveness of interventions and changes will be made as deemed necessary/or reviewed and updated at least every quarter. d. The resident/family will be included as part of the care plan process. e. Resident's at risk will be identified, so staff are aware of the increased need for monitoring. f. Falls/Incident reports will be reviewed in the Quality Assurance Meeting. g. All facility staff will be educated and responsibilities of responding to high risk residents as needed.

Based on observation, record review, staff interviews and review of policy/procedures, the facility failed to provide adequate supervision and proper transfer techniques in order to ensure against hazards from self and failed to direct the nursing care and services so the resident ' s needs are met (Resident #1, #3). The sample consisted of 4 residents and the facility reported a census of 32 residents. Findings include: 1. Resident #1 had an annual Minimum Data Set (MDS) assessment, with a reference date of 09/18/13, which reflected the resident had a Brief Interview for Mental Status (BIMS) score of 3. A score of 3 identified Resident #1 had a severe cognitive impairment. Resident #1 required extensive assistance with activities of daily living (ADL's) including transfer, toilet use and personal hygiene. Resident #1 demonstrated unsteadiness and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, moving on and off the toilet, and surface to surface transfer. The Comprehensive Care Plan dated 11/28/11 identified Resident #1 with a problem with falls and mobility, unsafe to walk by him/herself and fell in the past. The interventions directed to staff to perform the following: a. Resident #1 needed a staff member, a gait belt, and his /her 4 wheeled walkers to assist with ambulation. b. Resident #1 used a pad alarm in his/her wheelchair, recliner, and bed at all times (pad alarm has a pad that the resident sits or lays on and connects by cord to a box where it can be turned on/off, and alarms when pressure is taken off the pad). c. Keep the alarm box out of Resident #1's reach. d. Tabs alarm at all times, dated 10/23/13 (Tabs alarm is a pull string alarm; with the clip attached to the residents clothing, and when the magnet pulls from the alarm box the alarm sounds). An Incident/Accident Report dated 10/23/13 at 2:05 p.m. documented the resident ' s call light activated and the CNA (certified nursing assistant) responded. Resident #1 noted on the floor on his/her knees picking up cookies. A walker sat next to Resident #1. The report reflected Resident #1 used an alarm and it sounded. Changes to the care plan included a Tabs alarm on at all times. An Incident/Accident Report dated 11/08/13 at 2:45 p.m. documented Resident #1 found on the floor. Staff took vital signs and assessed Resident #1. Resident #1 was transferred to the emergency room . The Fall Investigation dated 11/08/13 at 2:45 p.m. documented Resident #1 ' s alarm not on/or functioning. The report documented the seat alarm did not sound (no mention of the Tabs alarm). The Nurse's Notes dated 11/08/13 at 2:45 p.m. documented the nurse walked by Resident #1's room and heard him/her yelling for help. The nurse found Resident #1 on the floor on his/her back. The seat alarm was on, but the batteries were dead, so it did not sound (no mention of the Tabs alarm). Resident #1 would not move his/her right leg and yelled he/she hurt everywhere. The Nurse ' s Notes dated 11/8/13 at 3:20 p.m. reflected the ambulance arrived and transferred the resident to the hospital emergency room . At 4:45 p.m. the facility telephoned the hospital for an update to the resident ' s condition. The hospital emergency room staff informed the facility the resident had a fractured hip and wrist and would be admitted . A Radiology Report dated 11/08/13 documented Resident #1 had comminuted (small pieces) fracture of the distal left radius (forearm) with dorsal impaction, and an ulnar styloid process fracture (wrist). Resident #1 also had a slightly distracted intertrochanteric fracture of the proximal left femur (hip). A hospital Discharge Summary dated 11/13/13 documented Resident #1 presented after a fall with a minimally displaced intertrochanteric fracture as well as a left distal radius fracture. Resident #1 was on Coumadin (anticoagulant) and received Vitamin K to bring the blood clotting level down to 1.5. Resident #1 went to the operating room on 11/10/13 for fixation of the left hip fracture. Resident #1's radius treated in just a cock-up wrist splint. Resident #1 not a strong candidate for rehabilitation due to his/her minimal ambulation status. A fax dated 11/20/13 notified the physician Resident #1 had a lot of pain not controlled well with Tramadol. The physician responded with new orders to increase the as needed Tramadol. A Physical therapy Plan of Care dated 11/14/13 documented (the physician) referred the resident to therapy following a recent total hip replacement. Therapy necessary for muscle weakness, inability to ambulate, inability to transfer, and inability to complete bed mobility. Resident #1 previously required supervision with bed mobility and transfer, and currently dependent for the same. The Occupational Therapy Plan of Care dated 11/14/13 documented the resident underwent [REDACTED]. The plan reflected occupational therapy as necessary for the resident to return to the prior level of function. During an observation dated 12/03/13 at 10:05 a.m. staff transferred Resident #1 from the wheelchair to the bed with the Hoyer (mechanical) lift. Resident #1 voiced for staff to hurry up, it hurt. In a written statement dated 11/09/13 Staff C Certified Nursing Assistant (CNA) wrote right after Resident #1 got finished with lunch she took him/her back to his/her bathroom. She unhooked the Tabs alarm and shut off the seat alarm, after it started to go off (sound). When finished, Staff C put Resident #1 in his/her recliner with the seat alarm on. The seat alarm beeped (sounded) when Resident #1 sat on it. Staff C clipped the Tabs alarm to the back of his/her right arm/shoulder. Staff C completed cares between 12:00 and 12:30 p.m. During an interview on 12/03/13 at 9:40 a.m. Staff C Certified Nursing Assistant (CNA) demonstrated how Resident #1 sat in the recliner (the day of the fall) with the Tabs alarm (box) to Resident #1's right and back out of reach, with the clip hooked to his/her right shoulder. She stated the pad alarm in the recliner beeped (sounded) when Resident #1 sat down. Staff C put Resident #1's feet up. Staff C stated Resident #1 could put the feet down, and the chair remote was located in a bag on the right side of the chair. Staff C put the call light to Resident #1's wrist via the flexible wrist band. Staff C stated Resident #1 sitting in the recliner a normal routine. She covered Resident #1 with a blanket. Staff C stated when they did walking rounds a little before 2:00 p.m. Resident #1 still sat in the recliner, but could not remember if awake. She said they toileted before and after meals and activities and bedtime. She said she assisted Resident #1 after lunch between 12:00 and 12:30 p.m. that day. During an interview on 12/04/13 at 12:30 p.m. Staff K Licensed Practical Nurse (LPN) stated she worked the day Resident #1 fell , starting at 2:00 p.m. and fairly new to the facility. She did not visualize Resident #1 prior to the fall that day. She walked down the hall when she heard Resident #1 call for help. Resident #1 laid close to his/her roommate ' s dresser, 5-10 feet from his/her recliner. Staff K stated Resident #1 toileted at 2:00 p.m. because he/she normally toileted before the change of shift (not that she knew it occurred). Staff K stated Resident #1 could remove the clip of the Tabs alarm him/herself. She didn't know what they did if a resident did that (removed the alarm); she was so new to the facility. Staff K stated no alarms sounded alerting them to Resident #1 getting up. Staff K agreed removal of the clip by the resident made the alarm ineffective and they needed to do something else. During an interview on 12/03/13 at 10:42 a.m. Staff D LPN stated he responded after Resident #1 fell , probably the 3rd nurse to get to the room. Resident #1 laid with his/her head closer to the roommate ' s dresser with his/her feet toward the recliner. He said the (privacy) curtain was pulled back so you could see the recliner from the dresser. He said the pad alarm sat in the recliner, the Tabs alarm on the stand with the string lying across the arm of the chair, and the call light laying across the other arm. He said Resident #1 would take the wrist bracelet off, but not aware he/she took the clip alarm off before. He said he checked the pad alarm and the batteries were dead. During an interview on 12/03/13 at 1:17 p.m. Staff F Registered Nurse (RN) stated Staff K found Resident #1 so she went to assist. The recliner foot rest was down. The walker was upright in front of Resident #1. She saw Resident #1 had external rotation of the leg. Resident #1 stated trying to go to the bathroom and complained of pain. Staff F did not see Resident #1 between 12:00 p.m. and the fall and not aware of anyone toileting him/her after noon. She stated she thought Resident #1 toileted frequently, every 1 to 1-1/2 hours prior to the fall. Staff F stated she never saw Resident #1 take the Tabs alarm off before. During an interview on 12/03/13 at 1:25 p.m. Staff B CNA stated Resident #1 would have toileted after lunch. Staff B stated Resident #1 had his/her call light on between 12:00 and 2:00 p.m. and thought it was time to get up. They did not get him/her up at that time. Staff B stated Resident #1 had removed the clip of the Tabs alarm before. She reported to the charge nurse and they started putting it further back instead of the shoulder. During an interview on 12/03/13 at 1:35 p.m. Staff A CNA stated she worked the day Resident #1 fell , doing baths. She did not see Resident #1. She said Resident #1 used the call light sometimes, but did not always know why he/she pulled it. Staff A stated Resident #1 would remove the clip of the Tabs alarm before the day he/she fell . She said they would clip it back on. She thought the charge staff knew this. During an interview on 12/03/13 at 1:54 p.m. Staff I, CNA stated the day Resident #1 fell she clocked in about 1:53 p.m. She stated they did rounds where they walked through the halls and the previous shift shared information on the residents. She saw Resident #1 sitting in his/her recliner when they walked by on rounds. Staff I stated she did not do anything with Resident #1 prior to the fall. Staff I stated normally Resident #1 would put his/her light on if he/she needed something. Staff I stated they answered lights and got people out to activities. They had not gotten to Resident #1 that day. Staff I stated Resident #1 had removed the clip from the Tabs alarm prior to that day and they would just clip it back on. During an interview on 12/03/13 at 2:02 p.m. Staff G CNA stated she came on at 2:00 p.m. the day Resident #1 fell . She did not think she did rounds down Resident #1's hall and didn't think she saw him/her prior to the fall. Staff G stated Resident #1 did remove the clip from the Tabs alarm frequently. Staff put it back on. She didn't think she reported it to the charge nurse, she may have mentioned it. She agreed it was not very effective if Resident #1 kept removing it, but stated he/she had the 2nd alarm. During an interview on 12/03/13 at 2:26 p.m. Staff H CNA stated she worked 2-10 the day Resident #1 fell . She did not think she saw Resident #1 before the fall. She sat with Resident #1 after the fall to keep him/her calm while waiting for the ambulance. She heard after the fall, Resident #1 removed the Tabs clip frequently him/herself before the fall. Staff H stated she was aware Resident #1 was capable of it, but never witnessed it herself. If she had, she would have told the charge nurse so they could change to a different clip. She thought Resident #1 toileted pretty often, every 2 hours or around there. 2) According to the Minimum Data Set (MDS) assessment with a reference date of 11/13/13, Resident #3 scored 8 on the Brief Interview for Mental Status (BIMS). A score of 8 identified a cognitive impairment. Resident #3 required extensive assistance with activities of daily living (ADL's) including transfer, toilet use and personal hygiene. The Comprehensive Care Plan dated 08/28/13 identified Resident #3 with a risk of falls and included the following approaches: a. 10/21/13 pivot transfer with assist of 1-2 at all times. b. 10/24/13 Assist of 2 with transfers/ambulation. c. 12/02/13 Hoyer lift for all transfers. Resident #3 demonstrated the following fall history per facility Incident/Accident Reports: a. 09/24/13 at 8:00 p.m. the nurse got called to Resident #3's room by the Certified Nursing assistant (CNA not identified). The nurse noted Resident #3 on the floor on his/her knees next to the bed. Resident #3 became weak and the CNA lowered him/her to the floor. The changes to the care plan included a physical therapy evaluation for transfers. b. 10/12/13 at 12:30 p.m. Resident #3 found on the floor of the bathroom. Resident #3 attempted to self-transfer from the wheelchair to the toilet. The changes to the care plan included a seat alarm at all times when in the wheelchair and recliner. c. 10/21/13 at 7:10 p.m. during transfer from the wheelchair to the bathroom, Resident #3's legs became weak and staff lowered him/her to the floor. The changes to the care plan included transfer Resident #3 with assist of 1 or 2 (staff) at all times. A Fall Investigation dated 10/21/13 and reviewed by the Director of Nursing on 10/24/13 reflected additional changes to the care plan of Assist of 2 (staff persons)for transfers and ambulation. An Incident/Accident Report dated 11/06/13 at 8:15 a.m. documented a CNA transferred Resident #3 from the wheelchair to the recliner and stated Resident #3's legs gave out and he/she lowered to the floor with the unidentified CNA's assist (the care plan directed 2 assist with transfers/ambulation). A Rehab Communication form dated 12/02/13 documented Physical Therapy recommended Resident #3 use the Hoyer (mechanical) lift for functional transfers due to the high level of assistance needed to decrease fall risk and caregiver burden. During an observation on 12/03/13 at 9:08 a.m. Staff A CNA and Staff B CNA transferred Resident #3 with a gait belt to the wheelchair. They pushed Resident #3 to the bathroom, assisted him/her to stand and transferred the resident to the toilet. After finished in the bathroom, Staff A and Staff B transferred Resident #3 with the gait belt back to the recliner (the care plan directed Hoyer lift for all transfers). During an interview on 12/03/13 at 1:35 p.m. Staff A CNA stated she did not know Resident #3 needed to transfer by the lift. The facility Falls Assessment Policy and Protocol dated 02/01/13 documented the purpose included the implementation of interventions to prevent or reduce the incidence of further falls. After assessing the resident and identifying potential causes of falls, specific interventions to manage falls would be identified on the care plan. Staff would be updated of the changes.

Based on observation, record review and staff interview, the facility failed to assure a resident with pressure sores received the necessary treatment and services to promote healing and prevent new sores from developing for 1 of 2 Residents reviewed (Resident #4). The facility identified a census of 35 residents. Findings include: A hospital transfer order dated 8/31/11, identified Resident #4 had been discharged to the nursing home following a post hip dislocation.The physician's orders [REDACTED]. The hospital transfer order revealed the current activity level limited to wheelchair or chair, and Resident #4 did not ambulate. The form indicated Resident #4 to wear a knee immobilizer when in bed. The hospital transfer order noted Resident #4 with a wound/skin area on his/her coccyx. The Admission Physicians Orders dated 08/31/11 documented Resident #4's treatments included a [MEDICATION NAME] to his/her coccyx, changed on bath days until healed, Telpha and tape to the left hip incision, changed daily until no drainage then discontinue, and Opscites to areas on left outer and inner legs and to discontinue when fall off. The orders included a question, "How long for the immobilizer?" with no answer. An initial Admission Care Plan dated 08/31/11 identified Resident #4 needed assistance of 1 or 2 staff with activities of daily living (ADL's). Resident #4 demonstrated confusion. He/she required assist of 2 for mobility and transfer, and was dependent for repositioning. Skin care indicated the use of waffle (air) boots. According to the Braden Scale dated 09/09/11, Resident #4 scored 11, indicating high risk for developing pressure ulcers. The Braden Scale reference tool recommended a list of possible interventions, not limited to any of the following: pressure reduction support surface, use foam wedge for 30 degree lateral positioning, maximal remobilization, protect heels, manage moisture, manage friction and shearing. According to the Minimum Data Set (MDS) assessment, dated 09/13/11, Resident #4 scored an 8 on the Brief interview for Mental Status (BIMS) indicating cognitive impairment. Resident #4 demonstrated dependence on staff for bed mobility, transfers, dressing and personal hygiene. During the assessment period, the resident did not walk in his/her room or corridor. Resident #4's [DIAGNOSES REDACTED]. The MDS indicated Resident #4 had 1 Stage 2 pressure ulcer. The Comprehensive Care Plan dated 09/14/11 identified Resident #4 with pressure ulcers and that he/she now had one (1) on his/her knee. The care plan approaches included: a. Check skin daily. b. Wear heel protectors when in bed c. Elevate heels off the bed with a pillow or cushion under calves. The Treatment Administration Record (TAR) dated 09/01/11 to 09/30/11 directed a left leg immobilizer to be worn when in bed. Remove immobilizer for ambulation. Staff initialed the use of the immobilizer each shift through 09/16/11, and 09/17/11 on the 7-3 shift. The TAR also directed air boots when in bed to bilateral legs dated 09/20/11 and initialed daily at hour of sleep (HS) starting 09/20/11. A Pressure Ulcer Documentation sheet revealed the following on his/her left lateral knee: on 09/12/11 a 3.2 by 1.2 cm area with a scant amount of drainage, a dark wound bed, and redness at the wound edges and surrounding tissue. A facsimile (fax) dated 09/12/11 notified the physician staff observed a pressure area to Resident #4's left lateral knee with a scant amount of drainage. Staff applied Triple Antibiotic Ointment (TAO) and Telpha. They would continue to monitor until the area healed. They requested advisement. The fax returned 2 days later "okay". The Pressure Ulcer Documentation sheet described the area on 09/14/11 as 3 by 2 cm area with a scant amount of drainage, a dark purple wound bed and red wound edges and surrounding tissue. A fax dated 09/14/11 requested orders for an ET (wound) evaluation and treatment for [REDACTED]. The Nurse's Notes dated 09/15/11 at 4:15 a.m. documented noting a fax from the physician, okay for ET (wound consult). At 11:23 a.m. a late entry for 09/14/11 at 10:05 a.m. Received and noted a signed fax related to the left lateral knee. Stated okay, no treatment given or requested. On 09/16/11 at 9:30 a.m. a CNA reported open skin to Resident #4's left ankle area. Fax to the physician and call to the family. At 11:30 a.m. placed a call to the physician's office regarding skin issues due to the immobilizer. At 12:00 p.m. received return call from the physician's office to discontinue the knee immobilizer. A Non-Pressure Skin Condition Report documented the following regarding Resident #4's left ankle: on 09/16/11, a 2 by 1 open area, surrounded by redness. A fax dated 09/16/11 notified the physician staff observed open skin to Resident #4's left ankle. Staff applied TAO and Telpha secured by tape. They would continue to monitor the area until healed. They requested advisement. The fax returned "okay". The clinical record lacked any documentation the facility assessed for the cause of the pressure to the left lateral knee at the time of its discovery or implemented new interventions to prevent the development of additional pressure sores. An ET Wound documentation sheet dated 09/20/11 documented the issue was a pressure ulcer. The left lateral knee ulcer appeared unstageable at that time. The lower left lateral knee measured 1.3 by 1 cm and the upper lateral knee measured 3 by 2 cm. The left upper lateral knee appeared 100% covered with yellow adherent slough (necrotic tissue in the process of separating from viable tissue). The lower left lateral knee showed dark red intact tissue. Resident #4's gluteal folds were pink and intact. The progress note documented a wound referral for an unstageable pressure ulcer to Resident #4's left lateral knee. Slough loosening in the ulcer. Reddened intact area noted to the left lower extremity secondary to the use of a leg immobilizer. The new orders included: a. Triad and Telpha to the left lateral knee ulcer, change daily and as needed. b. Skin prep daily for 1 week to the left lower extremity reddened area. c. Air boots when in bed to bilateral legs. A Pressure Ulcer Documentation sheet for the left lateral knee dated 09/21/11 described the area as 1.5 by 3.6 Stage II area with sero-sanguinous drainage, a dark purple wound bed, and red wound edges and surrounding tissue. On 09/27/11, a 3.6 by 1.6 Stage II area with no exudate, a black, red wound bed, and pink wound edges and surrounding tissue. According to the Non-Pressure Skin Condition Report, the left ankle area had been described on 09/23/11 as 1.4 by 1.4 cm area with light red skin with a dry scab. On 09/27/11 the area was 1 by 0.8 cm red scab with pink surrounding. An ET Wound documentation sheet dated 09/27/11 documented the issues were pressure ulcers to the left lateral knee and the left lower leg. The left lateral knee remained unstageable, and the left lower leg was a Stage 2. The left lateral knee measured 1.7 by 3 centimeters (cm) and the left lower leg measured 0.5 by 0.3 cm. The wound bed of the left lateral knee appeared 100% dark necrotic (dead) tissue, and the left lower leg showed red granular tissue. The wound nurse conducted follow up to the left lateral knee and left lower leg pressure ulcers. The ulcer to the left lateral knee deteriorated and unstageable. Resident #4 admitted to Hospice care and showed an overall decline in condition. Resident #4's ulcers were secondary to the use of the immobilizer. The left lateral knee treated with Triad and Telpha and foam to left lower leg. During an observation on 09/28/11 at 1:36 p.m. Resident #4 laid in bed on his/her back. Resident #4's pants were down around his/her lower legs and he/she did not have the waffle (air) boots on. The air boots laid on the floor at the foot of the bed. Staff B Registered Nurse (RN) performed the treatment to Resident #4's left lateral knee. During an interview on 09/28/11 at 2:17 p.m. Staff B RN stated Resident #4 had been in bed a little while before she did the treatment. During an observation on 09/29/11 at 10:33 a.m. Resident #4 laid in bed on his/her back with his/her shoes on. The air boots laid on the floor. At 11:33 a.m. Resident #4 remained in bed with his/her shoes on and the air boots on the floor. At 12:04 p.m. Resident #4 was ready to get up for lunch. He/She remained in bed with his/her shoes on and the air boots on the floor. When raising Resident #4 up off the bed with the lift he /she yelled out, so staff put him/her back down. Staff F Certified Nursing Assistant then removed Resident #4's shoes and applied the air boots. During an interview on 09/29/11 at 1:11 p.m. the Wound Nurse stated unstageable wounds are those where the necrotic tissue covers the ulcer and you cannot visualize the base of the wound. The Wound nurse stated when the necrotic tissue is debrided it could be a Stage 3 or 4 pressure ulcer. The Wound Nurse stated the air boots should be on whenever the resident was in bed, even during the day. The Wound Nurse stated Resident #4 declined and it was important to protect his/her heels. She stated Resident #4 should not wear his/her shoes in bed. During an interview on 09/29/11 at 11:20 a.m. Staff A Licensed Practical Nurse stated when she first noticed the area to Resident #4's left knee it was reddened. She put Telpha on to protect it. By the 16th Resident #4 had another area on the ankle and the knee had opened up. Staff A stated she called the doctor because they were caused by the immobilizer. According to Staff A, the physician stated to remove the immobilizer. Staff A stated they should have removed the immobilizer when they found the area on the knee. Staff A stated she called the family on the 16th when she found the 2nd area and notified them of both areas. During an interview on 09/29/11 at 10:00 a.m. the Nurse Consultant agreed the staff should have identified the cause of the pressure to the knee when the ulcer was first noted and intervened to alleviate the pressure and prevent further ulcers. During a subsequent interview on 09/29/11 at 3:04 p.m. the Nurse Consultant stated they were unable to find the facility policy regarding skin/pressure ulcers.