Every finding on record at Salem Lutheran Home

Based on observation, facility policy review, and staff interview, the facility failed to ensure food was served in a sanitary manner when the cook closed the oven door with her foot, opened the contaminated oven door with the oven mitt, picked up plates with the contaminated oven mitt, and picked up plates with a kitchen towel that had been placed on an unsanitized surface. The facility reported a census of 47 residents. Findings include: During the noon meal service observation on 8/12/2026 at approximately 12:00pm, Staff A, Dietary [NAME] did the following: a) Removed plates from the oven while wearing an oven mitt that was used to open the oven door. b) Closed the oven door with her foot and failed to sanitize the oven door handle afterward. c) Failed to sanitize the oven mitt after contact with oven door handle prior to touching plates used for resident meal service. d) Used a kitchen towel, not kept on a clean surface, to transfer the plates from a kitchen cart to the serving counter. The Hand Washing and Glove Use- Food Nutrition Service policy revised 7/14/2026 identified that employees involved in food preparation, distribution, and serving must consistently utilize good hygienic practices and techniques. During staff interview on 8/12/2026 at approximately 12:20 pm, the Dietary Manager reported that closing the oven door with her foot and grabbing plates with a towel that had been placed on a cart were not appropriate procedures and would not be considered sanitary. During staff interview on 8/12/2026 at approximately 2:30 pm, the Administrator reported that they would not expect these incidents to happen in the kitchen and agreed it could lead to unsanitary conditions or possibly be an infection control concern.

Based on clinical record review staff interview, and policy review the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications for 1 out of 5 sampled residents (Resident #5) reviewed. The facility reported a census of 47 residents.Findings include:Review of Resident #5's Minimum Data Set, dated [DATE] revealed Resident #5 admitted to the facility on [DATE] from home. The MDS further indicated that Resident #5 utilized antidepressant, and antianxiety medications during the 7 day look back period. Review of Resident #5's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Lorazepam (antianxiety medication) 0.5mg oral tablet to give 1 tablet by mouth every 2 hours related to anxiety/restlessness. The EHR page further revealed orders for Bupropion (antidepressant) oral tablet give 150mg by mouth one time a day for depression, Doxepin (antidepressant) 3mg oral tablet to give 1 tablet by mouth at bed time, Duloxetine (antidepressant) 30mg delayed release oral capsule give 2 capsules by mouth one time a day for antidepressant. Review of Resident #5's Care Plan with a revision date of 5/29/26 revealed no non-pharmalogical interventions or targeted behaviors for anxiety medications or antidepressants. Interview 8/12/26 at 9:50 AM with the Director of Nursing (DON) revealed that she would expect target behaviors, and non-pharmalogical interventions to be documented in the care plans. Review of a facility provided policy titled, Psychotropic Medications Rehab/Skilled with a revision date 12/9/25 indicated the behavior committee and/or care plan team will ensure the care plan is updated. This update will reflect non-pharmacological interventions to be used.

Based on clinical record review, interviews, and facility policy, the facility failed to notify the resident or representative of the daily cost for bed holds for 2 of 2 residents reviewed (Residents #1 and #50). The facility further failed to appropriately complete a medication reconciliation for 1 of 3 residents (Resident #52) that discharged from the facility. The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 documented an unplanned hospital discharge with an anticipated return to the facility. The Clinical Census report for Resident #50 documented the following: 5/20/26: Hospital leave 5/21/26: End hospital leave The Progress Note dated 5/20/26 at 5:19 PM for Resident #50 indicated the facility received a signed order to transfer Resident #50 to the emergency room. The Bed Hold Notice dated 5/20/26 for Resident #30 showed verbal authorization from the resident's representative but failed to specify the daily bed hold rate the representative agreed to pay. During an interview conducted on 8/13/26 at 8:02 AM, the Administrator confirmed the daily bed hold cost should be specified on the form. 2. Review of Resident #1's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. The MDS further revealed Resident #1 readmitted to the facility from a short-term general hospital stay on 6/11/26. Review of Resident #1's Electronic Healthcare Record (EHR) page titled, Progress Notes revealed an entry 6/8/26 at 2:50 PM indicating Resident #1 was admitted to the hospital for a urinary tract infection (UTI). Further review of the EHR revealed an entry 4/24/26 at 12:27 AM indicating Resident #1 was sent to the hospital for placement of a new catheter. Review of a facility provided documents titled, Notice of Bed-Hold Policy dated 4/24/26, and 6/8/26 revealed that the forms lacked the amount per day the resident or representative agreed to pay. Interview on 8/12/26 at 1:23 PM with Staff B Social Services confirmed there was no daily rate noted on the bed hold forms. Interview on 8/12/2026 at 1:28 PM with the Director of Nursing (DON) revealed that she would expect the daily rate to be on the bed hold notifications given to residents when they leave the facility for a hospital stay. 3. Review of Resident #52's MDS dated [DATE] revealed Resident #1 was admitted to the facility on [DATE] and had a planned discharge 7/1/26. Review of Resident #52's EHR page titled, Progress Notes revealed an entry dated 7/1/26 at 8:03 AM indicating Resident #52 discharged from the facility to another facility. Review of a facility provided document titled, Discharge summary dated [DATE] indicated there was no reconciliation of medications for Resident #52. Interview on 8/13/26 at 9:42 AM with the DON confirmed that the recap of stay was not completed correctly for Resident #52, and should have had the medications reconciled and documented. Review of a facility provided document titled, Bed-Hold-Rehab/Skilled with a revision date of 12/23/25 indicated the bed hold is to ensure the resident/resident representative is made aware of the facility's bed hold and reserve bed payment policy before and upon transfer. Review of another facility provided document titled, Discharge and Transfer with a revision date of 1/15/26 indicates when a resident is transferred to another skilled nursing facility the charge nurse or designated individual will complete the discharge summary.

Based on Medication Administration Record-Treatment Administration Record (MAR-TAR) review, Electronic Health Records (EHR) review, observation, policy review, and staff interviews the facility failed to ensure medication error rates are not 5 percent or greater by having a medication error rate of 16.67 percent. The facility reported a census of 47 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. Review of Resident #27's EHR titled, MAR-TAR documented a Physician's Order for lantus pen-injector to inject 55 units subcutaneously at bedtime and a Physician's Order for insulin aspart pen-injector to inject per sliding scale before meals and at bedtime.Observation on 8/11/26 at 12:52 PM of Staff C, Registered Nurse (RN) administration of insulin to Resident #27 revealed Staff C completed hand hygiene, cleanse septum of the insulin pen, dialed 6 units up into insulin pen, did not dial up 2 units for priming to ensure patency then waste, knocked on the door, cleansed right upper arm, did not apply gloves, inserted the syringe, administered the insulin, cleansed right arm where insulin was given, returned to the cart, placed needle tip into the sharps container and completed hand hygiene. 2. The MDS dated [DATE] revealed Resident #39 had a BIMS of 15 indicating no cognitive impairment. Review of Resident #39's EHR titled MAR-TAR documented a Physician's Order for a tresiba pen injector to inject 26 units once a day.Observation on 8/12/26 at 7:34 AM revealed the administration of insulin to Resident #39 by Staff C. Staff C removed blood glucose monitor for medication cart drawer, removed lancets, removed alcohol wipe, completed hand hygiene, applied gloves, cleansed insulin pen septum with an alcohol wipe, dialed up 26 units into the insulin pen, did not prime the insulin pen / did not waste 2 units to ensure patency, cleansed the area on Resident #39's left upper arm with alcohol wipe and administered 26 units in Resident #39's left upper arm. 3.The MDS dated [DATE] revealed Resident #42 had a BIMS of 13 indicating no cognitive impairment. Review of Resident #42's EHR titled MAR-TAR documented Physician's Orders for brovana nebulization solution 15 mcg/2mL give 2mL via nebulizer twice a day, pulmicort inhalation suspension 0.25mg/2mL give 1 vial inhaled twice a day and ipratropium-albuterol inhalation solution 0.5-2.5 mg/3mL give 1 vial inhaled four times a day.Observation on 8/11/26 at 12:43 PM revealed administration of nebulizer treatment to Resident #42. Staff C obtained a vial of ipratropium-albuterol from the medication cart, knocked on the door, entered the room, obtained nebulizer mask/reservoir from bedside table, nebulizer mask/reservoir about half full of clear liquid, nurse stated the nebulizer reservoir had less than what was in the currently full treatment, threw the medication away in the trash, filled the mask/reservoir with current medication and placed mask on Resident #42.On 8/11/26 at 12:44 PM Staff C Nurse asked how Resident #42 was feeling because he sounded better. Staff C stated Resident #42 had some shortness of breath and coughing that morning. Staff C stated the Staff F, Certified Medication Assistant (CMA) gave the breathing treatment that morning. Staff C stated Staff F did not tell her the medication was refused. Staff C stated she did not put the treatment on or take the treatment off that morning. Staff C explained Resident #42 could not take the mask off or hang it over on the bedside table by himself. Staff C acknowledged there was a large amount of medication left in the nebulizer reservoir when she entered the room. On 8/11/26 at 1:15 PM Staff F stated she did not give any breathing treatments that morning. Staff F stated she told Staff C she would need to give the nebulizer treatments because she had not given nebulizer treatments before. Staff F stated she did sign the ipratropium-albuterol and pulmicort in the MAR-TAR but she did not give the medications. On 8/11/26 at 1:19 PM Staff C stated Staff F had told her that morning that she would have to give the nebulizer treatments that morning. Staff C acknowledged she did not give the ipratropium-albuterol and pulmicort that morning but she did give brovana. Staff C stated Resident #42 was in bed at that time and someone else must have shut the nebulizer off. Staff C acknowledged she was supposed to give all the breathing treatment and did not.On 8/13/26 at 9:04 AM Staff E, Licensed Practical Nurse (LPN) stated she had worked at the facility for 24 years. Staff E acknowledged she did administer insulin to residents at the facility. Staff E explained she primed the insulin pen to ensure the needle was patent before administration of insulin.On 8/12/26 at 2:04 PM the Director of Nursing (DON) stated she expected the facility nurses to prime the insulin syringe with 2 units to ensure patency before administering the insulin. The DON stated the MAR should not have been signed off by Staff F and there should have been communication with the nurse and the nurse should have signed off when the medication was given. The DON stated Staff C should have ensured all of the medications were given. Review of a facility provided policy with a review date of 10/31/25 titled, Insulin Administration, Insulin Pens, Insulin Pumps documented when an insulin pen was utilized the dosage knob must be turned to 2 units to prime the pen and while holding the pen with the needle pointing upwards to press the button until at least a drop of insulin appears.

Based on observations, staff interviews, Electronic Medical Records (EHR), Medication Administration Records - Treatment Administration Records (MAR-TAR) and policy review the facility failed to ensure the residents were free of significant medication errors when nursing staff failed to prime an insulin pen to 2 of 2 residents reviewed (Resident #27 and #39). The facility reported a census of 47 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. Review of Resident #27's EHR titled, MAR-TAR documented a Physician's Order for lantus pen-injector to inject 55 units subcutaneously at bedtime and a Physician's Order for insulin aspart pen-injector to inject per sliding scale before meals and at bedtime.Observation on 8/11/26 at 12:52 PM of Staff C, Registered Nurse (RN) administration of insulin to Resident #27 revealed Staff C completed hand hygiene, cleanse septum of the insulin pen, dialed 6 units up into insulin pen, did not dial up 2 units for priming to ensure patency then waste, knocked on the door, cleansed right upper arm, did not apply gloves, inserted the syringe, administered the insulin, cleansed right arm where insulin was given, returned to the cart, placed needle tip into the sharps container and completed hand hygiene. 2. The MDS dated [DATE] revealed Resident #39 had a BIMS of 15 indicating no cognitive impairment. Review of Resident #39's EHR titled MAR-TAR documented a Physician's Order for a tresiba pen injector to inject 26 units once a day.Observation on 8/12/26 at 7:34 AM revealed the administration of insulin to Resident #39 by Staff C. Staff C removed blood glucose monitor for medication cart drawer, removed lancets, removed alcohol wipe, completed hand hygiene, applied gloves, cleansed insulin pen septum with an alcohol wipe, dialed up 26 units into the insulin pen, did not prime the insulin pen / did not waste 2 units to ensure patency, cleansed the area on Resident #39's left upper arm with alcohol wipe and administered 26 units in Resident #39's left upper arm. On 8/13/26 at 9:04 AM Staff E, Licensed Practical Nurse (LPN) stated she had worked at the facility for 24 years. Staff E acknowledged she did administer insulin to residents at the facility. Staff E explained she wore gloves for administering insulin and primed the insulin pen to ensure the needle was patent. On 8/12/26 at 2:04 PM the Director of Nursing (DON) stated she expected the facility nurses to prime the insulin syringe with 2 units to ensure patency before administering the insulin. Review of a facility provided policy reviewed 10/31/25 titled, Insulin Administration, Insulin Pens, Insulin Pumps documented when an insulin pen was utilized the dosage knob must be turned to 2 units to prime the pen and while holding the pen with the needle pointing upwards to press the button until at least a drop of insulin appears.

Based on observations, staff interviews, documents, Electronic Health Records (EHR), Medication Administration Records - Treatment Administration Records (MAR-TAR) and policy review the facility failed to ensure medications at the facility were labeled in accordance with currently accepted professional principles when insulin pens failed to be labeled with expiration date or open date on both treatment medication carts for 2 of 6 residents reviewed (Resident #16 and #27). The facility reported a census of 47 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment.Review of Resident #16's EHR titled, MAR-TAR documented a Physician's Order for tresiba pen-injector to inject 30 units subcutaneously in the morning and a Physician's Order for novolog pen-injector to inject 3 units subcutaneously twice a day.Observation on 8/13/26 at 9:20 AM of the nursing medication cart revealed Resident #16's Tresiba insulin pen with less than 100 units left and Resident #16's Novolog insulin pen with less than 100 units left. Both insulin pens revealed no open or expiration date.On 8/13/26 at 9:22 AM Staff D, Registered Nurse (RN) stated the insulin pen should have been dated when opened and should have the expiration date. 2. The MDS dated [DATE] revealed Resident #27 had a BIMS of 4 indicating severe cognitive impairment.Review of Resident #27's EHR titled, MAR-TAR documented a Physician's Order for lantus pen-injector to inject 55 units subcutaneously at bedtime and a Physician's Order for insulin aspart pen-injector to inject per sliding scale before meals and at bedtime.Observation on 8/13/26 at 9:46 AM of the Director of Nursing (DON) unlocked the treatment medication cart containing several resident's insulins. Observation revealed Resident #27's Novolog insulin pen with less than 10 units and Lantus insulin pen with less than 60 units. On 8/13/26 at 9:47 AM the DON acknowledged the insulin for Resident #27 did not have an open date or an expiration date. The DON stated the insulin should be dated with open date and expiration date. Review of a policy provided by the facility with review date of 10/31/25 titled, Insulin Administration, Insulin Pens, Insulin Pumps documented multi-dose vials should have open date written on vial. Refer to insulin storage parameters for storage times based on manufacturer recommendations. Policy documented to check the label on the vial carefully to ensure the correct type of insulin and date vial was opened.

Based on staff interview, resident interview, Electronic Health Records (EHR), Medication Administration Records - Treatment Administration Records (MAR-TAR) review, document review and policy review the facility failed to maintain medical records on a resident that were complete and accurate by failing to accurately document the staff who administered a medication for 1 of 6 residents reviewed (Resident #42) and failed to accurately document consent or declination for an immunization for 1 of 3 residents reviewed (Resident #21). The facility reported a census of 47 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. Review of Resident #42's EHR titled MAR-TAR documented Physician's Orders for brovana nebulization solution 15 mcg/2mL give 2mL via nebulizer twice a day, pulmicort inhalation suspension 0.25mg/2mL give 1 vial inhaled twice a day and ipratropium-albuterol inhalation solution 0.5-2.5 mg/3mL give 1 vial inhaled four times a day. Further review of Resident #42's MAR-TAR documented on 8/11/26 Staff F, Certified Medication Assistant (CMA)/ Certified Nurse Assistant (CNA) signed off the am dose of pulmicort and ipratropium-albuterol and Staff C, Registered Nurse (RN) had signed off the brovana. Observation on 8/11/26 at 12:43 PM revealed administration of nebulizer treatment to Resident #42. Staff C obtained a vial of ipratropium-albuterol from the medication cart, knocked on the door, entered the room, obtained nebulizer mask/reservoir from bedside table, nebulizer mask/reservoir about half full of clear liquid, nurse stated the nebulizer reservoir had less than what was in the currently full treatment, threw the medication away in the trash, filled the mask/reservoir with current medication and placed mask on Resident #42. On 8/11/26 at 12:44 PM Staff C Nurse asked how Resident #42 was feeling because he sounded better. Staff C stated Resident #42 had some shortness of breath and coughing that morning. Staff C stated the Staff F, Certified Medication Assistant (CMA) gave the breathing treatment that morning. Staff C stated Staff F did not tell her the medication was refused. Staff C stated she did not put the treatment on or take the treatment off that morning. Staff C explained Resident #42 could not take the mask off or hang it over on the bedside table by himself. Staff C acknowledged there was a large amount of medication left in the nebulizer reservoir when she entered the room. On 8/11/26 at 1:15 PM Staff F stated she did not give any breathing treatments that morning. Staff F stated she told Staff C she would need to give the nebulizer treatments because she had not given nebulizer treatments before. Staff F stated she did sign the ipratropium-albuterol and pulmicort in the MAR-TAR but she did not give the medications. On 8/11/26 at 1:19 PM Staff C stated Staff F had told her that morning that she would have to give the nebulizer treatments that morning. Staff C acknowledged she did not give the ipratropium-albuterol and pulmicort that morning but she did give brovana. Staff C stated Resident #42 was in bed at that time and someone else must have shut the nebulizer off. Staff C acknowledged she was supposed to give all the breathing treatment and did not. On 8/12/26 at 2:04 PM the Director of Nursing (DON) stated the MAR should not have been signed off by Staff F and there should have been communicated with the nurse and the nurse should have signed off when the medication was given. 2. Review of Resident #21's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. The MDS further indicated that Resident #21 was admitted to the facility on [DATE]. Interview on 8/11/26 at 11:40 AM with Resident #21 revealed that he was never offered the covid vaccine booster, and if it was offered he probably would have taken it. Review of Resident #21's EHR page titled, Progress Notes revealed an entry dated 7/29/26 at 10:54 revealed the facility received a signed order to receive Covid 19 booster and Flu vaccine if accepted. No further documentation was indicated if Resident #21 refused in the progress notes. Review of a facility provided undated document titled, Vaccine Informed Consent revealed Resident #21's signature with a hand written note of refused documented. Interview 8/11/26 at 11:48 AM with the Director of Nursing (DON) revealed that there should have been documentation if Resident #21 had declined the covid booster, and that the covid declination should have been dated when the resident signed the form to know when it was offered. Follow up interview 8/12/26 at 1:40 PM with the DON revealed that she would expect correct documentation in the records for residents when vaccines are declined or given. Review of a facility provided document titled, Legal Documentation Standards with a revision date of 2/10/25 indicated the medical record will document all facts and pertinent information. The document further indicated the record will be complete and contain all significant information.

Based on observation, Electronic Health Records (EHR) review, policy review and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a pressure ulcer, that should have been on Enhanced Barrier Precautions (EBP) for 1 of 1 reviewed (Resident #42), missed opportunities for hand hygiene when personal cares were completed for 1 of 3 reviewed (Resident #1) and failed to apply gloves to administer insulin for 1 of 2 reviewed (Resident #27). The facility reported a census of 47 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. Review of Resident #27's EHR titled, MAR-TAR documented a Physician's Order for lantus pen-injector to inject 55 units subcutaneously at bedtime and a Physician's Order for insulin aspart pen-injector to inject per sliding scale before meals and at bedtime. Observation on 8/11/26 at 12:52 PM of Staff C, Registered Nurse (RN) administration of insulin to Resident #27 revealed Staff C completed hand hygiene, cleanse septum of the insulin pen, dialed 6 units up into insulin pen, did not dial up 2 units for priming to ensure patency then waste, knocked on the door, cleansed right upper arm, did not apply gloves, inserted the syringe, administered the insulin, cleansed right arm where insulin was given, returned to the cart, placed needle tip into the sharps container and completed hand hygiene. On 8/13/26 at 9:04 AM Staff E, Licensed Practical Nurse (LPN) stated she had worked at the facility for 24 years. Staff E acknowledged she did administer insulin to residents at the facility. Staff E explained she wore gloves for administering insulin. 2. The MDS dated [DATE] revealed Resident #42 had a BIMS of 13 indicating no cognitive impairment. Review of Resident #42's EHR titled, Care Plan documented Resident #42 a stage 3 pressure ulcer to right lateral thigh initiated on 5/1/26. Review of Resident #42's EHR titled, MAR-TAR documented a Physician's Order for foam dressing to right lateral upper thigh change on bath days and as needed. Observation on 8/12/26 at 10:00 AM revealed no signage or PPE outside or inside of Resident #42's room. Observation on 8/12/26 at 10:06 AM revealed Staff C completed treatment for Resident #42's pressure ulcer. Staff C, Registered Nurse (RN) completed hand hygiene, applied gloves, did not apply a gown, removed old dressing to right lateral upper thigh, dime sized area with loss of skin, no drainage noted on previous dressing, wound cleansed with wound wash, gloves removed, hand hygiene completed, gloves applied, skin prep applied to area, foam island dressing dated, dressing applied to the area, gloves removed and hand hygiene completed. On 8/12/26 at 2:04 PM the Director of Nursing (DON) stated she would expect the nurse to wear gloves when administering insulin. On 8/13/26 at 9:04 AM Staff E, Licensed Practical Nurse (LPN) stated had worked at the facility for 24 years. Staff E explained the reasons she would wear Personal Protective Equipment (PPE) for residents with EBP was for wounds, catheter care, MDROs, if there were pressure ulcer treatments and they are open. Staff E stated there was an orange magnet that goes on the door frame and there is a station outside for PPE. Staff E stated Resident #42 does not require EBP. On 8/13/26 at 9:12 AM the DON stated Staff #42 should be on EBP related to the open wound (pressure ulcer). The DON acknowledged that there was no signage or EBP being utilized and should have been. 3. Review of Resident #1's MDS dated [DATE] indicated Resident #1 was admitted to the facility on [DATE]. The MDS further indicated that Resident #1 had a pressure ulcer. Review of Resident #1's EHR page titled, Clinical Physician Orders revealed an order to cover both areas on coccyx with a dressing to change daily and continue the current treatment for the left gluteal fold wound. Review of Resident #1's Care Plan with a revision date of 6/4/26 indicated Resident #1 requires Enhanced Barrier Precautions related to a stage 4 pressure ulcer, and suprapubic catheter. The care plan further indicated staff are to don gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, checking and changing, device care, and wound care. Observation on 8/12/26 at 10:16 AM Staff C RN completed hand hygiene outside of Resident #1's room and donned a gown and gloves. Staff C then gathered dressing supplies and opened Resident #1's door. Staff C was then observed to move Resident #1's bedside table, remove Resident #1's pants, and place a drainage pad under Resident #1. Staff C then removed Resident #1's old dressing and doffed her gloves. Staff C then reached under her gown for hand sanitizer. Staff C then proceeded to complete hand hygiene and don new gloves. Staff C was then observed to cleanse the area and pat dry with gauze. Staff C then doffed her gloves with no hand hygiene completed and donned a new pair of gloves. Staff C then completed the rest of the treatment and removed the gloves and gown. Hand hygiene was completed at the end of the treatment after doffing gloves and gown. Interview on 8/12/26 at 11:16 AM with the Director of Nursing (DON) revealed that she would expect the staff to complete proper hand hygiene as well as glove changing at the appropriate times during wound cares. Review of a facility provided policy titled, Hand Hygiene with a revision date of 6/8/26 indicated: Hand hygiene should be performed by employees: a. Before performing a clean/aseptic task b. After contact with blood or body fluids c. After removal of personal protective equipment/gloves d. After contact with a resident/patient The policy further indicated: Glove Use 1. If a task requires gloves, perform hand hygiene before donning gloves and touching the resident/patient/client. 2. Perform hand hygiene after removing gloves. Review of another facility provided policy titled, Standard, Enhanced Barrier, and Transmission-Based Precautions with a revision date of 4/30/26 indicated: a. Signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. b. Gowns and gloves should be readily available.

Based on clinical record review, staff interviews, facility document review, and policy review the facility failed to ensure that a resident was free of significant medication errors for 1 of 4 residents reviewed (Resident #1). On 4/1/26, staff failed to remove the plastic backing off of a Fentanyl (a powerful synthetic opioid) patch for which resulted in Resident #1 not receiving any medication through the patch and experiencing more pain and required an increase in the use of liquid morphine (a powerful, naturally occurring opioid analgesic derived from the opium poppy, primarily used to treat moderate to severe acute or chronic pain) medication until 4/3/26 when a new Fentanyl patch was replaced. The facility reported a census of 46 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 for which indicated severe cognitive decisions, is able to be understood and understands others, with hallucinations and delusions present along with resisting of cares. The MDS addressed the resident as substantial to maximal assistance on staff for all activities of daily living (toileting, oral and personal hygiene, and upper and lower body dressing) and pain described as frequent with intensity of a 2 out of a numeric scale of 1-10, poor prognosis with an opioid used within the last 7 days. The MDS included diagnosis of hypertension (a condition where blood force against the artery wall is consistently too high forcing the heart to work harder), diabetes mellitus, neurogenic bladder (a condition where nerve damage disrupts the communication between the brain and the bladder, resulting in a loss of bladder control), Non-Alzheimer's dementia, arthritis, anxiety and depression.The Plan of Care with a revision dated 4/5/26, documented a focus area that addresses the resident has chronic pain and is at risk for opioid overdose/complications related to opioid use-Fentanyl (a powerful synthetic opioid) 75 micrograms per hour. Interventions include, notify health care provider if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, provide resident and family with information about pain and options available for pain management and discuss and record preferences.The Progress Notes dated 4/3/26 at 4:16 PM, documented fentanyl transdermal patch 75 micrograms per hour apply patch one time a day every 2 days for pain.The Pain Level Summary dated 5/21/26, showed Resident #1 pain level (on a score of 1-10) on these dates and times for which liquid morphine was administered:4/1/26 at 00:04 AM= score of 44/1/26 at 5:27 AM= score of 44/1/26 at 7:25 AM= score of 24/1/26 at 12:00 PM= score of 34/2/26 at 00:29 AM=score of 54/2/26 at 5:11 AM= score of 54/2/26 at 12:07 PM= score of 54/2/26 at 5:36 PM= score of 74/2/26 at 11:56 PM= score of 54/3/26 at 5:38 AM=score of 5The Medication Error Report Form with date of error 4/1/26, revealed fentanyl 75 microgram patch, change every two days and that the resident response related to error was an increase in as needed morphine (a powerful, naturally occurring opioid analgesic derived from the opium poppy, primarily used to treat moderate to severe acute or chronic pain) usage.Review of the Facility Theft of Narcotic Medication with date of incident 4/3/26, revealed that at 4:16 PM, Staff E, LPN, went to replace a Fentanyl patch on Resident #1, while replacing the patch, Staff E noticed that the membrane on the old patch was not removed from the patch before it was applied to the resident. The patch was dated 4/1/26 and initialed. Since the membrane was not removed, the patch is essentially unused. No messages went out to the Administrator or the Director of Nursing regarding the incident. At 3:20 PM, it was determined that it was a Medication Error, that we need to educate the staff about the disposal of the Fentanyl patch. Statement received on 4/3/26 from Staff E, RN, had to change a Fentanyl patch on Resident #1, when taking off the old patch, it was noticed that the plastic backing was still on the Fentanyl patch that was applied to the resident with a tegaderm (a brand of transparent, sterile film dressings commonly used to act as a second skin), it was dated 4/1/26. After discovering the backing was still on the patch, Staff E, RN, reached out to Staff F, Licensed Practical Nurse (LPN) for guidance. Staff F, LPN informed Staff E, RN, to put the Fentanyl patch in an envelope and place it underneath the office door of Staff F, LPN. Education was immediately started using our policies and procedures for controlled substances and a test covering the information. Education covered counts, resident rights, medication storage, destruction of medications and not to share keys. All narcotics were counted on 4/7/26 with staff to ensure that nothing was missing. Incident will be taken to monthly quality assurance meeting for further review and recommendations. The narcotic count was never off during the count as the Fentanyl patch should have been discarded after it was taken off.The Medication Administration Record (MAR) for April 2026 documented Morphine Sulfate oral solution 20mg/mg, 0.5ml was given by mouth every 6 hours for pain. The MAR also documented an as needed (PRN) order for Morphine Sulfate oral solution 20mg/ml, 0.5ml by mouth every 1 hour as needed for pain. It was documented as given once on 4/3/26, four times on 4/4/26 and 4 times on 4/5/26. The MAR documented it was not given before this in April 2026. On 5/12/26 at 5:40 PM, Staff D, Registered Nurse (RN), confirmed and verified that the fentanyl patch that was found on 4/3/26 was not activated and that Staff D, failed to remove the plastic backing from the patch prior to applying to Resident #1 on 4/1/26.On 5/13/26 at 1:33 PM, Staff C, LPN, confirmed and verified that the fentanyl patch still had the plastic backing on when placed in the narcotic box in the locked medication room on 4/3/26.On 5/19/26 at 12:00 PM, Staff E, RN, confirmed and verified that the plastic backing was still on the fentanyl patch when it was removed from Resident #1 and was placed in the narcotic box in the locked medication room on 4/3/26.On 5/22/26 at 9:08 AM, Staff C, LPN, confirmed and verified that the primary care physician was not notified of the medication error per facility policy and procedure of the fentanyl patch not being activated on 4/3/26.On 5/22/26 at 11:22 AM, the Administrator, Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that the clinical record lacked documentation of the medication error and that the staff failed to notify the primary care physician of the medication error and it is expected that staff follow the facility policy with notifying the physician.Review of the Medication Errors with a revision dated 3/2/26, the purpose is to provide guidance in documenting and auditing medication errors. When a medication error occurs, it will be reported promptly to the attending physician, resident and or responsible party and documented. A significant medication error is one which causes the resident discomfort or jeopardizes his or her health and safety. When the resident receives an amount of medication that is great or less than the amount ordered by the physician. The Omission (medication ordered but not administered) or failure to administer an ordered dose to a resident by the time the next dose is due.

Based on clinical record review, policy and procedure review, resident and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 4 residents reviewed. (Resident #4). The facility identified a census of 46 residents.Findings include:Resident #4's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 for which indicated intact cognitive decisions, is able to be understood and understands others, and no behaviors or mood present. The MDS addressed the residents as dependent on staff for all activities of daily living (toileting hygiene, upper and lower body dressing, and personal hygiene) dependent on transfers and once in an electric wheelchair independent in the facility. The MDS included diagnosis of heart failure, hypertension (a condition where blood force against artery wall is consistently too high forcing the heart to work harder), diabetes mellitus, hemiplegia (paralysis affecting only one side of the body, caused by brain or spinal cord damage), anxiety and depression.The Care Plan with an initiated date 3/24/26, explained that the resident has a psychosocial well-being deficit of past trauma identified per trauma assessment. Interventions include, discuss residents' feelings relative to sadness, crying, isolation, assist/encourage/support resident to set realistic goals, provide assistance/supervision/support with identification of potential solutions to present problems and provide opportunities for resident and family to participate in care, assist resident to develop more appropriate methods of coping.On 5/12/26 at 4:44 PM, observed Resident #4 sitting in an electric wheelchair in her room. Dressed appropriately in slacks, and a long sleeve shirt. Resident #4 stated that Staff A, Certified Nursing Assistant (CNA), is rude, mean and disrespectful. Resident #4 went on to explain that Staff A, CNA, will throw Resident #4 call light at her and say that Resident #4 does not need to be changed and can wait. Resident #4 did not say anything to the facility Administrator or Director of Nursing due to repercussions from Staff A, CNA. Resident #4 stated that Staff A, CNA, does this type of behavior when they are alone in Resident #4's room.The Progress Notes dated 5/12/26 at 5:45 PM, late entry, documented, Administrator and Director of Nursing (DON) met with the resident on 5/12/26 at approximately 5:45 PM to discuss resident care concerns. Resident most recent BIMS score is 15. Physician notified of resident care concern. The Progress Notes dated 5/13/26 at 9:53 AM, documented Social Worker (SW) had conversation with Resident #4 regarding behaviors at night and what is triggering them. Resident #4 stated if the staff would put me to bed at a decent time. SW asked what time she is put to bed and she said 8:00-8:30 PM. SW asked what time she wanted to go to bed and Resident #4 stated 7:30 PM. SW asked if she is put to bed at 7:30 PM the behaviors would cease? Resident #4 said yes, that all she is asking. SW forwarded the information to the nurse managers.The 5 day report dated 5/16/26, documented that the Administrator and Interim DON were able to meet with Resident #4 after supper at 5:45 PM. Resident #4 stated that Staff A, CNA, yells at Resident #4, threw the call light one time, and is mean to Resident #4. Resident #4 went into a few other incidents with Staff A, CNA, not returning the water pitcher, and changes the brief too fast and does not do a good enough job. Resident #4 again, said that Staff A, CNA, is mean and Resident #4 does not trust Staff A, CNA. When asked why, Resident #4 did not mention this any other time, Resident #4 stated that she was afraid of backlash from Staff A, CNA. Resident #4 said that a scratch on the stomach was caused by a call light that was thrown at her, yet the DON looked at it and said that it was a long scratch that was scabbed over and would be almost impossible to get from a small call button. We distributed our policies on Abuse and Neglect to educate all staff and required them to sign that they understand it.On 5/19/26 at 1:45 PM, Resident #4 stated that since Staff A, CNA, has not been in the building, staff have been treating her with kindness, dignity and respect. On 5/20/26 at 1:22 PM, the facility Administrator confirmed, verified and acknowledged that the expectation of the staff is to treat all residents with dignity and respect at all times and to follow the facility policy for Resident Dignity. The Resident Dignity Policy dated 12/18/25, is that the policy is to promote care for residents in a manner and in an environment that maintains or enhances each residents dignity and respect in full recognition of his or her individuality. The purpose is to maintain the dignity of all residents, promote, encourage, support and enhance the residents self-esteem and to assist with respecting and ensuring resident rights.

Based on clinical record review, staff interview, and policy review, the facility failed to notify the physician of a pain patch that was not activated for 48 hours for 1 of 1 resident reviewed (Residents #1). The facility reported a census of 46 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 for which indicated severe cognitive decisions, is able to be understood and understands others, with hallucinations and delusions present along with resisting of cares. The MDS addressed the resident as substantial to maximal assistance on staff for all activities of daily living (toileting, oral and personal hygiene, and upper and lower body dressing) and pain described as frequent with intensity of a 2 out of a numeric scale of 1-10, and poor prognosis with an opioid used within the last 7 days. The MDS included diagnosis of hypertension (a condition where blood force against the artery wall is consistently too high forcing the heart to work harder), diabetes mellitus, neurogenic bladder (a condition where nerve damage disrupts the communication between the brain and the bladder, resulting in a loss of bladder control), Non-Alzheimer's dementia, arthritis, anxiety and depression.The Plan of Care with a revision dated 4/5/26, had a focus area that addresses the resident has chronic pain and is at risk for opioid overdose/complications related to opioid use-Fentanyl (a powerful synthetic opioid) 75 micrograms per hour. Interventions include, notify health care provider if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, provide resident and family with information about pain and options available for pain management and discuss and record preferences.The Progress Notes dated 4/3/26 at 4:16 PM, fentanyl transdermal patch 75 micrograms per hour apply patch one time a day every 2 days for pain.The Medication Error Report Form with date of error 4/1/26, revealed fentanyl 75 microgram patch, change every two days and that the resident response related to error was an increase in as needed morphine (a powerful, naturally occurring opioid analgesic derived from the opium poppy, primarily used to treat moderate to severe acute or chronic pain) usage.The review of the Progress Notes lacked documentation of the medication error and notification of the physician. On 5/12/26 at 5:40 PM, Staff D, Registered Nurse (RN), confirmed and verified that the fentanyl patch that was found on 4/3/26 was not activated and that Staff D, failed to remove the plastic backing from the patch prior to applying to Resident #1.On 5/13/26 at 1:33 PM, Staff C, Licensed Practical Nurse (LPN), confirmed and verifed that the fentanyl patch still had the plastic backing on when placed in the narcotic box in the locked medication room.On 5/19/26 at 12:00 PM, Staff E, RN, confirmed and verified that the plastic backing was still on the fentanyl patch when it was removed from Resident #1 and was placed in the narcotic box in the locked medication room.On 5/22/26 at 9:08 AM, Staff C, LPN, confirmed and verified that the primary care physician was not notified of the medication error per facility policy and procedure of the fentanyl patch not being activated on 4/3/26.On 5/22/26 at 11:22 AM, the Administrator, Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that the clinical record lacked documentation of the medication error and that the staff failed to notify the primary care physician of the medication error and it is expected that staff follow the facility policy with notifying the physician.Review of the Notification of Change with a revision dated 12/12/25, a facility must immediately inform the resident physician and notify, consistent with his or her authority, the resident representative(s) when there is: a need to alter treatment significantly-a need to discontinue or change an existing form of treatment or to commence a new form of treatment.Review of the Medication Errors with a revision dated 3/2/26, the purpose is to provide guidance in documenting and auditing medication errors. When a medication error occurs, it will be reported promptly to the attending physician, resident and or responsible party and documented.

Based on clinical record review, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations of abuse involving mistreatment, neglect, and injuries of unknown source were reported to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for 2 of 3 resident reviewed. (Resident #2 and Resident #9). The facility reported a census of 46 residents.Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognitive decisions. Resident #2 could understand others and others usually understood them. They have no behavior, mood or delirium. Resident #2 required partial to moderate assistance with all aspects of daily living (dressing, personal hygiene, transfers, oral hygiene and positioning) and no falls documented and a use of an anti-coagulant (medications that prevent blood from clotting or stop existing clots from getting larger) medication used in the last 7 days. The MDS included diagnoses of Non-Alzheimer's Dementia, muscle weakness, hypertension, (a chronic condition where blood force against artery walls is consistently too high), and repeated falls.The Care Plan Focus area revised on 3/17/26, identified that the resident is on an anti-coagulant therapy related to history of thrombosis (the formation of a blood clot inside a blood vessel, which obstructs the normal flow of blood) and emboli (detached, traveling masses,such as blood clots, air bubbles, or tumor cells, that move through the bloodstream) and has potential for skin impairment related to advancing dementia and needing more assistance with ambulation. Interventions include to identify potential causative factors and eliminate/resolve where possible. The Skin Observation tool dated 4/6/26 at 10:18 AM, documented right wrist has purple bruise measuring 2 centimeters by 1.5 centimeters. No swelling noted. No complaints of pain.On 5/20/26 at 2:02 PM, observed Resident #2 sitting in a recliner in her room, no noted purple bruise on the right wrist. Resident #2 was not able to recall an incident about a bruise to the right wrist.The clinical record lacked documentation of the investigation of the injury of unknown origin.On 5/22/26 at 12:02 PM, the facility Director of Nursing confirmed and verified that the clinical record lacked documentation of the incident with Resident #2 and that the expectation of the staff are to follow the facility procedure/policy for injuries of unknown origin. On 5/22/26 at 12:12 PM, the facility Administrator acknowledged that all staff are expected to report any allegations of abuse or injuries of unknown origin immediately and to start an investigation and that the clinical record lacked documentation of an incident report of that DIAL was notified. 2. Resident #9's MDS assessment dated [DATE], identified the resident with short and long term memory impairments with severe decision making abilities. Resident #9 could understand others and others usually understood them. They have behavior such as hallucinations and delusions, and resisting care. Resident #9 required partial to moderate assistance with dressing and supervision for oral, toileting and personal hygiene and independent in facility with ambulation and transfers with no assistive devices used and no falls documented and a use of an anti-coagulant (medications that prevent blood from clotting or stop existing clots from getting larger) medication used in the last 7 days. The MDS included diagnoses of malnutrition, anxiety and schizophrenia.The Plan of Care focus area with a revision dated 3/19/26, documented the resident is on an anticoagulant therapy related to history of pulmonary embolism (a sudden blockage in a lung artery, typically caused by a blood clot that travels from a deep vein in the legs). Interventions include to monitor/document/report bruising or sudden changes in mental status.The Skin Observation tool dated 4/13/26 at 6:01 PM, documented brown bruising noted to under left eye. Resident complains of pain to the area. No swelling noted upon inspection. Resident refused to allow staff to touch the area.The Progress Notes dated 4/13/26 at 6:04 PM, documented found brown bruising noted to underleft eye. Resident complains of pain. No swelling noted upon inspection and resident refused staff to touch the area.On 5/19/26 at 2:15 PM, observed Resident #9 sitting in the dining area in a recliner, dressed appropriately. Resident was not able to recall or have any recollection of an incident that resulted in the left eye being bruised.The clinical record lacked documentation of the investigation of the injury of unknown origin.On 5/22/26 at 12:02 PM, the facility Director of Nursing confirmed and verified that the clinical record lacked documentation of the incident with Resident #9 and that the expectation of the staff are to follow the facility procedure/policy for injuries of unknown origin. On 5/22/26 at 12:122 PM, the facility Administrator acknowledged that all staff are expected to report any allegations of abuse or injuries of unknown origin immediately and to start an investigation and that the clinical record lacked documentation of an incident report of which DIAL was notified. Review of the Abuse and Neglect policy revised 4/7/25, is to ensure that employees are knowledgeable regarding the reporting and investigative process of abuse, and neglect allegations. To ensure that all identified events of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. Alleged or suspected violations involving mistreatment or injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator, the following individuals have the administrative authority of the administrator for purposes of immediately reporting of alleged violations: the director of nursing services or the supervisor or social services.

Based on clinical record review, policy review, and staff interviews, the facility failed to investigate injuries of unknown injury for 2 of 3 residents reviewed (Resident #2 and Resident #9). Resident #2 had a bruise on the right wrist and Resident #9 had a bruise underneath the left eye. The facility reported a census of 46 residents.Finding include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognitive decisions. Resident #2 could understand others and others usually understood them. They have no behavior, mood or delirium. Resident #2 required partial to moderate assistance with all aspects of daily living (dressing, personal hygiene, transfers, oral hygiene and positioning) and no falls documented and a use of an anti-coagulant (medications that prevent blood from clotting or stop existing clots from getting larger) medication used in the last 7 days. The MDS included diagnoses of Non-Alzheimer's Dementia, muscle weakness, hypertension, (a chronic condition where blood force against artery walls is consistently too high), and repeated falls.The Care Plan Focus area revised on 3/17/26, identified that the resident is on an anti-coagulant therapy related to history of thrombosis (the formation of a blood clot inside a blood vessel, which obstructs the normal flow of blood) and emboli (detached, traveling masses,such as blood clots, air bubbles, or tumor cells, that move through the bloodstream) and has potential for skin impairment related to advancing dementia and needing more assistance with ambulation. Interventions include to identify potential causative factors and eliminate/resolve where possible. The Skin Observation tool dated 4/6/26 at 10:18 AM, documented right wrist has purple bruise measuring 2 centimeters by 1.5 centimeters. No swelling noted. No complaints of pain.On 5/20/26 at 2:02 PM, observed Resident #2 sitting in a recliner in her room, no noted purple bruise on the right wrist. Resident #2 was not able to recall an incident about a bruise to the right wrist.The clinical record lacked documentation of the right wrist bruise.On 5/22/26 at 12:02 PM, the facility Director of Nursing confirmed and verified that the clinical record lacked documentation of the incident with Resident #2 and that the expectation of the staff are to follow the facility procedure/policy for injuries of unknown origin. On 5/22/26 at 12:122 PM, the facility Administrator acknowledged that all staff are expected to report any allegations of abuse or injuries of unknown origin immediately and to start an investigation and that the clinical record lacked documentation of an incident report of that DIAL was notified. 2. Resident #9's MDS assessment dated [DATE], identified the resident with short and long term memory impairments with severe decision making abilities. Resident #9 could understand others and others usually understood them. They have behavior such as hallucinations and delusions, and resisting care. Resident #9 required partial to moderate assistance with dressing and supervision for oral, toileting and personal hygiene and independent in facility with ambulation and transfers with no assistive devices used and no falls documented and a use of an anti-coagulant (medications that prevent blood from clotting or stop existing clots from getting larger) medication used in the last 7 days. The MDS included diagnoses of malnutrition, anxiety and schizophrenia.The Plan of Care focus area with a revision dated 3/19/26, documented the resident is on an anticoagulant therapy related to history of pulmonary embolism (a sudden blockage in a lung artery, typically caused by a blood clot that travels from a deep vein in the legs). Interventions include to monitor/document/report bruising or sudden changes in mental status.The Skin Observation tool dated 4/13/26 at 6:01 PM, documented brown bruising noted to under left eye. Resident complains of pain to the area. No swelling noted upon inspection. Resident refused to allow staff to touch the area.The Progress Notes dated 4/13/26 at 6:04 PM, documented found brown bruising noted to underleft eye. Resident complains of pain. No swelling noted upon inspection and resident refused staff to touch the area.On 5/19/26 at 2:15 PM, observed Resident #9 sitting in the dining area in a recliner, dressed appropriately. Resident was not able to recall or have any recollection of an incident that resulted in the left eye being bruised.The clinical record lacked documentation of the investigation of the injury of unknown origin.On 5/22/26 at 12:02 PM, the facility Director of Nursing confirmed and verified that the clinical record lacked documentation of the incident with Resident #9 and that the expectation of the staff are to follow the facility procedure/policy for injuries of unknown origin. On 5/22/26 at 12:122 PM, the facility Administrator acknowledged that all staff are expected to report any allegations of abuse or injuries of unknown origin immediately and to start an investigation and that the clinical record lacked documentation of an incident report of which DIAL was notified. On 5/22/26 at 8:33 AM, the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the Administrator confirmed that no assessment was completed related to the report because they were unaware of Resident #2's and Resident #9's bruises. The ADON, DON and Administrator would expect for investigations to be completed if that was reported to them. The Administrator, DON and ADON revealed they would have investigated the incident if they were notified and this would be for their expectation. Review of policy revised 4/7/25 titled, Abuse and Neglect, documented the purpose is to ensure a complete review by the investigation team to identify events, such as suspicious bruising of residents/clients, occurrences, patterns and trends that may constituent abuse and to determine the direction of the investigation. All alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury and will ensure that any potential for further abuse is eliminated.

Based on resident and staff interviews, call light logs and the facility policy/procedure, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 3 of 4 residents reviewed (Resident #4, #5 and Resident #11). The facility identified a census of 46 residents.Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 for which indicated intact cognitive decisions, is able to be understood and understands others, and no behaviors or mood present. The MDS addressed the residents as dependent on staff for all activities of daily living (toileting hygiene, upper and lower body dressing, and personal hygiene) dependent on transfers and once in an electric wheelchair independent in the facility. The MDS included diagnosis of heart failure, hypertension (a condition where blood force against artery wall is consistently too high forcing the heart to work harder), diabetes mellitus, hemiplegia (paralysis affecting only one side of the body, caused by brain or spinal cord damage), anxiety and depression.On 5/13/26 at 9:20 AM, Resident #4 stated that it will take the staff over 15 minutes to answer the call light. Review of the [NAME]-Care Report from 5/16/26-5/17/26, for call light response times, revealed on 5/16/26 at 8:58 PM, Resident #4's call light was on for 34 minutes, 21 seconds, On 5/17/26 at 5:05 PM, was on for 46 minutes and 40 seconds and at 9:13 PM, for 31 minutes and 4 seconds.2. Resident #5 MDS assessment dated [DATE], documented the resident had a BIMS score of 15 for which indicated intact cognitive decisions, is able to be understood and understands others, no behaviors present and no resisting of cares. The MDS addressed the resident as dependent on staff for activities of daily living and once in an electric wheelchair independent in the facility with mobility. The MDS included diagnosis of heart failure, hypertension (a condition where blood force against artery wall is consistently too high forcing the heart to work harder), neurogenic bladder (a condition where nerve damage disrupts the communication between the brain and the bladder, resulting in loss of bladder control) and quadriplegia (the partial or total loss of motor function and sensation in all four limbs(arm and legs) and the torso).On 5/13/26 at 10:44 AM, Resident #5 stated that it will take over 15 minutes to have the call light answered.Review of the [NAME]-Care Report from 5/16/26-5/17/26, for call light response times, revealed on 5/17/26 at 7:57 PM, Resident #5's call light was on for 21 minutes and 53 seconds.3. Resident #11's MDS assessment dated [DATE], documented the resident had a BIMS score of 15 for which indicated intact cognitive decisions, is able to be understood and understands others, no behaviors present and no resisting of cares. The MDS documented the resident is dependent on staff for all activities of daily living and always incontinent of bladder. The MDS included diagnosis of anemia, heart failure, hypertension (a condition where blood force against artery wall is consistently too high forcing the heart to work harder), diabetes mellitus, cerebrovascular accident (blood flow to part of the brain is interrupted or reduced, depriving brain tissue of oxygen and leading to cell death), depression and unsteadiness on feet.On 5/20/26 at 9:00 AM, Resident #11 stated that it will take over 15 minutes to have the call light answered.Review of the [NAME]-Care Report from 5/16/26-5/17/26, for call light response times, revealed on 5/16/26 at 9:08 AM, Resident #5's call light on for 17 minutes and 28 seconds and on 5/17/26 at 7:40 PM, for 31 minutes and 22 seconds.On 5/20/26 at 10:33 AM, the facility Administrator acknowledged that the expectation of staff are to answer the resident call lights in a timely manner, within 15 minutes. On 5/20/26 at 12:56 PM, Staff B, Certified Nursing Assistant (CNA) confirmed and verified that call lights don't get answered within the 15 minutes.On 5/21/26 at 1:11 PM, the facility Director of Nursing acknowledged that the expectation of staff is to answer the resident call lights within 15 minutes.The Call Light Policy revised 7/8/25, stated that the purpose is to ensure residents always have a method of calling for assistance and to promptly answer residents call light. Respond to requests as soon as possible. Turn the call light off and inquire about residents' requests.

Based on clinical record review, facility investigation review, staff interview and facility policy review, the facility failed to properly destroy Resident #1's narcotic (pain) medication per facility policy/procedure. The facility identified a census of 46 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 for which indicated severe cognitive decisions, is able to be understood and understands others, with hallucinations and delusions present along with resisting of cares. The MDS addressed the resident as substantial to maximal assistance on staff for all activities of daily living (toileting, oral and personal hygiene, and upper and lower body dressing) and pain described as frequent with intensity of a 2 out of a numeric scale of 1-10, poor prognosis with an opioid used within the last 7 days. The MDS included diagnosis of hypertension (a condition where blood force against the artery wall is consistently too high forcing the heart to work harder), diabetes mellitus, neurogenic bladder (a condition where nerve damage disrupts the communication between the brain and the bladder, resulting in a loss of bladder control), Non-Alzheimer's dementia, arthritis, anxiety and depression.The Plan of Care with a revision dated 4/5/26, had a focus area that addresses the resident has chronic pain and is at risk for opioid overdose/complications related to opioid use-Fentanyl (a powerful synthetic opioid) 75 micrograms per hour. Interventions include, notify health care provider if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, provide resident and family with information about pain and options available for pain management and discuss and record preferences.The Progress Notes dated 4/3/26 at 4:16 PM, documented fentanyl transdermal patch 75 micrograms per hour apply patch one time a day every 2 days for pain.The Medication Error Report Form with date of error 4/1/26, revealed fentanyl 75 microgram patch, change every two days and that the resident response related to error was an increase in as needed morphine (a powerful, naturally occurring opioid analgesic derived from the opium poppy, primarily used to treat moderate to severe acute or chronic pain) usage.Review of the Facility Theft of Narcotic Medication with date of incident 4/3/26, revealed that at 4:16 PM, Staff E, LPN, went to replace a Fentanyl patch on Resident #1, while replacing the patch, Staff E noticed that the membrane on the old patch was not removed from the patch before it was applied to the resident. The patch was dated 4/1/26 and initialed. Since the membrane was not removed, the patch is essentially unused. No messages went out to the Administrator or the Director of Nursing regarding the incident. At 3:20 PM, it was determined that it was a Medication Error, that we need to educate the staff about the disposal of the Fentanyl patch. Statement received on 4/3/26 from Staff E, RN, had to change a Fentanyl patch on Resident #1, when taking off the old patch, it was noticed that the plastic backing was still on the Fentanyl patch that was applied to the resident with a tegaderm (a brand of transparent, sterile film dressings commonly used to act as a second skin), it was dated 4/1/26. After discovering the backing was still on the patch, Staff E, RN, reached out to Staff F, Licensed Practical Nurse (LPN) for guidance. Staff F, LPN informed Staff E, RN, to put the Fentanyl patch in an envelope and place it underneath the office door of Staff F, LPN. Education was immediately started using our policies and procedures for controlled substances and a test covering the information. Education covered counts, resident rights, medication storage, destruction of medications and not to share keys. All narcotics were counted on 4/7/26 with staff to ensure that nothing was missing. Incident will be taken to monthly quality assurance meeting for further review and recommendations. The narcotic count was never off during the count as the Fentanyl patch should have been discarded after it was taken off.On 5/12/26 at 5:45 PM, Staff D, Registered Nurse (RN), and Staff G, RN, confirmed and verified that the expectation of the staff are to follow the facilities policy/procedure for destroying patches and acknowledged that two staff are to destroy the patch.On 5/12/26 at 5:56 PM, Staff H, LPN, and Staff I, Certified Medication Aide (CMA) both confirmed and verified that the expectation of the staff are to have two nurses or a nurse and medication aide destroy the fentanyl patches in the drug buster or per facility policy/procedure.On 5/20/26 at 10:51 AM, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed and verified that the expectation of the nurses are to follow the policy/procedure for destroying narcotic medications and they acknowledged that the staff failed to follow the policy for destroying Resident #1 fentanyl patch.Review of the Medication:Transdermal Patch Application and Disposal revised 12/8/25, is that the purpose is to administer medication as ordered and to release a continuous and controlled dosage over a specific time period. For patch removal-Fentanyl and other controlled medication patches-disposal should be documented on the Individual Residents Narcotic Record. Narcotic patches should be destroyed by two licensed nurses, or a nurse and pharmacist. Where state guidelines allow a nurse and a trained medication aide may destroy narcotic patches.State-specific regulations regarding medication destruction must be followed. Fentanyl and other controlled medication patches should be folded in half with the sticky sides together and flushed down the toilet or use drug disposal systems such as Drug Buster or Rx Destroyer that minimize accidental exposure and diversion. Sharps containers and trash cans are not compliant. Review of the Medication Disposition revised 8/29/25, the policy is to provide instructions for the accurate disposal of medications. Discontinued medications are to be kept in a secure place in the medication room until these can be returned to the pharmacy or until destroyed according to state regulation. For Controlled substances, two nurses or a nurse and a medication aide must witness the destruction document to ensure accuracy of the count.

Based on clinical record review, staff interviews, and policy review the facility failed to maintain an accurate and complete resident clinical records for residents that had injuries of unknown origin for 2 of 3 residents reviewed (Resident #2 and Resident #9). The facility reported a census of 46 residents. Finding include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognitive decisions. Resident #2 could understand others and others usually understood them. They have no behavior, mood or delirium. Resident #2 required partial to moderate assistance with all aspects of daily living (dressing, personal hygiene, transfers, oral hygiene and positioning) and no falls documented and a use of an anti-coagulant (medications that prevent blood from clotting or stop existing clots from getting larger) medication used in the last 7 days. The MDS included diagnoses of Non-Alzheimer's Dementia, muscle weakness, hypertension, (a chronic condition where blood force against artery walls is consistently too high), and repeated falls.The Care Plan Focus area revised on 3/17/26, identified that the resident is on an anti-coagulant therapy related to history of thrombosis (the formation of a blood clot inside a blood vessel, which obstructs the normal flow of blood) and emboli (detached, traveling masses,such as blood clots, air bubbles, or tumor cells, that move through the bloodstream) and has potential for skin impairment related to advancing dementia and needing more assistance with ambulation. Interventions include to identify potential causative factors and eliminate/resolve where possible. The Skin Observation tool dated 4/6/26 at 10:18 AM, documented right wrist has purple bruise measuring 2 centimeters by 1.5 centimeters. No swelling noted. No complaints of pain.On 5/20/26 at 2:02 PM, observed Resident #2 sitting in a recliner in her room, no noted purple bruise on the right wrist. Resident #2 was not able to recall an incident about a bruise to the right wrist.The clinical record lacked documentation of the right wrist bruise.On 5/22/26 at 12:02 PM, the facility Director of Nursing confirmed and verified that the clinical record lacked documentation of the incident with Resident #2 and that the expectation of the staff are to follow the facility procedure/policy for documentation in the clinical record. 2. Resident #9's MDS assessment dated [DATE], identified the resident with short and long term memory impairments with severe decision making abilities. Resident #9 could understand others and others usually understood them. They have behavior such as hallucinations and delusions, and resisting care. Resident #9 required partial to moderate assistance with dressing and supervision for oral, toileting and personal hygiene and independent in facility with ambulation and transfers with no assistive devices used and no falls documented and a use of an anti-coagulant (medications that prevent blood from clotting or stop existing clots from getting larger) medication used in the last 7 days. The MDS included diagnoses of malnutrition, anxiety and schizophrenia.The Plan of Care focus area with a revision dated 3/19/26, documented the resident is on an anticoagulant therapy related to history of pulmonary embolism (a sudden blockage in a lung artery, typically caused by a blood clot that travels from a deep vein in the legs). Interventions include to monitor/document/report bruising or sudden changes in mental status.The Skin Observation tool dated 4/13/26 at 6:01 PM, documented brown bruising noted to under left eye. Resident complains of pain to the area. No swelling noted upon inspection. Resident refused to allow staff to touch the area.The Progress Notes dated 4/13/26 at 6:04 PM, documented found brown bruising noted to underleft eye. Resident complains of pain. No swelling noted upon inspection and resident refused staff to touch the area.On 5/19/26 at 2:15 PM, observed Resident #9 sitting in the dining area in a recliner, dressed appropriately. Resident was not able to recall or have any recollection of an incident that resulted in the left eye being bruised.The clinical record lacked documentation of the investigation of the injury of unknown origin.On 5/22/26 at 12:02 PM, the facility Director of Nursing confirmed and verified that the clinical record lacked documentation of the incident with Resident #9 and that the expectation of the staff are to follow the facility procedure/policy for documentation in the clinical record. Review of policy revised 5/29/25 titled, Health Information Management, stated that the purpose is to provide oversight of health information management services for the organization and assure timely availability of information for the care of patient, residents, and clients. The Scope is chart completion management.

Based on Electronic Health Record (EHR) review, resident interviews, family interviews, staff interviews and policy review the facility failed to provide dignity and respect when a nurse yelled at a resident about being outside of the facility and smoking on the sidewalk to 1 of 3 residents reviewed (Resident #1). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment.On 12/11/25 at 10:05 AM Resident #1's daughter explained staff were not allowed to take her mother outside to smoke if they were employed at the facility. Resident #1's daughter stated there was a situation where an employee took her mother outside to smoke and a nurse went outside and yelled at the nurse and the CNA. Resident #1 daughter said her mother does not need permission to smoke on the sidewalk. Resident #1's daughter explained that the sidewalk was not owned by the facility and was not part of the facility's property. Resident #1's daughter stated her mother can walk short distances on her own but will require one staff to walk her and one staff to push the wheelchair to follow. Resident #1's daughter stated Staff A, Certified Nurse Assistant (CNA) was the CNA that was outside with her mother during the incident. On 12/11/25 at 2:12 PM Resident #1 stated had been at the facility since 7/24/25. Resident #1 stated some staff treat her good and some treat her bad. Resident #1 stated she goes outside and smokes with her daughter. Resident #1 stated she was told that she could not go out to smoke. Resident #1 said the staff are not allowed to push her outside. Resident #1 explained the staff are not allowed to take her outside, not when they are on break or when they are not working. Resident #1 said there was staff that got in trouble for taking her outside to smoke. Resident #1 said Staff A and Staff B, CNA got written up. Resident #1 explained she could smoke on the side walk out front. Resident #1 said the Administrator said that he does not like a lot of people smoking on the sidewalk. Resident #1 stated when Staff B and Staff A took her out to smoke, Staff C, Licensed Practical Nurse yelled at all of them. Resident #1 said Staff C was yelling at her out the door that she could not smoke out there. Resident #1 said she was upset about the incident but she was not scared of the nurse. Resident #1 said she felt bad because she was the reason the staff were yelled at. Resident #1 explained she felt Staff C did not give her dignity or respect when she yelled at her. Resident #1 stated she had very little interaction with Staff C prior to the incident or after the incident. On 12/11/25 at 2:58 PM Staff C, LPN stated if she heard anyone yelling at a resident she would be on them. Staff C explained she was the enforcer at the facility. Staff C stated she tried not to talk down to a resident. Staff C said she had never yelled at a resident but she might have been stern at times. Staff C stated 2 of the CNAs took a resident outside to smoke and she was loud when she went outside to talk to them but they had to hear her. Staff C stated the 3 of them were on the facility's sidewalk not the public sidewalk. Staff C stated she was more upset with the CNAs than the resident. Staff C stated she told the resident that the CNAs are not to be taking her out to smoke. Staff C stated she told the resident only her family could take the resident outside. Staff C explained the resident told her that the Administrator told her that she could smoke on the public sidewalk. Staff C stated the CNAs was Staff A and she did not remember the other CNAs name. Staff C said the Director of Nursing (DON) after it happened. Staff C explained the facility owned the whole sidewalk in front of the facility and she knew that because the facility used to load and unload right on the corner. On 12/15/25 at 10:33 AM Staff A, CNA stated an incident occurred with Resident #1. Staff A explained Resident #1 had asked to be taken outside to smoke. Staff A stated she told Resident #1 over and over again that she could not. Staff A said Resident #1 then started crying and was told the other CNA was going to take her outside so Staff A took Resident #1 outside. Staff A explained that Staff C came outside and started yelling at her, Staff B and Resident #1. Staff A stated Resident #1 seemed upset that Staff C seemed angry when yelling at them and Resident #1. Staff A stated she was written up for taking Resident #1 outside to smoke and the write up was ripped up a week later. Staff A stated Staff D, Staff Development Coordinator destroyed the write up. Staff A stated she was told the staff are not supposed to take Resident #1 outside to smoke. Staff A stated Staff D stated there was no policy about staff taking Resident #1 outside to smoke. Staff A stated Staff D told her the staff just can't smoke with Resident #1. Staff A explained Resident #1 was and apologized for getting Staff A in trouble. Staff A stated there was no reason for Staff C to yell at the Resident #1. Staff A stated she did not report the incident to the administration. Staff A explained that Staff C did call the DON after the incident occurred. On 12/15/25 at 11:44 AM Staff B, CNA stated the Administrator and the DON said that staff can not take Resident #1 outside to smoke. Staff B stated she did not know what the rules about smoking outside were and does not know if the sidewalk is facility grounds. Staff B stated one time Resident #1 came up to the nurses station and Staff A took Resident #1 outside to smoke. Staff B said she opened the door for Resident #1 and Staff A. Staff B explained Resident #1 and Staff A went off the facility grounds. Staff A stated Staff C came out and told them they absolutely could not do that and they were going to be wrote up. Staff B explained Staff C said Resident #1 could not be outside smoking. Staff B stated Staff C was talking to them definitely in a stern voice and was not being very nice about it. Staff B said Staff C was talking in general to all 3 of them. Staff B explained Resident #1 said she was not on the property and she was on the sidewalk. Staff B stated Staff C said Resident #1 did not know what she was talking about and she had worked at the facility longer than the Administrator. Staff B stated Resident #1 did seem upset about the incident and possibly called her daughter. Staff B stated Resident #1 was upset because Staff B yelled at them. Staff B explained she did not see a reason staff would be yelling at a resident. Staff B stated she felt the administration knew because Staff C called the administration right away. Staff B stated she does not actually know what she is supposed to report to everybody. Staff B stated if she did see a staff yelling at a resident she felt she should report that incident. Staff B stated she did not notify the administration because she did not know if she was in the wrong in that incident. Staff B stated she felt Staff C was yelling more at the staff then the resident but she felt she probably should have reported the incident. Staff B stated she had taken the dependent adult abuse class at the facility. Staff B acknowledged she felt what she did was wrong and she should have reported the incident. On 12/15/25 at 4:18 PM Staff D, Staff Development Coordinator stated Staff A was written up but did not proceed with the write up. Staff D explained she was told by the administration to not proceed with the write up because the policies were conflicting. Staff D stated once all the information was processed they revoked the write up. Staff D stated the DON received notification from the charge nurse that Staff A had taken Resident #1 outside to smoke and DON spoke with Staff C. Staff D stated she did not talk to Resident #1 at all but believed that the DON talked to Resident #1 to tell her that staff could not take her outside to smoke. On 12/15/25 at 3:05 PM the DON stated there was no reason for any staff to be yelling at a resident. The DON said no staff had reported a staff yelled at a resident. The DON stated Resident #1 was to smoke across the street. The DON stated Resident #1 could not smoke on the sidewalk out front of the facility. The DON explained the city did not own the sidewalk out front. The DON stated there had been several concerns about Resident #1 smoking out front. The DON stated the staff can not take Resident #1 outside to smoke, not even if they are not on the clock. The DON explained staff not taking residents outside to smoke was part of the smoking policy. The DON then stated staff can not take residents outside to smoke but it is not in the policy. The DON stated one staff member was written up for taking Resident #1 outside to smoke. The DON stated it was Staff A that took Resident #1 outside to smoke. The DON stated Staff A had taken Resident #1 outside to smoke and they were smoking right outside the front door. The DON stated the on-call was notified and they called her. The DON stated she talked to Staff A and Staff A admitted that she did take Resident #1 outside. The DON stated she did not talk to Resident #1 during that incident. The DON explained it was only Staff A that she talked to. The DON stated she did not document the incident. On 12/15/25 at 4:28 PM the Administrator stated it does not specify in the policy that staff could not take the resident outside. The Administrator stated the lunch break was not on the clock but it puts risk on the facility for the staff to take the resident outside to smoke even when they are off the clock. The Administrator explained a friend or family member could take Resident #1 outside to smoke only if the friend is not a current employee at the facility. The Administrator explained if Resident #1 was on a sidewalk they are legally not on their property. The Administrator stated he had told staff that the sidewalk is not legally on their property. The Administrator acknowledged he did not know why the write up was taken away because there was no conflicting information. The Administrator acknowledged the incident was with Resident #1. The Administrator stated Resident #1 had been very apologetic about talking the staff into taking her outside to smoke. The Administrator said the incident was reported to them and the administration talked to Staff A and Staff A admitted to the situation. The Administrator stated there was no formal written investigation. The Administrator stated Staff C reported it to them. The Administrator stated the DON talked to Staff C about it. The Administrator explained Staff C was on duty that night. The Administrator said Staff C stated she told the staff not to take Resident #1 outside and they just continued outside. The Administrator stated he was not sure of the exact date the incident occurred. The Administrator stated he could not think of any incident where it would be appropriate for staff to yell at a resident unless they were in danger. The Administrator stated Staff A was going against what the staff were told. The Administrator acknowledged Staff C had to be delicate in handling the situation with the resident present. The Administrator explained when leadership is not in the building the charge nurse is in charge. The Administrator stated the charge nurse needed to make sure rules were being followed. The Administrator stated they would want the nurse to get the staff's attention but yelling at the staff would be unacceptable. The Administrator acknowledged that yelling at a resident would be seen as a dignity and respect issue. The Administrator stated when talked to Resident #1 the day after the incident there was no mention of the interaction with the nurse. The Administrator stated if there was a staff that yelled at a resident it should have been reported to the nurse and then passed on to the administration. Review of policy reviewed/revised on 12/11/24 titled, Resident Dignity documented the purpose of the policy was to maintain the dignity of all residents, to promote, encourage, support and enhance the residents' self-esteem, to promote a sense of self-worth and to assist with respecting and ensuring resident rights. The facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The interdisciplinary team will assist all staff members in maintaining the dignity of every resident. Ideas for maintaining a resident's dignity may include, but not be limited to providing the resident with privacy during visits from family and friends and refraining from practices demeaning to residents.

Based on clinical record review, family interview, resident interview, staff interview, and policy review the facility failed to assist residents with activities of daily living by not offering an opportunity to bathe for 2 of 3 residents reviewed (Resident #1,and #3). The facility reported a census of 56 residents. Finding include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed Resident #1 required moderate assistance with personal hygiene as well as needing total assistance with toileting hygiene. The MDS revealed diagnoses of arthritis, anxiety disorder, bipolar disorder, chronic obstructive pulmonary disease, and fibromyalgia. Interview 10/8/25 at 9:07 AM with Resident #1's family member revealed that Resident #1 has gone over a week without a bath. The family member further revealed that staff would ask when Resident #1 would like a bath, and then not return and mark Resident #1 down as a refusal. The family member then revealed that Resident #1 is at the facility for help with hygiene and respiratory issues. Interview 10/8/25 at 11:45 AM with Resident #1 revealed that she is not getting her baths at least twice a week. Resident #1 revealed that she would ask to have the bath later in the day, and staff just didn't come back, and then they will put her down as a refusal. Review of the Electronic Healthcare Record (EHR) page titled, Documentation Survey Report for the month of August 2025 revealed Resident #1 received a bath on the 5th, 7th, 11th, and 24th. The document further revealed that Resident #1 refused bathing on the 21st, and 28th. Review of the EHR page titled, Documentation Survey Report for the month of September 2025 revealed Resident #1 received a bath on 8th, 11th, 18th, 25th, and 29th. The document revealed Resident #1 did not refuse bathing this month. Review of the EHR page titled, Documentation Survey Report for the month of October 2025 revealed Resident #1 received a bath on the 2nd, and refused on the 7th. Review of the EHR page titled Progress Notes revealed an entry 9/4/25 at 10:57 AM that Resident #1 refused a shower. The Progress Notes further revealed an entry 8/25/25 at 9:09 AM the Resident #1 refused a shower/bath that morning. No further documentation of showers/baths were documented as being refused. 2. Review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed Resident #3 required maximal assistance with bathing/showering. Further review of the MDS revealed diagnoses of heart failure, peripheral vascular disease, renal insufficiency, diabetes mellitus, hyperlipidemia, arthritis, and morbid obesity. Interview 10/8/25 at 9:35 AM with Resident #3 revealed that he gets his baths 2-3 times a week. Resident #3 then revealed that if he doesn't get his bath on one day he will usually get it the next day unless the staff forget. Review of the EHR page titled, Documentation Survey Report for the month of August 2025 revealed Resident #3 received baths/showers on the 13th, 15th, 18th, 20th, 25th, and 29th. The document further revealed that Resident #3 refused baths/showers on the 1st, and 11th. Review of the EHR page titled, Documentation Survey Report for the month of September 2025 revealed Resident #3 received baths/showers on the 10th, 12th, 17th, 19th, 22nd, 24th, 26th, and 29th. The document revealed that baths were not applicable on the 1st, 3rd, 5th, 8th, 10th, 15th, 19th, 22nd, 24th, and 26th. Review of the EHR page titled, Progress Notes revealed no documentation of showers/baths being refused. Interview 10/8/25 at 12:00 PM with Staff A Nursing Assistant revealed residents should be showered or bathed every 3-4 days. Staff A then revealed if residents miss their bath day then they are moved to the next day. Staff A further revealed that if a resident refuses it will be in the charting in the progress notes. Interview 10/8/25 at 12:12 PM with Staff B Licensed Practical Nurse (LPN) revealed residents are supposed to be bathed 2 times a week. Staff B then revealed that if a resident's bath or shower is missed they will try to move the resident to the next day. Staff B further revealed nurses and CNAs are to chart if there is a refusal in the progress notes. Interview 10/8/25 at 12:15 PM with Staff C CNA revealed residents are supposed to be bathed twice a week. Staff C then revealed that it depends on staffing levels. Staff C further revealed that the facility will pull a med aide to help. Staff C then revealed refusals are normally charted, and then reported to the nurse. Staff C revealed that CNAs will also report to the next shift if a bath is missed. Staff C further revealed residents will be moved to the next day if they are missed on their bath/shower days. Staff C revealed that it is not uncommon for residents to go several days in between baths or showers as staff will call in leaving the floor short. Interview 10/8/25 at 12:20 PM with Staff D CNA revealed residents are bathed twice a week. Staff D revealed that if baths/showers are missed or refused it should be charted, and CNAs will let the nurse know. Staff D revealed sometimes they are short staffed, with no bath aid and residents miss baths. Staff D then further revealed that it is not uncommon for residents to go for several days in between bathing related to call ins or being short on the floor of staff. Interview 10/8/25 1:15 PM with the Administrator revealed that his expectation would be for residents to have baths/showers at least twice a week or per their request.Request for a policy from administration on frequency of bathing revealed no policy to review.

Based on clinical record review, family interview, staff interview, and policy review the facility failed to ensure 1 of 5 residents personal property was protected from loss or theft (Resident #14). The facility reported a census of 49 residents. Findings include: Review of Resident #14's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to perform the interview. The MDS further revealed diagnoses of progressive neurological conditions, cancer, non-Alzheimer's dementia, depression, and altered mental status. Interview 6/23/25 at 1:34 PM with Resident #14's family member revealed that Resident #14 was missing her wedding ring, and a birthstone ring. The family member then revealed that the facility was aware, and had not replaced the items. The family member further revealed that the rings were missing a couple months ago, and had notified the facility. Review of a facility provided document titled, Inventory of Personal Effects with a signature date of 8/13/18 revealed an entry under the jewelry section of the form saying ring, and watch. Review of the Electronic Healthcare Record (EHR) page titled, Progress Notes revealed an entry 4/30/25 at 1:41 PM that Social Services spoke with Resident #14's Family member about missing items and an investigation. Further review of this entry revealed that Social Services was going to speak with the Administrator and will follow up with Resident #14's family member on how to move forward. Further review of the Progress Notes revealed another entry 4/30/25 at 2:57 PM revealing Social Services had informed Resident #14's family member they had spoken with the Administrator, and the family member was welcome to proceed with filing with the sheriff's department. The entry further revealed that the facility would continue to look for the lost items. Interview 6/25/25 at 8:52 AM with Social Services revealed that She did file a grievance for the missing items for Resident #14, and that the items were never found or replaced. Social Services further revealed that inventory sheets should be completed at admission and updated at Care Plan meetings. Interview 6/25/25 at 10:22 AM with the Director of Nursing (DON) revealed that inventory sheets should be updated and correct as this was an expectation. The DON further revealed that her expectation would be for items to be replaced if lost. Review of a facility provided undated policy titled, Inventory of Personal Effects revealed: a. Inventory of personal effects should be completed on admission, and updated as new articles are acquired.

Based on document review, staff interviews, and the facility policy review, the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment for 1 out of 5 staff reviewed. The facility reported a census of 49 residents. Findings include: A review of personnel file of Staff G, Licensed Practical Nurse (LPN), revealed the background check was completed 3/15/25 while the hired date was 10/8/24. Background check was not completed prior to hire date. In an interview with Staff H, Human Resources, on 06/24/25 02:29 pm, she stated during an internal audit they didn't locate a background check on Staff G, LPN and they completed one immediately on 3/15/25. During an interview with the DON on 6/24/25 at 2:35 pm, she confirmed that the facility failed to complete a required background check prior to hiring Staff G. Review of the facility provided policy titled Abuse and Neglect-Rehab/Skilled, Adult Day Services, Therapy & Rehab revised 4/7/2025 documented: The location will not knowingly employ or otherwise engage individuals who have been found guilty of abusing, neglecting, exploiting, misappropriating property or mistreating residents/clients by a court of law or have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents/clients or misappropriation of their property or have a disciplinary action in effect against his or her professional license by a state licensure body as result of a finding of abuse, neglect, exploitation, mistreatment of residents/clients or misappropriation of resident/client property.

Based on facility record review, hospital record review, resident, and staff interviews, the facility failed to investigate a change in condition for three of three residents reviewed (Residents #22, #25, and #42). Two of the residents had a sudden increase of pain (Residents #22 and #25). Resident #22 walked independently in the facility and experienced a bout of dizziness causing her to fall on 5/13/23. At the time of the fall, Resident #22 denied pain but started to report pain later that evening and requested pain medication. Resident #22 did not use any as needed medication until after her fall on 5/13/23. Resident #22 received no evaluation by a provider until 5/17/23. During the hospital stay, the staff determined Resident #22 had multiple compression fractures in her back. Resident #22 received treatment to one of the compression fractures involving an invasive procedure. Resident #25 received a scheduled pain medication for chronic pain and used a standing lift for transfers. Resident #25 reported that she had an increase in pain after a staff member transferred her with the standing mechanical lift. The facility failed to determine when the injury occurred and failed to have Resident #22 evaluated following her increased pain until Resident #22 requested to go to the emergency room . After a change in condition, the facility sent Resident #25 to the hospital who discovered a compression fracture. In addition, the facility failed to assess Resident #42 who had a history of urinary tract infections (UTI) and sepsis (an infection that is so severe it spreads to the blood) when he experienced signs and symptoms of a UTI. The facility did not provide interventions to Resident #42 until he transferred to the emergency room (ER) seven days after the first documented symptom. Findings include: 1. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the Resident #22 required limited assistance of one person with dressing. She could independently move in bed, walk in her room, walk in the corridor, use the toilet, and complete her personal hygiene. Resident #22 used a walker and a wheelchair. She could stabilize herself without staff assistance but was not steady with moving from a seated to a standing position, turning around, moving on and off the toilet, and surface-to-surface transfer. Resident #22 received a scheduled pain medication in the previous five days of the lookback period. She had one fall without injury since the previous assessment. The Care Plan Focus revised 6/9/22 indicated that Resident #22 had a risk for falls related to her history of falls. The interventions directed the staff to monitor her for significant change in gait, mobility, positioning device, standing balance, sitting balance, and lower extremity joint function. On 6/1/23 at 2:10 PM observed Resident #22 in her recliner in her room. Resident #22 said that she did not have pain but she did have a lot of pain before and after her back surgery. She said that she got getting dizzy and that's what caused her falls. The Incident Report dated 5/13/23 at 10:30 AM indicated that Staff K, Licensed Practical Nurse (LPN), witnessed Resident #22 fall backwards to the floor landing on her buttocks, then she laid herself down. The Incident Note dated 5/13/23 at 10:30 AM labeled as a Late Entry listed that Staff K witnessed Resident #22 fall. She walked form her bathroom to her chair and fell backward landing on her buttock, then she laid herself down. Resident #22's had range of motion (ROM) within her normal limits. She denied pain and did not hit her head. The staff assisted her with two and a mechanical lift to bed. The nurse notified the Director of Nursing (DON), the physician, and the daughter. The eAdmin Record (Default Note) on 5/13/2023 at 7:07 PM indicated that Resident #22 received a tramadol HCl Oral Tablet 50 milligrams (MG) for back and shoulder pain. Resident #22's family remained at her bedside and requested as needed (PRN) administration as soon as possible (ASPA) as she rarely had such a high pain level. The eAdmin Record (Default Note) on 5/14/23 at 7:45 AM listed that Resident #22 complained of pain from her fall the day before. The eAdmin Record (Default Note) on 5/15/23 at 12:13 AM recorded that Resident #22 could not sleep and requested a PRN pain medication due to pain all over. The Care Plan Review note dated 5/15/23 listed that Resident #22 had one fall during the lookback without injury. She met her pain goal with routine Tylenol. The eAdmin Record (Default Note) on 5/16/23 at 7:30 AM documented that Resident #22 reported back pain. The Communication/Visit with Physician on 5/16/23 at 7:33 PM indicated that Resident #22 had a lot of pain at the start of the shift. She reported the pain came from a fall over the weekend. The physician gave an order for an X-ray of her spine. At 5:45 PM she received the X-ray. In addition, the physician gave an order for a urinalysis (UA). The physician reported that too much tramadol could cause hallucinations. The Health Status Note dated 5/17/23 at 4:15 AM Resident #22 experienced hallucinations and complained of pain but did not know why. Resident #22's May 2023 Medication Administration Record (MAR) listed the following orders and usage: a. 3/24/23 - Tramadol 50 milligrams (mg) one tab three times as day as needed (PRN) for pain. i. Resident #22 did not use the medication until the 13th. ii. Resident #22 received on 5/13 for pain of 6/10, 5/14/23 for pain 8/10, and 5/15/23 for pain of 5/15. b. 3/24/23 - Tramadol 50 MG a half tablet three times a day PRN pain. i. Resident #22 did not use the medication until the 13th. ii. Resident #22 received a half tablet of Tramadol on 5/15 for pain of 8/10. 5/16 for pain of 4/10. The Transfer to Hospital V5 on 5/17/23 at 3:34 PM revealed the nurse sent Resident #22 to the hospital due to complaints of pain rated 8 out of the 10-pain scale (0 no pain, 10 worst pain ever) in her left and right scapula. The Provider Progress Notes dated 5/20/23 at 6:47 PM lists Resident #22's assessment finding as a closed fracture of multiple thoracic vertebrae and an acute cystitis without hematuria (bladder infection without blood in the urine). The Plan directed that the MRI showed a burst fracture (A type of traumatic spinal injury in which a vertebra breaks from a high-energy axial load such as traffic collisions or falls from a great height or high speed, and some kinds of seizures), with shards of vertebra penetrating surrounding tissues and sometimes the spinal canal) at C7 and an endplate compression fracture of L1. The MRI Thoracic Spine without Contrast Results dated 5/20/23 indicated that the evaluation of Resident #22's thoracic spine demonstrates mild exaggeration of the normal thoracic kyphosis. Resident #22 had vertebral body hemangiomas (common vascular lesion found within the vertebral body of the thoracic and lumbar spine) on the T12, T11, and T4. Resident #22 had a T6 burst fracture with fracture line extending to involve the back and front cortex (an outer or surrounding layer of an organ or body part) of the vertebrae. The Provider Progress Notes dated 5/26/23 at 9:54 AM indicated that Resident #22 had a fall two weeks before. She had increased pain since that time. The pain increases with movement and appears constant within the mid back. The pain severity ranges from 6-9 out of 10 on the pain scale. The MRI (specialized assessment images of the body) demonstrated an acute (short-term) supra endplate compression (a type of vertebral fracture that occurs when the vertebrae compress and collapse) of the T6 vertebral body with approximately 50% loss of height. The note indicated to proceed with vertebroplasty (a procedure involving special cement injected into a fractured vertebra - with the goal of relieving spinal pain and restoring mobility). The Discharge Summary dated 5/26/23 included four diagnoses Resident #22 received treatment for in the hospital. a. Osteoporosis b. Closed fracture of multiple thoracic vertebrae c. Closed stable burst fracture of the sixth thoracic vertebra with delayed healing. d. Closed fracture of lumbar vertebra, unspecified fracture morphology, unspecified lumbar vertebral level. The Discharge Summary directed the nursing facility to schedule the Prolia injection (injection used to treat bone loss). On 6/1/23 at 3:40 PM Resident #22's Representative (RR #22) said that they got a call from the facility after her fall on 5/13 that Resident #22 had a great deal of pain. She thought they facility called her over a weekend, and they brought in a portable X-ray machine on a Monday or Tuesday. Resident #22 had surgery and then she fell again the day she went back to the facility. On 6/5/23 at 1:37 PM a Clinic Nurse verified that the clinic received a call from the facility on 5/13/23 regarding Resident #22's fall. She did not see in the notes that the doctor responded with any specific questions or new orders. On 6/5/23 at 9:35 AM Staff K said that as she walked down the hallway, she saw Resident #22 fall back as she transferred to her chair. She said that Resident #22 denied pain at the time, she called an on-call nurse, and left a message. She denied knowing if the doctor called back for a follow up or if anyone followed up later with the doctor. On 6/6/23 at 8:11 AM the DON said that she expected the nurse to call the on-call doctor who worked as the emergency room (ER) doctor over a weekend, if an incident occurred at the facility. The DON agreed that someone followed-up with the doctor when Resident #22 continued to have pain after her fall. 47261 2. Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #25 required extensive assistance of two persons with bed mobility, dressing, and toilet use. In addition, she required total dependence on two persons for transfers, and extensive assistance of one person for personal hygiene. The assessment indicated that Resident #25 could not ambulate (walk) and needed one person to push her wheelchair. The MDS included diagnoses of cancer, heart failure, diabetes, depression, and a compression fracture of the spine (broken bone caused by weakness in the back). On 5/30/23 at 10:53 AM Resident #25 stated she fell out of a lift and fractured her back. She stated she went to the hospital and had a raging urinary tract infection (UTI), fluid on her heart, and a fracture in her back. In another interview the same day at 1:05 PM, the resident explained that she fell out of a standing lift, as Staff D, Certified Nursing Assistant (CNA), operated it. She reported that she did not have anyone else in the room when it happened. Resident #25 added that staff now use a full-body mechanical lift to transfer her. Resident #25 explained that oftentimes the staff transfer her alone when there is supposed to be two people. On her wall at the head of the bed, observed a sign that instructed to only use a nonmechanical stand-to-sit for Resident #25. The Health Status Note dated 4/16/23 at 9:00 PM indicated that Resident #25 reported that her pain management routine worked and she slept better. She added that she could get around better with her medication schedule with the Tylenol and tramadol (pain medication). The Health Status Note dated 4/18/23 at 12:54 PM written by Staff F, Registered Nurse (RN), indicated that a Certified Nurse Aide (CNA) reported that Resident #25 did not stand well in the mechanical standing lift with an assist of one. The CNA described that Resident #25 pulled her arms up and bent her knees. The Health Status Note dated 4/19/23 at 1:38 AM documented by Staff E, Licensed Practical Nurse (LPN), that Resident #25 continued to have difficulty standing with transfers. The Health Status Note dated 4/25/23 at 6:54 AM labeled Late Entry written by Staff F indicated Resident #25 complained of shortness of breath, shallow respirations, poor eye contact, flat voice, and diminished lung sounds. Resident #25 had stable vital signs, oxygen saturation of 98% on room air, denies pain while in bed, and when up has pain of 7 of out 10 (0 no pain, 10 the most pain). The nurse encouraged Resident #25 to increase their activity. The Communication - Other Note dated 4/25/23 at 2:50 PM listed that the nurse requested a muscle relaxer per therapy recommendation. The Communication/Visit with Physician Note dated 4/25/23 at 8:30 PM labeled Late Entry detailed new orders by the provider. Resident #25 will have X-rays on the next day of the T-Spine (upper middle back), and L-Spine (middle to lower back). In addition, the provider provided an order for baclofen (muscle relaxer) one tablet three times a day as needed for back spasms. The nurse notified the family and updated the clinical record. The Health Status Note dated 4/26/23 at 11:56 AM indicated that Resident #25 had an X-ray. She continued to complain of pain with activity. The Lab/Diagnostics Note dated 4/27/23 at 5:41 AM listed that the facility received the x-ray results and faxed them to the Primary Care Provider (PCP). The Health Status Note dated 4/27/23 at 9:30 AM written by Staff F indicated that Resident #25 continued to complain of sharp pain on her left of her back radiating to the flank area (lower left side of back) without radiation to her left arm. Vital signs remain stable with an oxygen saturation of 88% (normal is 90% and above), blood pressure of 126/58, temperature of 95 (average 98.6), pulse of 88 (typical range 60-100), and respirations (typical range 12-20). As the staff assisted Resident #25 to the bath chair in the standing mechanical lift, she complained of a sharp pain in her left side of her back. Resident #25 received her scheduled Tramadol (pain medication) and Tylenol earlier in the morning. The Communication/Visit with Physician Note on 4/27/23 at 10:12 AM identified the nurse called the PCP's office to provide an update on Resident #25's condition. The Communication/Visit with Physician Note on 4/27/23 at 1:41 PM indicated that the facility received a fax from the physician that dictated that Resident #25 had chronic (long-term) degenerative changes. The physician directed to schedule an appointment with her PCP in the office unless she would not wait. The nurse updated the resident and her niece then got a bed hold agreement. The nurse provided a report to the emergency room (ER). The Health Status Note dated 4/27/23 at 1:50 PM recorded that Resident #25 went to the ER with staff in the facility van. The ED Provider Notes dated 4/27/23 at 2:37 PM listed Resident #25's chief complaint as a report of slipping from the sit-stand machine and jarred her back making her pain worse in her back around to her abdomen. Resident #25 came to the ER for an evaluation of mid back pain. She reported when in a lift the machine came down somewhat quickly and stopped. As that happened she developed immediate onset of mid back pain. Resident #25 denied extension of the pain into her legs but did feel like it came across her upper abdomen to her chest. She reports a history of chronic low back pain but explained her current pain is different. Resident #25 denied any exacerbation of her regular back pain. She tried tramadol that day with little or no relief. Resident #25 did have an X-ray the day before that had negative results of any acute fracture. The assessment revealed that Resident #25 had some tenderness at approximately T-11 on palpation (a type of touch used to assess). The Discharge instructions directed to increase her tramadol to 50 milligrams (mg) three times a day for one week and continue Tylenol. Apply ice to the affected area for 20 minutes per hour while awake for that day and the next day. If worsening or changing symptoms contact the clinic and follow-up as needed. The Final Impression list thoracic back sprain, initial encounter. The Progress Notes dated 4/29/23 at 9:29 AM indicated that Resident #25 had back pain of the thoracolumbar region for greater than six weeks. She started on a muscle relaxant and received tramadol for her pain without improvement. The etiology of the pain could be from a kidney infection, however, due to the musculoskeletal nature, regarding the full-boy mechanical lift incident in the nursing home, proceed with CT scans to rule out a compression fracture or any other potential etiology of her back pain while hospitalized . The CT Thoracic Spine without contrast dated 4/29/23 impression listed the following a. Inferior endplate fracture at the T8 b. Degenerative change of the spine. There is central canal stenosis and neurol foraminal narrowing at T10-11. c. Small effusions with bibasilar atelectasis d. Findings suggesting pulmonary edema. The Progress Notes dated 4/30/23 at 8:23 AM indicated that Resident #25 told her PCP that she had an incident at the nursing home where she fell . She described the incident as the staff tried to transfer her and pivot her standing, her legs gave out and she went down rather hard on her buttocks into the chair. She reported that she felt the worsening back pain at that time but could not remember when the incident occurred. The Communication/Visit with Physician on 5/2/23 at 3:57 AM the facility received Resident #25's X-ray results the PCP wrote that the X-rays on 4/26/23 with negative results. The X-ray results on 4/29/23 revealed a compression fracture at her T-8. The PCP questioned if Resident #25 had a fall. The nurse responded that they did not know of any falls but she did use a sit to stand with a sling. Resident #25 chicken wings (bends her arms at an upward angle) and needs to sit quickly. The Communication/Visit with Physician dated 5/2/23 at 2:21 PM indicated the PCP reviewed the X-Ray and Resident #25 remained in the hospital. The PCP wrote that Resident #25 reported that she fell at the nursing home. The PCP explained that Resident #25 had a compression fracture of her T-8. The PCP indicated that her record did not have any documented falls. On 5/31/23 at 1:35 PM the Director of Nursing (DON) reported that they did not do an investigation or report regarding resident's compression fracture findings due to the hospital discovering it. She explained that they reviewed their records and found no staff reports or documentation of a fall. On 5/31/23 at 2:45 PM Staff F reported that she did not think that she documented on 4/18 that anyone told her that Resident #25 had problems with the mechanical standing lift, and if she did, she couldn't remember. She denied remembering any incidents or concerns with Resident #25 using the stand. On 5/31/23 at 3:06 PM Staff E, Licensed Practical Nurse (LPN), remarked that she could not remember documenting on 4/19 that Resident #25 had difficulty with the mechanical standing lift. She reported that she did not know about any incidents with Resident #25 using the stand and complaining of back pain. When asked what she would do if that someone reported that to her, she replied that she would let therapy know, but therapy said resident did fine with the mechanical standing lift so to keep using it. On 5/31/23 at 3:20 PM Staff H, Occupational Therapist (OT), explained that that all staff received training that they could always do more for the resident, but not less. She stated if the staff or the resident felt uncomfortable using the standing mechanical lift or standing lift, they could always use a full-body mechanical lift to transfer the resident without having to call them before using it, and have the nurse notify them of the concern to address it the following day. She stated that Resident #25 did do well with the lift in therapy and that in her opinion, Resident #25 tried harder for them (therapy). She also felt that Resident #25 felt more comfortable with some staff than others. She stated that staff use chicken winging, but it can present differently from one staff member to another, such as elbows pointed out away from the body or pointing upwards like a flapping motion. On 6/1/23 at 10:30 AM Resident #25's physician from the ER explained her compression fracture was consistent with a sudden stop coming down in the lift. 46875 3. Resident #42's MDS assessment dated [DATE] listed a readmitted [DATE] from an acute hospital. The MDS identified a BIMs score of 14, indicating intact cognition. The MDS indicated that Resident #42 required extensive assistance of two persons with bed mobility and toilet use. The MDS listed that Resident #42 required total dependence of two persons with transfers and could not ambulate. The MDS identified that Resident #42 had an indwelling catheter. The MDS identified Resident #42 is at risk for developing pressure ulcer and that he had an unhealed stage 2 pressure ulcer during the seven-day lookback period. The MDS included diagnoses of hypertension (high blood pressure), obstructive uropathy, end stage renal disease, and malnutrition. On 5/30/23 at 1:28 PM Resident #42 reported that he went to the hospital a couple of days ago. The Care Plan Focus revised on 7/21/22 indicated that Resident #42 had an indwelling catheter related to benign prostatic hyperplasia with obstructive uropathy (prostate gland enlargement with obstructed urinary flow). The Care Plan intervention dated 12/9/21 directed the staff to monitor for signs and symptoms of a urinary tract infection such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. The Transfer to Hospital V5 note dated 2/13/23 at 3:23 p.m. indicated that Resident #42 went to the hospital due to urosepsis (severe UTI). The eAdmin Record (Default Note) dated 2/16/23 at 1:26 p.m. indicated that Resident #42 remained in the hospital. The Last BM and Admit/Re-Admit note dated 2/17/23 at 7:13 p.m. indicated that Resident #42 had a septic UTI that required hospitalization . Resident #42 required physical therapy for strengthening. A Physician order dated 2/17/23 directed staff to administer Apixaban (anticoagulant/blood thinner) 2.5mg (milligrams) two times a day for atrial fibrillation (irregular heart rate). The Care Plan revised on 5/17/23 identified Resident #42 was on anticoagulant therapy and directed staff to monitor, document and report to the doctor as needed for signs and symptoms of anticoagulant complications such as bruising. The Health Status note dated 5/20/23 at 3:58 p.m. indicated that Resident #42 had strong smelling dark urine. The note directed to push fluids. The Communication/Visit with Physician dated 5/23/23 at 1:38 p.m. identified that Resident #42 saw the physician for nursing home rounds. The physician gave no new orders. The Health Status note dated 5/24/23 at 12:07 a.m. documented that Resident #42 experienced confusion. He attempted to change the channel on his tv with his recliner remote. The Care Plan Review note dated 5/26/23 at 7:46 a.m. indicated that Resident #42 used apixaban without adverse reactions. The Health Status dated on 5/27/23 at 2:09 p.m. listed that the nurse faxed the physician on 5/26/23 due to Resident #42's strong smelling urine that contained mucus and his confusion. At the time of the note, the physician had not responded to the fax. Resident #42 appeared slumped in the chair most of the time, with purple urine in his urinary catheter. He reported being fine just tired. The nurse noted his vital signs with in normal range for him. Resident #42 described his urine flowing across the floor that made a puddle in front of him that he could see. The nurse looked at the floor and noted it as dry. The nurse visited with the ER staff about Resident #42 and received an order to send him for an evaluation. At 2:40 PM Resident #42 left the facility in route to the hospital with his family following. Resident #42's After Visit Summary from the ER dated 5/27/23 listed a diagnosis of a urinary tract infection with hematuria (blood in urine). The form instructed the facility to administer Bactrim DS as ordered. The Health Status note on 5/28/23 at 2:26 a.m. indicated that Resident #42 returned to the facility at 7:35 p.m. with a diagnosis of a UTI and a new order to start Bactrim DS (antibiotic) by mouth twice a day for five days. The Order Details dated 5/29/23 identified an order for Bactrim DS Oral Tablet 800-160 milligrams (MG) one tablet two times a day for a UTI for 5 days. Resident #42's clinical record lacked documentation, assessment, treatment, and follow up on Resident #42's urinary symptoms after 5/20/23 until 5/27/23. On 6/1/23 at 7:25 a.m. observed Resident #42 lying in bed with his catheter drainage bag hanging from the bed and touching the floor. The urinary catheter contained pink tinged urine in the tubing and the bag. Resident #42's arms appeared to have extensive bruising (dark in color), the left arm looked to have an old scabbed skin tear. Staff C, LPN, reported that Resident #42 commonly had bruises to his arms. On 6/1/23 at 1:07 p.m. Staff S, License Practice Nurse (LPN), acknowledged that he made an entry in the progress notes on 5/20/23 regarding Resident #42's dark and strong-smelling urine. Staff S reported having concern because he knew Resident #42 had a history of UTIs and sepsis. Staff S stated he thought he faxed the physician but could not state for sure. Staff S explained that he only worked weekends and did not know what happened on Monday through Thursday. Staff S verified that he sent Resident #42 to the ER the following Saturday (5/27) due to Resident #42 appearing dopey, slouchy, and had purple colored urine. On 6/1/23 at 1:38 p.m. the Director of Nursing (DON) reported that she could not locate a physician notification on or after 5/20/23 until Resident #42 went to the ER. On 6/1/23 at 4:51 p.m. the DON reported the facility did not have a policy for UTIs. The Change in Condition Policy revised 3/29/23 instructed the purpose of the policy related to the following: 1.To improve communication between nurses and a provider with nursing is monitoring a change in condition. 2. To enhance the nursing evaluation of and documentation of a resident who has a condition change. 3. To provide a standard format to collect pertinent clinical data prior to contacting the provider when there is a condition change. 4. To standardize shift to shift communication about a resident change in condition On 6/5/23 at 10:52 a.m. the DON stated she expected the nurse to notify the Physician with a condition change and to complete a follow-up urinary assessment. On 6/5/23 at 4:25 p.m. observed Resident #42's bilateral arms and hands with extensive dark colored bruising. Observed two black colored scabbed areas to the left wrist area and one black colored scab to the left elbow area. Observed Resident #42's bilateral arms were very dry. Resident #42 reported the bruising occurred from bumping his arms. On 6/5/23 at 4:30 p.m. Staff T, Certified Nursing Assistant (CNA) reported Resident #42's arms usually appear like that. Staff T, CNA stated Resident #42 picks at his arms at times and usually wears short sleeve shirts. Review of Resident #42's clinical record lacked documentation, assessment, and treatment on the bruises and scabbed areas to the bilateral arms and hands. In addition, the record lacked a skin assessment, an incident report, notification to the physician or his family. The clinical record lacked an intervention or treatment to reduce the risk of further bruising. The clinical record contained no request for labs related to his use anticoagulant therapy and bruising. The facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/23 documented if staff observed a bruise, contusion, abrasion, or skin tear on a resident, staff should report it to the nurse immediately. The policy further directed to monitor the bruise/contusion/skin tear/abrasion every week, document any changes and/or progress towards healing, and update the resident's Care Plan. On 6/5/23 at 5:10 p.m. the DON explained that she expected an assessment of bruises and scabbed areas with documentation according to the facility policy.

Based on interviews, emergency room , hospital and facility record review, the facility failed to provide adequate nursing supervision to prevent injuries for 3 of 4 residents reviewed (Residents #22, #25, and #33) for falls. In addition, the facility failed to complete neurological assessments for 1 of 4 residents (Resident #22) reviewed for falls. Despite the facility documenting that Resident #25 had difficulties with standing with her transfers using the mechanical standing lift, no one adjusted the transfer technique to ensure her safety with transfers. Due to the staff continuing to transfer Resident #25 with an unsafe technique, she fell out of the standing lift resulting in a compression fracture in her back. Resident #33 had a history of falls and the facility added interventions to the Incident Report or the Progress notes but never updated the Care Plan to reflect the interventions. In addition, the facility knew that some of the interventions did not work but did not modify the intervention. The facility could not provide documentation to verify the implementation or modification of the interventions. On the fourth fall, Resident #33 fell fracturing her hip and required surgery to repair it. Resident #22 experience an unwitnessed fall that resulted in an emergency room visit following her discharge earlier in the day from the hospital. See F684 regarding additional information related to Resident #22. Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #25 required extensive assistance of two persons with bed mobility, dressing, and toilet use. In addition, she required total dependence on two persons for transfers, and extensive assistance of one person for personal hygiene. The assessment indicated that Resident #25 could not ambulate (walk) and needed one person to push her wheelchair. The MDS included diagnoses of cancer, heart failure, diabetes, depression, and a compression fracture of the spine (broken bone caused by weakness in the back). On 5/30/23 at 10:53 AM Resident #25 stated she fell out of a lift and fractured her back. She stated she went to the hospital and had a raging urinary tract infection (UTI), fluid on her heart, and a fracture in her back. In another interview the same day at 1:05 PM, the resident explained that she fell out of a standing lift, as Staff D, Certified Nursing Assistant (CNA), operated it. She reported that she did not have anyone else in the room when it happened. Resident #25 added that staff now use a full-body mechanical lift to transfer her. Resident #25 explained that oftentimes the staff transfer her alone when there is supposed to be two people. On her wall at the head of the bed, observed a sign that instructed to only use a nonmechanical stand-to-sit for Resident #25. The Health Status Note dated 4/16/23 at 9:00 PM indicated that Resident #25 reported that her pain management routine worked and she slept better. She added that she could get around better with her medication schedule with the Tylenol and tramadol (pain medication). The Health Status Note dated 4/18/23 at 12:54 PM written by Staff F, Registered Nurse (RN), indicated that a Certified Nurse Aide (CNA) reported that Resident #25 did not stand well in the mechanical standing lift with an assist of one. The CNA described that Resident #25 pulled her arms up and bent her knees. The Health Status Note dated 4/19/23 at 1:38 AM documented by Staff E, Licensed Practical Nurse (LPN), that Resident #25 continued to have difficulty standing with transfers. The Health Status Note dated 4/25/23 at 6:54 AM labeled Late Entry written by Staff F indicated Resident #25 complained of shortness of breath, shallow respirations, poor eye contact, flat voice, and diminished lung sounds. Resident #25 had stable vital signs, oxygen saturation of 98% on room air, denies pain while in bed, and when up has pain of 7 of out 10 (0 no pain, 10 the most pain). The nurse encouraged Resident #25 to increase their activity. The Communication - Other Note dated 4/25/23 at 2:50 PM listed that the nurse requested a muscle relaxer per therapy recommendation. The Communication/Visit with Physician Note dated 4/25/23 at 8:30 PM labeled Late Entry detailed new orders by the provider. Resident #25 will have X-rays on the next day of the T-Spine (upper middle back), and L-Spine (middle to lower back). In addition, the provider provided an order for baclofen (muscle relaxer) one tablet three times a day as needed for back spasms. The nurse notified the family and updated the clinical record. The Health Status Note dated 4/26/23 at 11:56 AM indicated that Resident #25 had an X-ray. She continued to complain of pain with activity. The Lab/Diagnostics Note dated 4/27/23 at 5:41 AM listed that the facility received the x-ray results and faxed them to the Primary Care Provider (PCP). The Health Status Note dated 4/27/23 at 9:30 AM written by Staff F indicated that Resident #25 continued to complain of sharp pain on her left of her back radiating to the flank area (lower left side of back) without radiation to her left arm. Vital signs remain stable with an oxygen saturation of 88% (normal is 90% and above), blood pressure of 126/58, temperature of 95 (average 98.6), pulse of 88 (typical range 60-100), and respirations (typical range 12-20). As the staff assisted Resident #25 to the bath chair in the standing mechanical lift, she complained of a sharp pain in her left side of her back. Resident #25 received her scheduled Tramadol (pain medication) and Tylenol earlier in the morning. The Communication/Visit with Physician Note on 4/27/23 at 10:12 AM identified the nurse called the PCP's office to provide an update on Resident #25's condition. The Communication/Visit with Physician Note on 4/27/23 at 1:41 PM indicated that the facility received a fax from the physician that dictated that Resident #25 had chronic (long-term) degenerative changes. The physician directed to schedule an appointment with her PCP in the office unless she would not wait. The nurse updated the resident and her niece then got a bed hold agreement. The nurse provided a report to the emergency room (ER). The Health Status Note dated 4/27/23 at 1:50 PM recorded that Resident #25 went to the ER with staff in the facility van. The ED Provider Notes dated 4/27/23 at 2:37 PM listed Resident #25's chief complaint as a report of slipping from the sit-stand machine and jarred her back making her pain worse in her back around to her abdomen. Resident #25 came to the ER for an evaluation of mid back pain. She reported when in a lift the machine came down somewhat quickly and stopped. As that happened she developed immediate onset of mid back pain. Resident #25 denied extension of the pain into her legs but did feel like it came across her upper abdomen to her chest. She reports a history of chronic low back pain but explained her current pain is different. Resident #25 denied any exacerbation of her regular back pain. She tried tramadol that day with little or no relief. Resident #25 did have an X-ray the day before that had negative results of any acute fracture. The assessment revealed that Resident #25 had some tenderness at approximately T-11 on palpation (a type of touch used to assess). The Discharge instructions directed to increase her tramadol to 50 milligrams (mg) three times a day for one week and continue Tylenol. Apply ice to the affected area for 20 minutes per hour while awake for that day and the next day. If worsening or changing symptoms contact the clinic and follow-up as needed. The Final Impression list thoracic back sprain, initial encounter. The Health Status Note dated 4/27/23 at 6:15 PM written by Staff F indicated that Resident #25 returned to facility, refused supper, and requested to go to her room. She appeared alert and oriented. When the nurse went to give Resident #25 her evening medications, she noted involuntary jerking of resident's head and arms. She further documented that Resident #25 appeared pale and had a clear but vague speech. Resident #25 could not hold her medication cup but could to take her medications without difficulty. The Health Status Note dated 4/27/23 at 8:15 PM written by Staff F described Resident #25 as continuing to act different from usual, she could not feed herself, she did not speak, and had weak extremities. The Communication - Other Note dated 4/27/23 at 8:20 PM identified that the nurse called the ER and notified them of Resident #25's condition. The ER recommended sending her to the ER for an evaluation. The nurse contacted 911. The ED Provider Notes dated 4/27/23 at 9:47 PM listed a chief complaint of an altered mental status. The nursing home staff reported that she could not speak, feed herself, or stand. The nursing home staff indicated this started after returning from the ER that afternoon. The note listed that Resident #25 came to the ER earlier in the day and had a negative work-up at that time. After returning to the nursing home, she became more lethargic, could not speak, or feed herself. Resident #25 returned to the hospital in an ambulance and could not give any history but could follow commands. Her physical exam revealed that she opened her eyes to a sternal rub (type of touch used when unable to arouse) and could make eye contact. She had generalized weakness but not focal deficits noted. The Plan/Medical Decision-Making section listed the hospital would admit her for neurological (neuro) checks and telemetry (heart monitoring). The provider indicated that they did not know the cause of her delirium but would check a urinalysis (UA) to rule out a cystitis (bladder infection). The Communication - Other Note dated 4/27/23 at 10:56 PM listed that the facility received a call from the ER nurse. The ER nurse reported they planned to keep Resident #25 for observation that night. The ER completed a CT Scan (special imaging) the revealed no changes. The ER planned to check neurological (neuro) checks (assessment to determine changes in the brain). They reported that she continued to be twitchy at times. Resident #35 had on and off issues with being able to talk, knowing her name, and knowing what was happening. The History and Physical dated 4/28/23 at 9:14 AM repeated the information from the ED Provider note from 4/27/23. The note added that the hospital found her to have nasty looking urine. They admitted her and started her on ceftriaxone (an antibiotic) with a diagnosis of acute delirium. The morning of 4/28/23 Resident #25 observed awake and responding appropriately. She appeared very somnolent, very cool, and clammy. The Assessment section listed delirium, permanent atrial fibrillation (irregular heart rate), type 2 diabetes mellitus with other specified complication. The Plan listed to admit her to acute care, already started on ceftriaxone for pretty nasty looking urine. Her last culture did grow Proteus (bacteria), which should be susceptible to ceftriaxone. The Communication - Other Note dated 4/29/23 at 1:06 AM identified that the nurse called the hospital for an update on Resident #25. The hospital reported that Resident #25 had congestive heart failure, elevated renal function, a urinary tract infection (UTI), an okay chest X-ray, and a negative CT of her head. Resident #25 received oxygen and albuterol treatments (inhaled steroids to open the lungs). She continued to have confusion and inability to track. The Progress Notes dated 4/29/23 at 9:29 AM indicated that Resident #25 had back pain of the thoracolumbar region for greater than six weeks. She started on a muscle relaxant and received tramadol for her pain without improvement. The etiology of the pain could be from a kidney infection, however, due to the musculoskeletal nature, regarding the full-boy mechanical lift incident in the nursing home, proceed with CT scans to rule out a compression fracture or any other potential etiology of her back pain while hospitalized . The CT Thoracic Spine without contrast dated 4/29/23 impression listed the following a. Inferior endplate fracture at the T8 b. Degenerative change of the spine. There is central canal stenosis and neurol foraminal narrowing at T10-11. c. Small effusions with bibasilar atelectasis d. Findings suggesting pulmonary edema. The Progress Notes dated 4/30/23 at 8:23 AM indicated that Resident #25 told her PCP that she had an incident at the nursing home where she fell . She described the incident as the staff tried to transfer her and pivot her standing, her legs gave out and she went down rather hard on her buttocks into the chair. She reported that she felt the worsening back pain at that time but could not remember when the incident occurred. The Communication/Visit with Physician on 5/2/23 at 3:57 AM the facility received Resident #25's X-ray results the PCP wrote that the X-rays on 4/26/23 with negative results. The X-ray results on 4/29/23 revealed a compression fracture at her T-8. The PCP questioned if Resident #25 had a fall. The nurse responded that they did not know of any falls but she did use a sit to stand with a sling. Resident #25 chicken wings (bends her arms at an upward angle) and needs to sit quickly. The Communication/Visit with Physician dated 5/2/23 at 2:21 PM indicated the PCP reviewed the X-Ray and Resident #25 remained in the hospital. The PCP wrote that Resident #25 reported that she fell at the nursing home. The PCP explained that Resident #25 had a compression fracture of her T-8. The PCP indicated that her record did not have any documented falls. On 5/31/23 at 1:35 PM the Director of Nursing (DON) reported that they did not do an investigation or report regarding resident's compression fracture findings due to the hospital discovering it. She explained that they reviewed their records and found no staff reports or documentation of a fall. On 5/31/23 at 2:45 PM Staff F reported that she did not think that she documented on 4/18 that anyone told her that Resident #25 had problems with the mechanical standing lift, and if she did, she couldn't remember. She denied remembering any incidents or concerns with Resident #25 using the stand. On 5/31/23 at 3:06 PM Staff E, Licensed Practical Nurse (LPN), remarked that she could not remember documenting on 4/19 that Resident #25 had difficulty with the mechanical standing lift. She reported that she did not know about any incidents with Resident #25 using the stand and complaining of back pain. When asked what she would do if that someone reported that to her, she replied that she would let therapy know, but therapy said resident did fine with the mechanical standing lift so to keep using it. On 5/31/23 at 3:20 PM Staff H, Occupational Therapist (OT), explained that that all staff received training that they could always do more for the resident, but not less. She stated if the staff or the resident felt uncomfortable using the standing mechanical lift or standing lift, they could always use a full-body mechanical lift to transfer the resident without having to call them before using it, and have the nurse notify them of the concern to address it the following day. She stated that Resident #25 did do well with the lift in therapy and that in her opinion, Resident #25 tried harder for them (therapy). She also felt that Resident #25 felt more comfortable with some staff than others. She stated that staff use chicken winging, but it can present differently from one staff member to another, such as elbows pointed out away from the body or pointing upwards like a flapping motion. On 6/1/23 at 10:30 AM Resident #25's physician from the ER explained her compression fracture was consistent with a sudden stop coming down in the lift. 46875 2. Resident #33's MDS dated [DATE] assessment identified a BIMs score of score of 99, which indicating that Resident #33 could not complete the interview. The MDS identified a completed staff assessment for mental status that indicated Resident #33 had moderately impaired decision making. The MDS identified Resident #33 required supervision and assistance of one person with bed mobility. The MDS described Resident #33 as independent with transfers and ambulation. The MDS indicated that Resident #33 required limited assistance of one person for toilet use. The MDS documented Resident #33 had occasional incontinence of bladder. The MDS included diagnoses of diabetes mellitus, Alzheimer's disease, malnutrition, anxiety, and depression. The Incident Report (IR) labeled Found on Floor dated 1/4/23 at 9:30 a.m. indicated that the staff found Resident #33 on the floor with her pants and briefs around her knees. Resident #33 could not describe what happened. The Immediate Action Taken identified the nurse requested a urinalysis (UA) and wound culture from the Primary Care Provider (PCP) due to her high blood sugars. Resident #33's Falls Tool assessment dated [DATE] listed a score of 20, indicating a high risk for falls. The Incident note dated 1/5/23 at 5:22 a.m. identified that a Certified Nurse Aide (CNA) found Resident #33 lying on the floor with her supper tray. Resident #33's clinical record lacked an IR or a Fall Tools Assessment related to the fall on 1/5/23. The Health Status note dated 1/5/23 at 5:41 p.m. indicated the staff attempted the whole shift to obtain a urine specimen. Resident #33 did not understand the need and moved the collection hat from the toilet several times. The staff did get the wound culture. The clinical record lacked documentation that of completion of the 30 minutes checks for the 1/12/23 fall intervention. The IR labeled Slipped or fell dated 1/12/23 at 7:25 p.m. identified that the nurse heard a loud thud and found Resident #33 lying on her right side next to the toilet with her head under the sink holding on to a dry brief and a dry pair of pants. Resident #33 reported she slipped while going to the bathroom. The IR documented an immediate intervention of 30-minute checks. Resident #33's Falls Tool assessment dated [DATE] listed a score of 19, indicating a high risk for falls. The IR labeled Found on Floor dated 1/21/23 at 7:00 p.m. indicated that a Certified Nurse Aide (CNA) found Resident #33 on the floor by her bathroom with her head facing towards the bathroom lying on her right side. The IR listed an immediate intervention of a motion alarm in her room to alert staff when she went to the bathroom. Resident #33's Care Plan lacked documentation of the intervention of a motion alarm following the fall on 1/21/23. Resident #33's Falls Tool assessment dated [DATE] listed a score of 19, indicating a high risk for falls. The IR labeled Found on Floor dated 2/21/23 at 7:45 p.m. indicated that the staff found Resident #33 on the floor in her room. The staff assisted Resident #33 to bed with a mechanical lift. After getting off the floor, Resident #33 started complaining of pain. The nurse sent her to the emergency room for possible fracture to her left hip. The IR lacked documentation if the motion sensor was in place and functioning at the time of the fall. The Immediate Action's description indicated the nurse put a pressure mat alarm to her recliner. The Transfer to the Hospital V5 note dated 2/21/23 at 8:15 p.m. indicated that Resident #33 went to the hospital due to a fall with a pain level of 10 on the pain scale of 0 meaning no pain and 10 meaning excruciating pain. The Health Status note dated 2/21/23 at 11:51 p.m. documented that the staff heard a loud noise in Resident #33's room at 7:45 p.m. Upon entering the room, they found Resident #33 on the floor rolling around calling for her mother. The nurse called for assistance of another nurse then assessed Resident #33. The assessment revealed that Resident #33 complained of significant pain in her left thigh/hip area. When the nurse palpated (assessment touch) the area during her assessment, Resident #33 did not respond with pain and the nurse did not notice shortness of her left leg at that time. After the staff assisted her with two people off the floor with a full-body mechanical lift and put her in her chair, she continued to complain of pain to her left thigh/hip. At 8:05 p.m. the nurse contacted the emergency room (ER) and received an order to transfer Resident #33 to the ER. The nurse contacted emergency medical services (EMS) who arrived and transported Resident #33 to the ER. The ER called the facility to notify them that Resident #33 fractured her left hip and they transferred her to another hospital. Resident #33's Falls Tool assessment dated [DATE] listed a score of 19, indicating a high risk for falls. The hospital's Discharge Documents dated 2/28/23 listed Resident #33's principal discharge diagnosis as a left intertrochanteric fracture (hip fracture) following an intramedullary nail (a type of repair in hip surgery) with a left hip hematoma (large bruise), anemia (low blood volume), and hypotension (low blood pressure). The Reason for Admission indicated that Resident #33 fell at the nursing home and fractured her hip. Resident #33 did not appear lucid at the time of admission but her daughter consented to her having hip surgery. The documents included an order to for treatment of an incisional wound. The Last BM and Admit/Readmit note dated 2/28/23 at 3:10 p.m. recorded that Resident #33 went to the hospital for a left hip fracture. Resident #33 required the skilled services of a daily assessment, blood transfusion two times, and diabetes management. On 6/1/23 at 10:00 a.m. Staff M, Restorative Aide, described herself as the person responsible for checking the resident alarms in the facility. Staff M stated she put the alarms in place and check them on the 5th of each month. Staff M reported Resident #33 had an assigned motion sensor prior to her fall when she fractured her hip. Staff M reported that Resident #33 would turn around the motion sensor or put it in a drawer to prevent it from alerting the staff. Staff M stated after her fall with fracture, they decided to switch to a pressure alarm. Staff M reported that she tracked and documented the alarms on a flow sheet. On 6/1/23 at 10:17 a.m. Staff N, Certified Medication Aide (CMA), reported that Resident #33 used to have a motion sensor in her room. Staff N stated the motion sensor chimed at the nurses' desk. Staff explained that the alarm stop chiming after Resident #33 moved out of the way of the alarm. Staff N added that if staff are not at the nurses' station or in the hallway, they could not hear the chimes from the motion sensor. Staff N reported that sometimes she found the motion alarm turned towards the wall and she would correct it. Staff N explained that Resident #33 knew the purpose of the alarm. Staff N reported that Resident #33 received the pressure alarm after her fall with fracture. On 6/1/23 at 11:00 a.m. Staff I, Registered Nurse (RN)/MDS Coordinator, acknowledged and verified that Resident #33's Care Plan did not have the motion sensor added it. Staff I reported they placed the motion sensor in Resident #33's room and put the base for the motion sensor at the nurses' station. Staff I stated the motion sensor chimed at the desk while the resident is near the sensor and then it stopped chiming when she moved out of range. Staff I verified that staff could not hear the chimes if they are not close to the nurses' desk if it chimed. Staff I expressed that she hated alarms. The Weekly Monitoring of Alarms form indicated the staff checked Resident #33 pull tab alarm on 2/31/23 (2/28/23 last day in February 2023). The form lacked any documentation regarding a motion sensor for Resident #33. The Weekly Monitoring of Alarms form included a scribbled section that Resident #33 had a pull tab alarm. Above the scribble listed a chair pressure alarm. The form indicated that someone checked the alarm on 3/26/23 and changed the sensor mat on 4/5/23. The form included scratched out documentation for the battery change due date and the 5 for 4/5/23 with an 8 written above. The Fall Prevention and Management policy revised 3/29/23 listed the purpose of the policy as the following: a. To promote resident well-being by developing and implementing a fall prevention and management program b. To identify risk factors and implement interventions before a fall occurs c. To give prompt treatment after a fall occurs d. To prevent further injury e. To provide guidance for documentation. The policy directed staff after a fall to complete an Incident Report in risk management, complete a Fall Tool assessment, and update the Care Plan with any changes or new interventions. The Procedure directed the staff to not move the resident. In addition, the policy instructs to not move the resident has a suspected hip fracture. The Alarms - Bed, Chair, and Door policy revised 8/24/22 listed the Purpose of the policy as to ensure dignified and appropriate use of alarms based on the resident's condition and identify a process used to check the facility alarms. The policy further directed the Rehab or Nursing staff to check the motion sensor daily to check the alarms functionality. Staff should check the resident's condition to determine if the resident benefited from the use of an alarm. On 6/5/23 at 10:52 a.m. the DON reported that she expected the staff to assess the effectiveness of a fall intervention. If the intervention did not work, she expected them to change the intervention. On 6/5/23 at 5:15 p.m. the DON verified that she could not locate the 30-minute checks for 1/12/23. On 6/6/23 at 3:02 p.m. the DON reported that she expected the nurse to complete a Fall Risk evaluation quarterly and after a fall. 41785 3. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the Resident #22 required limited assistance of one person with dressing. She could independently move in bed, walk in her room, walk in the corridor, use the toilet, and complete her personal hygiene. Resident #22 used a walker and a wheelchair. She could stabilize herself without staff assistance but was not steady with moving from a seated to a standing position, turning around, moving on and off the toilet, and surface-to-surface transfer. Resident #22 received a scheduled pain medication in the previous five days of the lookback period. She had one fall without injury since the previous assessment. The Care Plan Focus revised 6/9/22 indicated that Resident #22 had a risk for falls related to her history of falls. The interventions directed the staff to monitor her for significant change in gait, mobility, positioning device, standing balance, sitting balance, and lower extremity joint function. On 6/1/23 at 2:10 PM observed Resident #22 in her recliner in her room. Resident #22 said that she did not have pain but she did have a lot of pain before and after her back surgery. She said that she kept getting dizzy and that's what caused her falls. The Discharge Summary dated 5/26/23 included four diagnoses Resident #22 received treatment for in the hospital. a. Osteoporosis b. Closed fracture of multiple thoracic vertebrae c. Closed stable burst fracture of the sixth thoracic vertebra with delayed healing. d. Closed fracture of lumbar vertebra, unspecified fracture morphology, unspecified lumbar vertebral level. The Discharge Summary directed the nursing facility to schedule the Prolia injection (injection used to treat bone loss). On 6/1/23 at 3:40 PM Resident #22's Representative (RR #22) said that they got a call from the facility after her fall on 5/13 that Resident #22 had a great deal of pain. She thought the facility called her over a weekend, and they brought in a portable X-ray machine on a Monday or Tuesday. Resident #22 had surgery and then she fell again the day she went back to the facility. The Incident Note dated 5/26/23 at 11:58 PM indicated that the nurse went to Resident #22's room at 8:00 PM and found her lying on the floor by her bed on her left side. She appeared wrapped up in her bed pad and complained of pain when moved. Resident #22 had increased confusion talking about nonexistent children that she needed to find and that she had mouse traps around her bed. Resident #22 could not say what happened due to her confusion and hallucinations. Resident #22's Representative (RR #22) arrived while Resident #22 remained on the floor. She requested to have her evaluated at the hospital due to her having vertebroplasty (a procedure involving special cement injected into a fractured vertebra - with the goal of relieving spinal pain and restoring mobility) that morning. At 10:20 PM the hospital called to notify that Resident #22 would return to the facility by ambulance. They reported that she appeared alert, oriented, doing well, and walking ok. RR #22 questioned if she could have a motion alarm that night. The Neuro Check - V 4 dated 5/26/23 at 8:15 PM indicated that Resident #22 had weakness to all her extremities, confusion, and hallucination. The Neuro Check - V 4 dated 5/26/23 at 8:45 PM lacked an assessment of her eyes, hand strength, or orientation with the vital signs from the 8:15 PM assessment. The Comments section described Resident #22 as stable and the facility waited for the ambulance. On 6/5/23 at 8:06 AM the Director of Nursing (DON) said that when a fall occurred the team met to discuss the incident, but, they did not necessarily do a root cause analysis or document the meetings. On 6/6/23 at 8:11 AM the DON provided a hard copy the neurological assessments and referred to the electronic assessments that included eye assessment, hand strength and orientation. She said that she expected the staff to take a set of vitals and complete all the areas of the assessment when a resident had an unwitnessed fall.

Based on clinical record reviews, facility policy reviews, and staff interviews, the facility failed to provide an adequate assessment and timely intervention for a change in condition for 1 of 3 residents reviewed (Resident #3). Staff changed Resident #3's catheter due to it being plugged on 7/29/22. After 7/31/22 at 1:59 p.m. Resident #3's clinical record lacked documentation of urinary output. The staff failed to assess the lack of output. On 8/1/22, Certified Nursing Assistants (CNAs) reported that Resident #3 had blood in her incontinent pad. The nurse repositioned the catheter and thought it was okay, not knowing that Resident #3 did not have output recorded for the previous two shifts. She did not check the catheter the rest of her shift to assure it drained. Resident #3 also complained of her stomach hurting. The Speech Therapist (ST) reported that Resident #3 may have aspirated at lunch. The nurse assessed lung sounds and vital signs, noting Resident #3 had a blank stare. The family wanted Resident #3 sent to the hospital. Another nurse assessed Resident #3 and who claimed that was Resident #3 at her baseline. During an assessment, the nurse noted Resident #3's abdomen tender in her lower quadrants. The family pointed out blood in her catheter bag. They discovered Resident #3's incontinent pad saturated in bloody urine. After the nurse changed the catheter, it had an immediate return of 500 cubic centimeters (ccs). The nurse clamped the catheter for a few minutes and when released she had an additional 500 cc's of urine. The family called Resident #3's physician prompting a transfer to the emergency room (ER). The facility reported a census of 54 residents. Findings include: According to the Minimum Data Set Assessment (MDS) assessment dated [DATE] Resident #3 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #3 required extensive assistance with activities of daily living (ADL's) including bed mobility, dressing, toilet use, and personal hygiene. Resident #3 had an indwelling urinary catheter. Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 had a feeding tube and a mechanically altered diet. The Care Plan revised 6/30/22 identified Resident #3 had an indwelling (urinary) catheter related to chronic urinary tract infections (urinary tract infection ([CONDITION(S)]'s)) and [CONDITION(S)]. The interventions included: a. Monitoring/documentation for pain/discomfort due to the catheter. b. Monitoring, recording, and reporting to the health care provider signs/symptoms (s/s) of a [CONDITION(S)]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and a change in eating patterns. c. Catheter care by Certified Nursing Assistants (CNA's) every shift and as needed. d. May wear a leg bag during the day and straight catheter drainage bag at night. e. Reporting unusual observations/conditions to the nurse. f. Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The Care Plan Focus initiated on 6/17/22 indicated that Resident #3 required a tube feeding related to neurosarcoidosis (an [CONDITION(S)] disease that affects the nervous system, such as the brain or spinal cord). The interventions included monitoring/reporting to the nurse signs and symptoms of complications of tube feeding (coughing, choking, etc.). A Follow up Question Report dated 7/21/22 to 8/1/22 recorded the following urinary catheter outputs for Resident #3: 7/31/22 at 1:59 p.m. 400 ccs. 7/31/22 at 7:04 p.m. not applicable. 8/1/22 at 5:10 a.m. response not required. 8/1/22 at 10:12 a.m. response not required. The Progress Notes dated 8/1/22 at 1:13 p.m. documented that at 7:30 a.m. the nurse got called to Resident #3's room. Resident #3 had blood in her urine. When the nurse checked the catheter, she noted it got pulled out about two inches. The nurse deflated the bulb and repositioned it. Resident #3 complained that her stomach hurt. An assessment of her abdomen determined her bowel sounds sounded active. Resident #3 received assistance to her wheelchair, and then to breakfast. She only drank a little bit of juice. She went to therapy to work with Physical Therapy (PT) and Occupational Therapy (OT). Resident #3 talked to the nurse when she checked her blood sugar before dinner. ST took Resident #3 to dinner. She reported that Resident #3 choked on a noodle. The nurse checked Resident #3's vital signs and they were within normal limits. Resident #3's lungs sounded diminished but the nurse did not hear any wheezes. Resident #3 appeared to have a blank expression on her face. The nurse called Resident #3's physician's nurse and left a message for her to call back. Resident #3 had family with her. The nurse had the aides lay her down. The Progress Notes dated 8/1/22 at 1:15 p.m. documented that Staff F, Registered Nurse (RN), evaluated Resident #3 for another nurse, related to her general condition. The assessment determined her neurological check within normal range, her pupils equal and reactive, her lungs clear, and her skin felt warm and dry, noted tenderness in the lower quadrants of her abdomen but her bowel sounds remained active in all quadrants. Resident #3's had an Accu Chek (blood sugar) of 116 and stable vital signs. The Progress Notes dated 8/1/22 at 2:05 p.m. documented that Staff F assessed Resident #3 with the Nurse Manager (NM) and her family present. Nurse reported findings to the family and the NM. The nurse found Resident #3's assessment within normal limits (WNL). Staff F encouraged Resident #3 to lay down for a while since she had been up in the wheelchair since 8 a.m. The family insisted that Resident #3 needed to be sent out to the hospital as soon as possible. The NM and Staff F explained that the facility had to follow certain procedures especially since Resident #3 did not appear to be in distress. They reassured the family that the prior nurse called the physician's office. The family left the room instantly. The NM then received a call from another family member that informed the NM she had the Power of Attorney (POA) and wanted Resident #3 immediately sent to the hospital. The NM attempted to educate the family that the ambulance could go to the nearest hospital for Resident #3 to be assessed, and they had to have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NM reminded the family that the time she went to the ER, they went to the closest hospital. Once at that hospital, that hospital made the decision to transport her. The family insisted the facility van driver drive her to their preferred hospital ER. The NM again attempted to educate the family that if Resident #3 needed to be seen in the ER for an emergency, for Resident #3's safety, the staff could not transport her to the ER in the facility vehicle. The family then hung up on the NM with no further comments. The Progress Notes dated 8/1/22 at 2:17 p.m. documented that the staff encouraged laid Resident #3 down in bed. When the staff removed Resident #3's, they observed the brief saturated with bright red urine. The nurse attempted to irrigate the catheter, but met resistance. The nurse removed the catheter and discovered the tip had sediment making it hard. The nurse inserted a new catheter without difficulty, and received an immediate return of greater than 500 ccs of bright red urine. The nurse clamped the catheter for a few minutes, and after releasing the clamp, the catheter had an additional immediate return of 500 ccs. The Progress Notes dated 8/1/22 at 2:30 p.m. documented the physician's nurse returned the call, with an okay to send Resident #3 to the ER, if the family felt she had a change in condition. The hospital's History and Physical dated 8/2/22 at 8:04 a.m. identified that Resident #3 got admitted to the hospital on 8/1/22. The documentation indicated that Resident #3 was new to the provider but got asked to see her while in the hospital regarding her chronic health conditions, [CONDITION(S)], and aspiration. Resident #3 presented with catheter complications. Resident #3 had a very complicated medical history with neurosarcoidosis, diabetes, [CONDITION(S)], and cardiovascular disease. She had a dislodged catheter with hematuria (blood in the urine). She had symptoms for 24 hours of hematuria, urinary retention (likely from the dislodgement of the catheter), and an overall decline in status. Resident #3 did aspirate during lunch the previous day. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan directed to admit to acute care due to the following: a. Hematuria with [CONDITION(S)] as catheter complication - continue intravenous [MEDICATION(S)] and wait for culture results due to a history of resistant organisms that could require an alteration in drug therapy. b. Chronic immune suppression for neurosarcoidosis - on [MEDICATION(S)] and [MEDICATION(S)] 60 milligrams (mg) daily. [MEDICATION(S)] (antibiotic) for PCP (Pneumocystis carinii pneumonia) prophylaxis c. [CONDITION(S)] in the ER, subsequent blood pressures remained stable - if low they could increase the steroid stress dose but Resident #3 already on a substantial dose. The Progress Notes dated 8/2/22 at 5:25 a.m. documented that the nurse called the hospital to see about Resident #3's status. The hospital nurse reported that they admitted Resident #3 at 9:30 p.m. to the hospital for low blood pressure, hematuria, and an altered mental status. At 12:30 a.m., a hospital nurse reported that they changed Resident #3's catheter that the facility changed on Friday with the hard sediment blocking the catheter flow. The catheter had the sediment blocking the tip making it hard again. Interviews with staff, family, and providers regarding events preceding, on, and following 8/1/22 included: a. On 8/24/22 at 9:23 a.m. Resident #3's family stated the ST sat with Resident #3 for lunch on 8/1/22. The ST noticed Resident #3 did not appear at her baseline, and another family member reported that to the nurse. Resident #3 did not follow commands or speech. She had a decreased urinary output. The nurse changed her catheter and the family member heard she had 1300 cc of urine output, then another partially filled bag. The nurse did not think she needed to go to the hospital. The NM told the family they had to follow protocol, and she would not tell them again. She called Resident #3's provider, who called the facility and said to send her to the hospital. She stayed in the hospital for 10 days. The family felt if they wanted their mom to go to the hospital, the facility should send her there. They felt they wasted time. b. On 8/24/22 at 6:41 p.m. Staff A, CNA, explained that she worked on the floor where Resident #3 resided on 8/1/22 with an agency CNA. Resident #3 had blood in her catheter bag right away that shift. She informed Staff C, Licensed Practical Nurse (LPN) and she pushed fluids through the catheter, then they moved her to a wheelchair. She went to breakfast and didn't eat anything. The nurse reported that because she had okay vital signs (VS) she was okay. She didn't eat anything for lunch. She notified the nurse and she didn't do anything. Resident #3's daughter came around 12:30 p.m. and she wanted Resident #3 to go to the hospital. The NM observed as two other CNA's came and did something with the catheter bag and feeding tube. c. On 8/25/22 at 9:41 a.m. Staff B, CNA, stated that on 8/1/22 Resident #3 complained of stomach pain in the morning and then at lunch she had a glazed stare. Resident #3's family came at lunchtime. The family wanted her sent out. Staff F said she was just tired. The CNA's thought it was more than being tired. When they changed Resident #3, they discovered her incontinent pad saturated with blood. They got the nurse to come in and the NM watched her. Staff F changed Resident #3's catheter. She got 1500 cc's out (by looking at the bag), then she kinked it because she learned if they ran out too much at once they could have spasms. She didn't know how much they got out after she unkinked it. d. On 8/25/22 at 12:01 p.m. Staff C explained that she worked on 8/1/22. She was supposed to work from 6 a.m. to 12 p.m. but the person who would come in had novel Coronavirus 2019 (COVID). Resident #3 had blood in her brief in the morning with the catheter pulled out about two inches. She deflated the bulb, repositioned the tube, reinflated it, and it seemed okay. The ST took Resident #3 to lunch and she had choked or aspirated on something. Her eyes were glazed over, and you could put your hand right up to her face with no response. The family wanted her seen and she got the paperwork ready and called the physician's office. She was supposed to leave at 12 so she told Staff F what happened, what the ST told her, and what the family wanted. She left at that point. In a follow up on 8/30/22 at 9:48 a.m. Staff C reported that on 8/1/22 Resident #3 had blood in the catheter bag and it did not drain. She did not know there had been no documented output the previous two shifts. She said if the staff noted abnormal output, like no output that should have been reported. She would have changed the catheter if she had known that. She thought it drained when she repositioned the catheter. She did not check the rest of her shift. The ST reported she thought Resident #3 may have aspirated at lunchtime. She checked her out around 1 p.m. and her eyes didn't move when she put her hand up. Resident #3's daughter wanted her sent out. She told Staff F her family wanted her sent out. She didn't get to do a very good report, because Staff F didn't come back, and it was done in passing. e. On 8/25/22 at 12:46 p.m. the Speech Therapist (ST) said she did sit with Resident #3 at lunch on 8/1/22. Resident #3 did not follow directions like she had done at other times. The ST thought Resident #3 aspirated on something and told Staff C that she should be NPO (nothing by mouth) because of her high risk for choking. Staff C asked Staff F to assess Resident #3. Staff F said she assessed Resident #3 and she would not send her to the hospital. The family wanted her sent. The ST said Resident #3 definitely had a change from her baseline. f. On 8/29/22 at 12:10 p.m. the NM stated on 8/1/22 she became involved with Resident #3 around 1:30, 2 o'clock. Staff C left and Resident #3's family wanted her sent out. Staff C said no change in Resident #3's condition. Staff F wanted support. Resident #3 sat in the wheelchair watching TV. Staff F took her vitals, and they were baseline. The family insisted something was wrong. They pulled up her pant leg and her catheter bag had blood tinged urine, maybe 50 ccs. She did not stay in the room when Staff F took care of the catheter. g. On 8/29/22 at 12:38 p.m. Staff F explained that she worked the other part of the building until Staff C left on 8/1/22. Staff C thought Resident #3 acted a little differently, less responsive, pupils not as reactive. Staff F did not think she presented any differently than normal. The family wanted her sent out, so Staff C called her physician's office and left a message. As the physician was not easy to get a hold of. Staff F said she had another day when they didn't think Resident #3 acted quite right. When they laid her down, she was just fine. The family said something about the catheter. The urine appeared discolored and not much of it. When they changed her brief, they discovered it soaked with bloody urine. When she changed the catheter she had immediate return of ruby colored urine and the tip plugged in the catheter. After about 500 ccs drained she clamped the catheter. She said the catheter drained another 500 ccs after she unclamped it. She really didn't know about the urine prior to the family bringing it up. h. On 8/29/22 at 12:53 p.m. the Staffing Agency CNA reported that she worked on 8/1/22, the day Resident #3 went to the hospital. When they got her up in the morning she had blood in her brief. They told the nurse and she flushed the catheter. Resident #3 refused to eat and reported that she didn't feel good. After lunch she had more blood in her brief and not much in the bag. Resident #3 said she puked but she did not. i. On 8/29/22 at 3:55 p.m. the Physician who cared for Resident #3 in the hospital stated Resident #3 needed to be in the hospital. She needed fluids for [CONDITION(S)] when she came in. She needed antibiotics. Those were started but had to be changed because they didn't cover the infection. The facility should have checked to make sure the catheter continued to drain after they adjusted it. If Resident #3 had no urine output, they should have assessed why she had no output. In a follow up interview on 8/30/22 at 2:40 p.m. the Physician stated the [CONDITION(S)] was not life threatening. She said Resident #3 was septic (the body's extreme response to an infection) by blood cultures. She said Resident #3's medications could mask the symptoms of infection. j. On 8/29/22 at 4:14 p.m. Staff H, CNA, said that Resident #3 did not have any output to record on 8/1/22 at 5:10 a.m. k. On 8/30/22 at 8:38 a.m. Staff I, CNA, stated she didn't remember, but if she documented not applicable on the 7/31/22 evening shift urine output record, either Resident #3 had no output, or someone else had emptied it. l. On 8/30/22 at 12:13 p.m. Staff J, CNA, stated she worked the day Resident #3 transferred to the hospital. Resident #3 was bleeding and had blood in her bed. The nurse kept saying she was fine, just a little blood. They were worried because it seemed like she had something wrong. m. On 8/31/22 at 9:48 a.m. the Physician's nurse stated they received a call in the morning of 8/1/22 from the facility regarding insulin. At 2:02 p.m. Resident #3's family member called concerned about Resident #3 and told them about the catheter. They in turn called the facility and told them Resident #3 needed to be evaluated in the ER. She said Resident #3 had a complex case. n. On 8/31/22 at 10:13 a.m. the Director of Nursing stated she expected staff to monitor catheter outputs, and report to the nurse low or no output. The nurse should assess the situation and intervene accordingly. The facility policy Intake & Output with Hydration Guidelines reviewed/revised 4/25/22 directed to measure fluid intake and/or output on residents who received tube feedings, intravenous fluids, or had urinary catheters. Residents with urinary catheters needed the contents of the drainage bag measured and recorded in the EMR (electronic health record).

Based on record review, hospital report, policy review, and staff and family interviews, the facility failed to adequately monitor and implement measures to prevent constipation for 1 of 1 residents reviewed for bowel regime (Resident #16). Resident #16 transferred to the emergency room with severe pain in the abdomen and nausea. A Computerized tomography (CT) exam detected a large ball of stool measuring 10 centimeters in diameter in the rectum and large colonic stool burden throughout the colon. The Resident #16 went 12 days without bowel intervention. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set assessment dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive deficits. He required limited assistance with the help of one for bed mobility, transfers, and walking. An MDS dated [DATE] showed that he had a change in status and required extensive assistance with the help of one for bed mobility, transfers and toilet use. According to the Care Plan initiated on 11/12/21, Resident #16 had a suprapubic catheter, required assistance of one staff for transfers, hygiene, clothing management, and continent of bowel. The Bowel and Bladder schedule for February 2022 documented the resident had no bowel movement for 12 days from 2/2/22 to 2/14/22. The Clinical Alert Report documented the staff received notification Resident #16 went 3 days without a bowel movement 2/12/22, 2/13/22, 2/14/22, 2/15/22, and 2/18/22. The Clinical Record lacked documentation of bowel interventions from 2/9/22 to 2/19/22. A Nursing Note dated 2/19/22 at 3:10 AM, showed that the resident had a change in condition with abdominal pain, and decreased bowel sounds. At 3:46 AM, the resident complained of pain all over and reported to staff that he was unable to produce a bowel movement. He had severe pain in the abdomen and the resident reported he felt like he would throw up. He transferred to the emergency room for evaluation. A Hospital Report dated 2/20/20 at 12:39 PM, on page 11, documented a computerized tomography (CT) exam detected a large ball of stool measuring 10 centimeters in diameter in the rectum and large colonic stool burden throughout the colon. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/12/22 at 9:20 AM, Staff G, Certified Nursing Assistant, stated the end of February the resident had more pain and often groaned. On 4/12/22 at 8:47 AM, Staff D, Registered Nurse, noticed the resident had become more unsteady on his feet in February and had increased pain. She said that he struggled with constipation and believed it attributed to his increased confusion because once he would have a bowel movement, the confusion would subside for a period of time. On 4/11/22 at 10:25 PM, Staff D, Registered Nurse, stated the bowel movement status would come up on the dashboard of the electronic chart and often times, the secretary would print off the alerts for the nurses. She said that this would tell them when it had been 3 days since a resident had a bowel movement. On 4/12/22 at 3:05 PM, Staff H, Certified Nurse Aide, stated she noticed a decline in Resident #16 and she reported to the nursing staff that the resident wasn't eating and wasn't coming out of the room and had an unsteady gait. She said that his wife would tell the staff that he was telling her that he had to go to the bathroom but then he wouldn't be able to go because he was constipated. On 4/12/22 at 4:23 PM, the Director of Nursing (DON) stated she went through the hospitalization that the impaction was found and that information did not get communicated to them upon return from hospital. The hospital also did not put it as an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that the resident did take himself to restroom at times so the aides were probably not aware of when he would have a bowel movement for sure. On 4/14/22 at 9:26 AM, Resident #16's spouse stated her husband would spend most of his days in the room with her and the two of them sat together in recliner chairs. She said that he had bowel issues and in the mornings he would come in and tell her when he had incontinence of the bowel and he would be very embarrassed about that. She did not recall staff coming in and offering to take him to the bathroom, he would usually ask her to put the call light on when he needed help. According to the Bowel Protocol policy dated June 2019, if a resident were to go 3 days without a bowel movement, staff were to give them 30 milligram (mg) of milk of magnesia, wait 8 hours if no bowel movement then give 2 tabs of Senna. Wait an additional 8 hours, if no bowel movement assess for impaction, and give Dulcolax suppository 10 mg per rectum. On day 4 of no bowel movement, check for impaction, then give a fleet's enema and wait another 8 hours. If there was still no bowel movement, reassess for bowel impaction, obtain all vital signs, assess for abdominal distention and bowel sounds and the contact provider.

Based on record review, policy review and interviews the facility failed to provide adequate supervision and timely interventions for 1 of 3 residents reviewed for falls. Resident #16 fell on [DATE] without an adequate intervention and fell again on 3/10/22 sustaining a fracture hip. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive deficits. He required limited assistance with one staff for bed mobility, transfers, and walking. An MDS dated [DATE] showed he had a change in status and required extensive assistance with help of one for bed mobility, transfers and toilet use. The Care Plan revised on 11/12/21 directed staff to educate resident/family about safety reminders and what to do if fall occurs, review for significant changes in cognition safety awareness and decision making capacity, and review resident's history of recent or recurrent falls. According to a Physical Therapy Discharge Summary dated 12/14/21 at 9:15 AM, Resident #16 had shown gains in gait and transfer during his time in physical therapy which allowed for increased independence. The discharge plan and instructions were for long term care restorative nursing plan and assistance of one staff. A Care Conference note dated 2/16/22 at 7:05 PM, showed that the resident's family had concerns that the resident was not getting restorative services. The facility response to the family was that they would have the aides available to come to the resident's room for services or go to the therapy room for exercises according to the resident's preference. The Falls Tool dated 3/2/22 documented an action plan of refer the resident to therapy completed by the Director of Nurses. The Nursing Noted dated 3/3/22 at 7:12 PM, documented the resident attended physical and occupational therapy and worked on strengthening, ambulation transferring. A Nursing Note entered on 3/10/22 at 1:07 PM, documented on 3/8/22 at 8:30 AM the resident found on the floor in his room facing the bed. At that time, he stated that he wanted to use the bathroom. The staff educated him on using his call light. An Incident Report dated 3/10/22 at 11:10 PM, documented that staff heard a loud thud that evening and went to the resident's room to find him on the floor face down and blood under his head. They rolled him onto his back and found a laceration above his right eye and obvious hip rotation. He was sent to the emergency room . On 3/11/22 at 10:13 AM, the IDT note documented the IDT met regarding the fall on 3/8/22 and reviewed the care plan and added increased room checks related to confusion. Regarding the fall on 3/10/22, staff were instructed to attach a bed bag to the resident's walker at night time so if resident ambulates, urine bag ready for mobility. In a Hospital Report dated 3/11/22 at 1:25 PM, the resident suffered with a closed fracture of the right hip. On 4/13/22 3:25 PM, Staff L, Licensed Practicing Nurse, stated she worked the overnight shift and was present when Resident #16 fell in his room and broke his hip. She said that she hadn't worked with the resident too often because she was usually in another hallway but the other nurse called for her help that night when they found his on the floor. Staff L said that the resident was laying in the doorway of his bathroom and there was blood pooling around his head. She said that the other nurse told her that he wouldn't usually get up and walk on his own. On 4/12/22 at 9:40 AM the DON said that they did not have documentation of increased room checks intervention established after the 3/8/22 fall. On 4/12/22 at 3:05 PM, Staff H, Certified Nurse Aide, stated she did notice a decline in Resident #16 and she had reported to the nursing staff that he wasn't eating and wasn't coming out of the room and had an unsteady gait. She remembered coming into work one morning and they had someone sitting with him one on one overnight because he was restless. She thought that was just after one of the first falls. She said that his wife would tell the staff that he would say he had to go to the bathroom but then he wouldn't be able to go because he was constipated. She did not remember a time when he was on increased room checks. On 4/14/22 at 9:00 AM, the Director of Nursing reported that the resident often refused the restorative services and in the month of February he refused on 11 occasions. On 4/14/22 at 9:26 AM, Resident #16's spouse stated her husband would spend most his days in the room with her and the two of them sat together in recliner chairs. She said that he had bowel issues and in the mornings he would come in and tell her when he had incontinence of the bowel and he would be very embarrassed about that. She did not recall staff coming in and offering to take him to the bathroom, he would usually ask her to put the call light on when he needed help. She said that her husband did not like to be around people much so when the staff would come in and offer to take him to the therapy room for exercise, he didn't want to go. She said sometimes they would offer to do exercises in the room but not always. On 4/13/22 at 2:04 PM, Resident #16's Physician remembered that during the hospital stay he had changed some medications, especially the medication used for bladder spasms and pain and saw a great improvement in the resident's confusion. He remembered getting faxes shortly after the hospitalization on [DATE] saying that the resident was uncomfortable so he thought that maybe he was unsuccessful in controlling his pain. He said that certainly a regular exercise program could have helped with balance and gait and ultimately decreased the risk of falls. They tried a brace on his knee while he was in the hospital but the resident did not tolerate that well and was uncomfortable with that. According to the Restorative Documentation policy dated 5/19/21, through restorative nursing programs, our residents can maintain independence to avoid becoming more dependent on caregivers or to maintain gains made in therapy. Restorative nursing programs can be initiated without therapy involvement, however, therapy can be integral to assisting with program referral. The Nursing Care, Implementation and Screening - Rehab/Skilled Therapy and Rehab policy updated on 4/12/22, showed that the goal of restorative nursing care was to attain and maintain the maximum possible independence and/or prevent rapid declines through interventions for each resident.

Based on observations, record review and staff interviews, the facility failed to prevent accidents and hazards for 1 of 4 residents reviewed. Resident #47 fell in a parking lot of a local gas station when staff failed to ambulate the resident with a gait belt as the resident walked on uneven ground. The resident transported to the hospital and admitted to ICU (intensive care unit) after scans showed a subdural hematoma from the fall. The facility reported a census of 53 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] assessed Resident #47 with a Brief Interview for Mental Status (BIMS) score of 10 ( moderate cognitive impairment). The resident required extensive assistance of one staff for bed mobility and toileting. Transfers and locomotion required the limited assistance of one staff. The care plan updated on 4/27/21, identified Resident #47 with a self-care performance deficit related to diabetic [CONDITION(S)]. The care plan revealed the resident at risk for falls and alteration in activity related to loss of lower limb and he was learning to balance and walk with prosthetic leg. The care plan directed staff to provide stand by assist with a gait belt and walker and to ensure a safe environment. An incident report dated 10/28/21 at 2:18 PM revealed Staff F Licensed Practicing Nurse was summoned to a local gas station. The facility van driver stopped at a local gas station and allowed the resident to get out. The resident fell in the parking lot. Staff F stated when she arrived at the gas station, she observed the resident laying on the concrete ground approximately 5 feet away from the vehicle and the back of his head was bleeding. Emergency medical technicians (EMTs) arrived and transferred the resident to the hospital. An emergency department note dated 10/28/21 identified the chief complaint as fall. The resident walked outside and tripped, The resident fell backwards and hit the left posterior aspect of his head and also his left elbow. The resident reported 6 out of 10 head pain on a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain. The report identified a left elbow abrasion. A computerized tomography (CT) scan of the head performed 10/28/21 identified a very small acute subdural hemorrhage adjacent to the falx with maximum thickness measuring 3 mm (millimeter). No midline shift or mass effect. The CT report also identified a left parietal scalp soft tissue hematoma. X-rays of the chest, pelvis and left elbow did not identify fractures. The ED report revealed the resident admitted to ICU (intensive care unit) in guarded condition. A discharge summary dated 11/2/21 identified admitting diagnosis as: fall. The principal diagnosis (definitive condition responsible for admission) listed as subdural hemorrhage. On 2/21/22 at 12:05 PM Staff A Certified Nursing Assistant) stated she drove the van. She identified herself as very familiar with the residents and their transfer and ambulation needs. She stated in October when Resident #47 fell at the gas station, they were on their way back to the facility after an appointment and the resident asked her to stop at the convenience store so he could buy something. She stated she drove the facility van that did not have a wheel chair lift and the resident sat in the front seat. Staff A stated the resident required assistance with transferring in and out of the van, and with his prosthetic leg, he required guidance and help. Staff A said the resident transferred out of the van without problems and she stayed next to him, without using a gait belt, as he pushed the walker through the parking lot of the gas station. She revealed the concrete in the parking lot very uneven with areas of cracks and heaving slabs. There were many areas where there were lips in the concrete and the resident used a walker with wheels on the front legs and skies in the back. Staff A said that the resident did not rush with his ambulation, but moved forward very slowly because of the prosthetic leg. She stated as she walked along side of him, the front wheels of the walker got stuck on an uneven area in the concrete. The resident then lost his balance and fell back onto the concrete and hit his head. She thought the walker landed on top of the resident. Staff A reported several bystanders came to assist with keeping the resident warm and support his head while they waited for the ambulance. Staff A remembered that there was no snow or ice on the ground, but the weather was cold. Staff A stated she did not stop at the gas station with any other resident. She sometimes stopped at a drive-through and get something to eat. She said the administration went through policy with her after the incident and she understood what the expectations were going forward. On 02/23/22 at 10:06 AM, Staff A stated the resident did not use a gait belt when the fall occurred. She acknowledged there was a gait belt in the van but she did not put it on the resident the day they stopped at the gas station. On 02/22/22 at 11:26 AM the Director of Nursing (DON) stated staff sometimes take residents to the grocery store or other outside activities, however, those residents must be independent and Resident #47 was not. The DON suggested Staff A should have left the resident in the van and gone in to get the food for him. She stated the facility did not have a specific policy related to a resident being independent in order to take them out. The DON said she believed when the residents' walker caught on the concrete, that he over-corrected and then lost his balance and fell backwards. A policy dated 7/19/21 Fall Prevention and Management directed staff to communicate risks and interventions for residents communicate any changes in the resident on daily basis to help prevent falls. A policy titled Vehicle Transfer dated 6/2/21 directed staff to park the vehicle in a flat area with smooth surface and place the gait belt on the resident before transferring unless otherwise contraindicated.

Based on observations, record review, staff and family interviews, the facility failed to provide adequate supervision and proper use of assistance devices to mitigate a resident's risk for elopement for 1 of 5 residents reviewed (Resident #1). On 8/31/21 at approximately 7:45 PM cognitively impaired Resident #1, with a history of wandering and elopement attempts, exited the building by following a visitor out the alarmed front door. Facility staff stated they assumed it was the visitor leaving and shut off the alarm. Staff stated they did not know the resident left the building. Approximately 20 minutes later, an off duty staff member observed the resident walking two and a half blocks south on Highway 173. The resident walked on the opposite side of the highway walking with his walker wearing shorts, a t-shirt and shoes. The off duty staff reported minimal traffic at the time she observed the resident. The weather was 71 degrees and no precipitation. The resident revealed he was looking for his wife to have supper with her at the pub and complained of feeling very tired. This resulted in immediate jeopardy for the facility. The facility reported a census of 49 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) l dated 8/24/21 identified Resident #1 with diagnoses that included: Alzheimer's disease, [CONDITION(S)], coronary artery disease, hypertension, diabetes, dementia, anxiety and depression. The MDS assessed the resident with a Brief Interview for Mental Status (BIMS)score of 3 (severe cognitive impairment). The resident required extensive assistance of 1 staff for dressing, bathing and toileting and required supervision with transfers and ambulation. The MDS revealed the resident fell since admission and identified his balance as not steady during transfer transition and walking. The Care Plan dated 5/10/19 identified Resident #1 with impaired cognitive function related to dementia. He required supervision with decisions. The care plan also revealed the resident had a potential for elopement last revised on 2/17/20 related to Alzheimer's disease as evidenced by the resident packing his belongings, attempting to leave the facility, talking about returning home and actually leaving the building. Progress Notes: On 7/11/21 at 4:10 PM the resident got out the first set of the exit doors at the kitchen but did not make it outside. He exited as a visitor came in. A nurse aide talked the resident back into the facility without further incident. On 7/13/21 at 10:02 PM earlier in the evening the resident had clothes, cheerios, and other belongings piled high on the seat of his walker. The resident was by the dining room and seated by the front door. Staff tried getting him to go back to his room and he refused saying he was going out that door, pointing to the front door, going to his brothers to get his truck. Staff tried to get him to go to the phone to talk to his wife and he refused. Another staff convinced the resident that his brother was going to be late coming to pick him up and he should wait in his room. The resident then walked back to his room and laid down in his bed. On 7/15/21 at 9:52 PM the resident was exit seeking and tried to go out the east entrance. When staff intervened, he became angry and threatened to hit staff. He stated he would break the door to leave. Staff got him back to his room. On 7/24/21 at 3:08 AM the resident was up wandering around and going into others rooms, turning lights on and scared another resident. Staff took him back to his room per a wheelchair as he resisted going to his room. On 7/31/21 at 11:50 PM the resident walked the halls with his walker and stated he planned to go buy beer. The resident kept pushing on the front door and did get the first door open sounding the alarm. It took four staff members to get him back to the nurse's station to call his wife. She did not answer so staff left a message for her. The resident sat at the nurse station for a while and then went back to his room. On 8/31/21 at 8:32 PM staff found the resident outside the facility. He returned to the facility with no injuries noted. The staff notified the physician and family. On 9/3/21 at 3:01 AM resident not sleeping well tonight and walked the halls. On 9/6/21 at 10:54 PM the resident came out of his room and stated he had things to do. Staff informed him everyone was in bed. He sat in the lounge for a while and then went back to his room. On 9/8/21 at 11:31 PM the resident used his tray table for support and pushed it out of his room and brought it into the nurses station. He stated would take the table out the door. Staff redirected him to his room but he returned to the hall pushing himself on his walker around the halls going into other residents rooms. On 9/13/21 at 9:48 PM the resident is awake and trying to leave the facility. He is looking for his wife and stated he's going to break out a window to get away from the facility if he has to. Administrator Interview Summary of Incident: On 9/7/21 at 2:20 PM the Administrator stated the evening of 8/31/21 there was a family member of another resident that set off the alarm to the main entrance when she brought her dad back into the facility. She immediately told a staff member that she set off the alarm and she added that she is now leaving in case she sets it off again. The Administrator stated one of the facility aides, Staff C certified nurse aide (CNA), lives next door, was off shift and out for an evening walk. The aide saw Resident #1 downtown across from the town pub walking on the sidewalk. Approximately 20 minutes lapsed from the time the main entrance door alarm sounded until the off duty aide saw the resident. The aide reported the resident was walking with his walker wearing shorts, a t-shirt and shoes. He told the off duty aide he planned to meet his wife for dinner at the pub but could not find her. He stated he felt very tired and denied injury. The Administrator stated it was 77 degrees outside with a light breeze and no precipitation. There were no restaurants or businesses open that night so there was not much traffic. The Administrator stated the aide took the resident back to the facility. Staff working reported they did not know the resident left the facility until the aide brought him back. The aide working Staff D CNA, assumed the door alarm that went off was the family member leaving so she silenced the alarm without looking to see if a resident left. Upon return to the facility, a nurse assessed the resident with no injuries found. The Administrator stated when he called and interviewed the family member, he asked about the possibility of Resident #1 following her outside. The family member stated she did see someone behind her but she didn't pay attention to who it was. The facility immediately hung signs for visitors to alert them to watch for residents behind them when they leave. They educated all staff on 9/1/21 on door alarm and elopement policy and procedures. He added that he also educated the family member involved and the Social Services Director followed up on the resident and his exit seeking behavior. Observations: Observation of care on 9/7/21 at 3:10 PM showed the court yard door opened and the door alarm sounded. Staff A CNA, immediately responded to the alarm. She stated it is facility policy that when a door alarm sounds they are to go to the panel on the wall and see which door it is. They then alert staff and go to that door to investigate who went out. If they do not find anyone outside the door, they are to start a resident head count and start full elopement procedure. On 9/7/21 at 3:15 PM Staff B stated as soon as a door alarm sounds they are to check the panel and see which door it is. They then go and check that door to see who went out. They are not to shut off the alarm until there is an all clear. Observation on 9/7/21 at 4:10 PM revealed the facility on the east side of highway 173 and the pub on the west side of highway 173. The pub is down a hill approximately 2 to 3 blocks south. The edge of town is 3 blocks farther south and the highway continues south with a gravel shoulder and corn fields on each side of the highway. Staff involved with the incident: On 9/8/21 at 12:32 PM with Staff C CNA stated she worked as a bath aide on day shift at the facility and worked at the facility for [AGE] years. She lives across the street from the facility and on the evening of 8/31/21 she stated she walked uphill going north on the highway that runs through town and saw the resident on the sidewalk in front of the pub approximately 2 ½ blocks from the facility walking downhill going south. She stated it was around dusk but not dark yet. She stated the resident was on the opposite side of the facility and wore shorts, a t-shirt and shoes. When she approached, the resident recognized her and told her he was looking for his wife because he planned to meet her for supper. He told her was okay and just very tired. She stated businesses close on Tuesday nights so there was not much traffic. Staff C stated there was a lady across the street that she knew and the lady came and assisted to get the resident into her car to take him back to the facility. Staff C stated she helped get him into the facility with the help of Staff D and then she left to go back home once she knew he was safe. On 9/8/21 at 1:00 PM with Staff D CNA stated she helped get the resident back into the facility. She stated the facility staff did not know the resident got out because all the staff working assumed it was a family member leaving. She stated the charge nurse told her a family member just left so she shut off the door alarm without checking for any residents outside. She stated she took the resident back to his room and helped him get ready for bed. He told her he had been on an adventure and felt very tired. She stated the facility trained all the staff the next day about elopement and door alarms. On 9/8/21 at 1:59 PM the Director of Nursing (DON) stated the highway the resident was found on is county highway 173 and the speed limit through town is 25 miles per hour. The Door Alarm Policy dated 5/7/19 documented: The staff member that answers the alarm at the alarm panel must double check to assure accuracy, which alarm is sounding prior to silencing the alarm. The alarm is not to be turned off until a staff member goes to the door and assures that a resident has not left the building. If a second staff member is available, the staff member silencing the alarm should direct the second staff member to page overhead, please check the west door, and please check the west door. This includes going outside to rule out elopement. If you see someone and are not sure who they are, please ask questions that will help determine if this is a resident or a guest. If no one is observed and staff is unable to verify who sounded the alarm, a resident head count must be completed to rule out elopement. If a resident is unaccounted for at head count, the elopement policy will be implemented. When it has been confirmed that the alarm was not an elopement, an all clear will be paged overhead so that all staff is aware that the alarm was answered and followed up appropriately. Once hearing the page, west door clear, west door clear, the alarm may be silenced. On 9/8/21 at 3:28 PM with Resident #2's daughter stated her dad is a resident at the facility. He wanted to go on a ride that evening and they returned to the facility. She stated she backed up to the facility to get him out of the car easier. She noticed she set the alarm off when she took him in so she let the nurse know it was her and that she was leaving in case the door alarm sounded again. She stated when she left she was upset because her dad was upset about her leaving him and she was in a hurry to leave. She stated she remembered seeing someone up by the front entrance but did not pay attention to who it was. As she left, she punched in the door code and went out. As she drove off, her car did not face the facility so she did not see if anyone followed her out. She stated it was possible someone followed her out. She stated the facility saw on camera that the resident followed her out. The facility called her and did training with her and she stated she will never let anyone follow her out again. Immediate Jeopardy Removal: The facility removed the immediate jeopardy on 9-1-21 after they hung signs for visitors to alert them to watch for residents behind them when they leave and educating all staff on 9/1/21 on door alarm and elopement policy and procedures. The facility also educated the family member involved and the Social Services Director followed up on the resident and his exit seeking behavior. Facility action to remove the immediate jeopardy resulted in past noncompliance. The State Agency notified the facility of the immediate jeopardy on 9-9-21.

Based on observations, record review, family and staff interviews the facility failed to provide care to prevent a pressure ulcer and failed to provide care to prevent deterioration of pressure ulcers for 1 of 3 residents reviewed. (Resident #54) The facility reported a census of 54 residents. Findings include: The Face Sheet for Resident #54 documented [DIAGNOSES REDACTED]. The resident's Care Plan contained an update on 8/12/19 following a fall with fracture from independent in room to needing staff assist of 2 and the total lift. The significant change Minimum Data Set ((MDS) dated [DATE] documented Resident #54 did not have any pressure ulcers but was at risk of developing pressure ulcers. It coded her as needing extensive assist of 2 staff for bed mobility and total care of 2 staff for transfers. She scored 11/15 on her Brief Interview of Mental Status (BI[CONDITION]) which indicated moderate cognitive impairment. The resident utilized an indwelling foley catheter and was always incontinent of bowel. The Braden Assessment on 8/19/19 documented she scored at 16 for being at mild risk for pressure related breakdown. The Braden Assessment on 9/27/19 documented she scored at 13 for being at moderate risk for pressure related breakdown. The Braden Assessment on 11/12/19 documented she scored 15 for being at mild risk for pressure related breakdown. The Braden Assessment on 1/21/20 documented she scored 11 for being at high risk for pressure related breakdown. The quarterly MDS dated [DATE] documented the resident did not have any pressure ulcers but was at risk of developing pressure ulcers. It coded her to require extensive assist of 2 staff for bed mobility and total care of 2 staff for transfers. She scored 9/15 on her BI[CONDITION] indicating moderate cognitive impairment. the MDS identified the resident as always incontinent of urine and frequently incontinent of bowel. It also coded her as having a significant weight loss. The Progress Note dated [DATE] at 11:59 AM documented the resident returned from a medical appointment accompanied by her son with an order to remove the sling when the resident is in her wheelchair and that the care plan was updated. The Wound Data Collection Tool dated 10/17/19 documented the resident with a red moist area to her coccyx. The Wound Data Collection Tool dated 10/22/19 documented no rash noted. The Skin Observation form dated 10/30/19 documented the right buttock with a red open area measuring 2cm (centimeters) by 1cm and covered with border foam dressing. The Order Summary Report dated 10/17/19-1/31/20 lacked any documentation of the order for border foam dressing or any other orders for the open area to the right buttock until 11/3/19. The Progress Notes lacked documentation of physician notification until [DATE]. The Wound Data Collection form dated 11/5/19 documented the resident with a stage 3 area to her coccyx measuring 2cm in length by 0.7cm in width by 0.2cm in depth. Wound characteristics documented [AGE] percent granulation, 10 percent slough and 10 percent eschar. The Skin Observation form dated 11/5/19 documented the resident with an open area to her right buttock measuring 2.5cm by 1.1cm, an open area to her lower left buttock measuring 2.5cm by 1cm and an open area to her upper left buttock measuring 2cm by 2.5cm. The form indicated the facility faxed the physician for an order for [REDACTED].>There was no further documentation regarding the left upper and lower buttock areas. The Progress Note dated 11/5/19 at 10:58 AM documented the dietician recommended [MED] nutritional supplement twice daily. The chart lacked any documentation of requesting that supplement until she seen by her physician on 11/12/19. The Progress Note dated 11/7/19 at 11:16 AM documented her appetite was less with intake of meals at 25 to 50 percent. The Progress Note dated 11/10/19 at 2:59 PM documented her appetite was still poor. The Progress Note dated 11/12/19 at 10:14 AM documented the dietician continues to recommend [MED]. The Clinic Note dated 11/12/19 documented the physician order [REDACTED].>The Wound Data Collection form dated 11/12/19 documented the dressing was not present and the resident with a stage 3 area to her coccyx measuring 2cm in length by 1.3cm in width by 0.2 cm in depth. Wound characteristics documented 100 percent slough. The Skin Observation form dated 11/12/19 documented the resident had a open area to her right upper buttock measuring 2cm by 0.9cm by 0.1cm. The Progress Note dated 11/13/19 at 12:59 PM documented the resident experienced pain with dressing changes and the facility would request stronger pain medication from the physician. The Progress Note dated 11/15/19 at 1:08 AM documented the physician ordered [MED] ([MEDICATION NAME]) 500 milligrams every 6 hours for 7 days and then to report back to the physician. The significant change MDS dated [DATE] documented the resident at risk for pressure ulcer development with one stage 3 pressure ulcer. The MDS coded the resident to require extensive assist of 2 staff for bed mobility and total care of 2 staff for transfers. She was unable to complete the BI[CONDITION] and was documented as having modified independence for cognitive skills. It coded her as always incontinent of bowel and bladder. The Wound Data Collection form dated 11/19/19 documented the dressing as not present and the resident had a stage 3 area to her coccyx measuring 2.5cm in length by 2cm in width by 0.7cm in depth. It also documented a stage 2 area on the residents right buttock measuring 2cm by 1cm by 0.2cm in depth. The facility faxed the physician to request a treatment change and to request an indwelling urinary catheter due to large amount of urinary incontinence. A care plan with revision on 11/6/19 identified the resident with a pressure sore related to hypertension, [MEDICAL CONDITION] and decreased mobility. The care plan contained the intervention to avoid positioning on back with initiation date and revision dates of 11/6/19. The care plan directed staff to provide pressure reduction mattress to bed with initiation and revision dates of 11/23/18. On 1/30/20 at 10:47 AM the Director of Nursing (DON) described this pressure reduction mattress as the same mattress provided to all residents. The care plan did not contain every 2 hour repositioning interventions until 11/26/19 when it directed staff to turn and reposition the resident every 2 hours when in bed. The care plan directed staff to leave the sling under the resident until canceled on 6/17/19. (A physician note 10/2/19 identified sling as under the resident). The care plan did not identify pressure reduction for the wheelchair or recliner until date initiated 11/26/19 and revision on 1[DATE]. The care plan ientified low air loss mattress date initiated 11/16/19 and revision 1[DATE]. The Care Plan lacked any revisions or updates prior to 11/26/19 except for the intervention to avoid positioning resident on her back. It was added on 11/6/19 after the sores developed. The Wound Data Collection form dated 11/26/19 identified the wound dressing not present and the current treatment as collagen/hydrogel and border foam. The form identified the resident with an unstageable pressure ulcer on her sacrum measuring 3cm in length by 4cm in width by 2cm in depth. Wound characteristics documented 25 percent slough and [AGE] percent eschar with a foul odor present. The wound appeared reddened with purulent drainage. The second Wound Data Collection form dated 11/26/19 documented the resident had a stage 2 pressure area on her right buttock measuring 1.4cm in length by 0.9cm in width by 0.1cm in depth. The form identified a large pressure ulcer next to this sore with possible infection. The resident grimaced and flinched with pain. A physician order [REDACTED]. A wound care specialist started seeing the resident 11/28/19. The Wound Data Collection form dated 12/3/19 documented the resident had an unstageable pressure ulcer on her sacrum measuring 3.8cm in length by 3.7cm in width and no depth measured. Wound characteristics documented 95 percent slough and 5 percent eschar with tunneling. Mechanical debridement scheduled for the pressure sore that day. The form identified the resident with continuous pain to the area, The physician ordered [MEDICATION NAME] (narcotic) for the pain. The description of the wound was listed as possible worsening of infection, increased size/drainage and worsening pain. The wound had a foul necrotic odor. he second Wound Data Collection form dated 12/3/19 documented the resident had a stage 2 pressure area on her right buttock measuring 1.5cm in length by 1.6cm in width by 0.2cm in depth. The form identified the resident with dull achy pain from the wound that worsened while sitting and caused the resident to flinch/grimace. Staff placed the resident in bed between meals. The Wound Data Collection form dated [DATE] documented the resident had an unstageable pressure ulcer on her sacrum measuring 5.2cm in length by 6.2cm in width and 3.4 cm in depth. Wound description documented possible worsening of infection, increased size and drainage and worsening pain. The resident grimaced with light touch and laid down after meals. The resident utilized [MEDICATION NAME] (narcotic) and [MEDICATION NAME] for pain. Wound characteristics documented [AGE] percent slough and 20 percent eschar with a foul necrotic odor present. Tunneling was present. The treatment was [MED] in wound bed covered with border foam. Mechanical debridement at the bedside was scheduled. The second Wound Data Collection form dated [DATE] documented the resident had a stage 2 pressure area on her right buttock measuring 1.5cm in length by 01.6cm in width by 0.2cm in depth. A physician fax dated 12/12/19 identified a treatment change for the sacral pressure wound. The new order directed staff to apply wet to dry packing, using Dakins solution .0125 daily and PRN (as needed) and cover with foam dressing. The Wound Data Collection form dated 1[DATE] documented the resident had an stage 4 pressure ulcer on her sacrum measuring 6.1cm in length by 4.2cm in width and 4.2 cm in depth. Wound description documented resident hollering out and grimacing in pain. Staff administered pain medication prior to the treatment change. Wound characteristics documented 90 percent slough and 10 percent epithelization and a foul odor in her room. Staff documented dressing and treatment as Dakins gauze in wound bed, covered with border foam, diathermy, pressure reduction mattress on bed and cushion on chair, repositioning and pain management. The second Wound Data Collection form dated 1[DATE] documented the resident had a stage 2 pressure area on her right buttock measuring 1.5cm in length by 0.9cm in width by 0.2 cm in depth. The quarterly MDS dated [DATE] documented the resident was at risk for pressure ulcer development and had one Stage 4 pressure ulcer. It coded her as needing extensive assist of 2 staff for bed mobility and transfers, having an indwelling catheter and always incontinent of bowel. The Wound Data Collection form dated 12/24/19 documented the sacral wound measured 5.9 cm in length by 5 cm in width and 4.2 cm in depth. Wound characteristics documented [AGE] percent granulation 20 percent slough and 20 percent eschar with a strong four odor. The second Wound Data Collection form dated 12/24/19 documented the resident had a stage 2 pressure area on her right buttock measuring 1 cm in length by 0.8 cm in width by 0.2cm in depth. A fax to the physician dated 1[DATE] revealed an update of the coccyx wound. The wound previously contained pink edges on exterior opening and those edges now appear green/black. The resident is totally dependent with cares in bed and doesn't reposition on own. Staff turns every 2 hours and transfers the resident with a hoyer lift. The whites of the resident's eyes appear yellow and the resident's stomach remains distended. The Wound Data Collection form dated 12/31/19 documented the sacral wound measured 6.5 cm in length by 6.5 cm in width and 4 cm in depth. Wound characteristics documented [AGE] percent granulation 25 percent slough with a strong four odor. Current wet to dry dressing being used until the wound vac arrives. The Wound Data Collection forms dated 1/6 and 1/7/20 did not include measurements. Tunneling was described as 4.8 cm. ay 10-12 o'clock. there were no other measurements. No other wound assessments found for the right buttock. The Wound Data Collection form dated 1/14/20 documented the stage 4 pressure ulcer on her sacrum measured 5.9 cm in length by 5.4 cm in width and 4 cm in depth. Resident described to be in pain continuously with movement. Wound characteristics documented 92 epithelized and 8 percent slough with a mild four odor. Apiece of bone was removed from the wound bed. Documentation of conversation with family about hospice. The dressing/treatment listed: LALAP mattress, high protein diet, shakes/[MED], NWPT-[AGE]mmhg (wound vac) and talked with family about hospice. The Order Summary Report dated 1/14/20 documented an order for [REDACTED].>A physician order [REDACTED]. Change 3 times a week and PRN. A clinic note dated 1/16/20 revealed the resident is [AGE] years old and was seen for follow up. The resident admitted to hospice due to decline in function and nonhealing and worsening wound. The family requests discontinuation of wound vac. The physician documented the resident did not appear ill and rested peacefully in bed. The resident did not respond to commands appropriately. The Wound Data Collection form dated 1/21/20 documented the stage 4 pressure ulcer on her sacrum measured 6 cm in length by 5.4 cm in width and 5.3 cm in depth. The evaluation of the wound included the comment increased bone. Resident described as moaning in pain during bed checks. Wound characteristics documented a piece of bone removed from the wound bed during cares. The Wound Data Collection form dated 1/28/20 documented the stage 4 pressure ulcer on her sacrum measured 6.5 cm in length by 6 cm in width and 5.5 cm in depth. Observations showed on 1/29/20 at 9:45 AM LPN Staff F and CNA (certified nurse aide) Staff G present to help with the bed mobility. The resident laid on the right side on an alternating air mattress. Both staff washed their hands and donned gloves. Staff G held the resident in place on her right side while Staff F removed an old dressing exposing an open wound approximately the size of a baseball. Staff F identified tunneling present. She removed her gloves and used hand sanitizer, she then applied clean gloves and used saline soaked gauze to clean the wound and also used saline spray to flush the wound. Staff G removed her dirty gloves, used hand sanitizer and applied clean gloves. She used 3M skin prep spray and sprayed around the edge of the wound and then packed it with 2 wet 4x4 gauze pads that she fluffed. She then covered it with a foam dressing. The resident grimaced and said ouch several times during cares. Observation on [DATE] at 2:40 PM of the resident in bed laying on her back. Observation on 1/28/20 at 10:40 AM of the resident in bed laying on her back asleep. Observation on 1/30/20 at 10:45 AM of the resident in bed laying on her back asleep with no pillows found in her bed for positioning. The resident's daughter in law stated on 1/28/20 at 10:41 AM that she and her husband are concerned with how the pressure ulcer developed here. The physician told them last fall at a doctor appointment that the blue sling should not be left under the resident because it contributed to the breakdown. She stated it took the facility quite awhile before they started removing it from under her. The DON stated on 1/30/20 at 10:47 AM she expected nurses to notify the physician immediately with any new open areas and then update the care plan. She also expected staff to update the care plan ongoing with changes and also expected initiation of dietician recommendations immediately.

Based on observation, record review, resident, family and staff interviews and review of the facility video footage and policy and procedures, the facility failed to provide Resident #2 with the required therapeutic and modified diet, resulting in the resident choking and later died . This situation caused an immediate health and safety concern. The sample consisted of 7 residents and the facility reported a census of 67 residents. Findings include: A Certificate of Death form dated [DATE] indicated Resident #2 passed away [DATE] at 12:28 a.m. related to an injury that occurred on [DATE] at 1 p.m. when the patient aspirated a large piece of hot dog and some other food while he/she had been eating lunch. The hot dog occluded 80% of the distal trachea (wind pipe) and fully occluded the left main stem bronchus. The identified cause of death were the following: Acute hypoxemic [MEDICAL CONDITION]. Aspiration Pneumonitis. Aspiration of food. Resident #2 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS identified the resident had [DIAGNOSES REDACTED]. and a [MEDICAL CONDITION] disorder. The assessment indicated the resident had a Brief Interview or Mental Status (BIMS) score of 3 out of 15. A score of 3 represented the resident had a severe cognitively impairment. The MDS identified the resident had fluctuating disorganized thinking, required supervision while eating and required a mechanically altered diet. A Care Plan with a focus area initiated on [DATE] indicated the resident had activities of daily living (ADL) self-care performance deficit related to [MEDICAL CONDITION] and dementia as evidenced by an inability to care for self. The approaches directed the staff to do the following: Resident requires set up and reminders to eat slowly. Notify the nurse if staff observed trouble swallowing. Review of the Progress Notes revealed the following documentation as dated: On [DATE] at 10:49 p.m., the resident ate popcorn and apple slices at the center television lounge when a resident's family member noticed the resident experienced difficulty breathing, color red/purple, lips cyanotic and unable to speak initially first. The resident coughed up pieces of apple and popcorn, his voice cleared and color returned to normal after an effective cough. The resident denied pain, lungs clear and he had a temperature of 98.1 Fahrenheit (normal 98.6), blood pressure of ,[DATE] (normal), pulse 74 (normal ,[DATE]), respirations 20 (normal ,[DATE]) and an oxygen saturation rate of 95 percent (normal ,[DATE] percent). On [DATE] at 1:15 p.m. the physician changed the diet order to all ground foods. The nurse returned the order to the physician for clarification. On [DATE] at 12:04 a.m. the new physician orders [REDACTED]. A Fax Communication form signed by a Physician (not dated) directed staff on the above stated diet directives. The Speech Therapy Plan of Care, dated [DATE], identified the resident had previous therapy on [DATE] for dysphagia. The Speech Therapy Progress and Discharge Summary dated [DATE] indicated the resident had a medical [DIAGNOSES REDACTED]. An [DATE] activity calendar identified a State Fair Day at 10:30 a.m. on [DATE]. A form titled Choking dated [DATE] at 6:19 p.m. identified the following incident: Staff F (licensed practical nurse) called to the chapel via the intercom system at 10:00 a.m. and she responded immediately. Resident #2 sat in a wheelchair with his face purple/blue, not breathing with visible vomit on his shirt and visibly choking. Staff F was told the resident at been eating a corn dog. The form indicated no other nurse present. Staff F sent the Activity Director to get the Director of Nursing Services (DNS) and Staff F called 911. Staff F attempted the [MEDICATION NAME] maneuver at 10 a.m. multiple times while the resident remained in the wheel chair. The DNS entered and they slid the patient out of the wheel- chair and on to the floor. The resident's code status verified as a full code (requested to have CPR (cardio-pulmonary resuscitation) if should stop breathing and no heart beat). The staff continued the [MEDICATION NAME] maneuver with suctioning until 2 pieces of hot dog became dislodged and swept out of the resident's mouth. With additional suctioning, Resident #2 started moving air and his color turned from purple/blue to red. Resident #2 began to respond to the nurses. The resident did not lose consciousness and continued with a heart rate. The nurse placed oxygen at 10 liters by mask device and the resident's saturation registered at 80%. The resident's blood pressure and heart rate stable. The lung sounds were wet and diminished. The medics arrived and transported the resident to a local hospital. The resident left the facility in a stable condition with the airway patent, vital signs stable and alert and oriented. A facility Investigation form dated [DATE] indicated the choking episode occurred at 10:03 a.m. The summarization of factors that may have contributed to the incident included the following: The resident to receive a ground meat diet except for a hamburger patty and instead given a corn dog. The resident known to eat fast. A Choking Incident timeline signed by the DNS (not dated) and review of the video timeline identified the following events: At 9:57 a.m. - Each resident in the chapel received a cup of corn dogs and a napkin from a cart being pushed by a family member or volunteer and Activity Director. At 9:58 a.m. - Resident #2 received a cup of corn dogs by the volunteer. At 9:59 - The resident poured 4 corn dogs into his mouth. At 10:00 a.m. - The Activity Director left the chapel. At 10:01 - Questioned choking. At 10:02 - The resident placed another corn dog in his mouth. At 10:03 - Resident #6 sat beside the resident and looked at Resident #2. At 10:04:23 - Nurse called and [MEDICATION NAME] initiated. At 10:04:56 - The DNS was called. At 10:04:56 - The DNS entered the chapel. At 10:05:17 - Staff positioned the resident on the floor and continued abdominal thrusts. At 10:06 - Called CNA's for removal of the residents. At 10:06 - Switched from Staff F to the DNS for abdominal thrusts and a call placed for the crash cart. At 10:07 - Abdominal thrusts continued the resident remained alert. At 10:07 - 2 hot dogs removed and his airway been suctioned. At 10:07:52 - All food removed. At 10:08 - Recovery. At 10:08:41 - Mouth suctioned and oxygen on. At 10:09 - Mouth suctioned and oxygen on. At 10:09 - The Administrator entered the chapel. At 10:10 - Recovery position while awaited the ambulance crew arrival. At 10:12 - Vitals (pulse, blood pressure, pulse) taken. At 10:14 - More suction (given). At 10:15 - An Emergency Medical Tech (EMT) arrived. At 10:17 - Staff sat the resident up. At 10:19 - The resident positioned in the wheel chair and suctioned again. At 10:21 - The DNS left the chapel with the resident stable. At 10:23 - Oxygen taken again. At 10:23-The ambulance crew arrived. At 10:28 - The resident left the facility. On [DATE] at 9:02 a.m. the Activity Director was interviewed and stated the facility celebrated the State Fair that week and served all types of food pertaining to what food served at the fair. The staff member finished the last tray of corn dogs when another resident's family member/volunteer asked to pass them out to the residents. The volunteer gave another resident that required a pureed diet, a cup with 4 pieces of corn dog in it. The Activity Director knew the resident required a pureed diet so she took the corn dogs and took the resident to the center nurse's station in an attempt to get the corn dogs changed to the appropriate consistency. There had been no nurse present so she gave the corn dogs to another resident present and on a known regular diet. The Activity Director stated she then returned to the chapel and told the volunteer she would return but she had to let another family member out of the West doorway of the facility. The Activity Director stated when she returned to the chapel a couple of the residents said Resident #2 had not looked well and noticed vomit on his chest. The Activity Director stated when she returned with Kleenex, she noticed the resident had been choking. The Activity Director stated she proceeded around the back of the wheelchair and attempted the [MEDICATION NAME] but because of his stature, she could not get hands around the residents so paged for a nurse to the chapel but failed to page stat. The Activity Director then went to get the DNS who followed her immediately into the chapel. The DON yelled for staff to call 911 and to remove all residents from the chapel. The Activity Director called 911 and when the Assistant Director of Nursing (ADON) arrived she took over the telephone call and the Activity Director took the residents out of the chapel while the other staff members kept working with the resident. After she removed a couple of residents, she did not return to the chapel. The Activity Director confirmed she was aware the resident required a special diet of ground meat. On [DATE] at 4:08 p.m. the Activity Director was interviewed and stated she questioned her inconsistencies with her above statement following a viewing of the video footage revealed she stood next to the resident when the family member/volunteer gave the resident the mini corn dogs. The Activity Director stated at the time she was more focused on the resident who also received the mini corn dogs, when that resident required a pureed diet. The 2nd inconsistency she identified was her failure to perform the [MEDICATION NAME] as she stated above. The Activity Director stated she thought she had performed the maneuver but videos do not lie. On [DATE] at 2:08 p.m. the family member/volunteer was interviewed and stated she visited her spouse the day of the incident, however, she could not recall what had been served and stated she had not assisted in the serving process. On [DATE] at 2:17 p.m. Staff F, Licensed Practical Nurse (LPN) stated a calm page requested a nurse in the chapel. Staff F stated as she walked to the chapel, the Activity Director informed her in a casual manner Resident #2 was choking. Staff F stated she then ran to the chapel as the Activity Director informed her that she tried the [MEDICATION NAME] maneuver. Staff F stated when she entered the chapel, she could tell the resident had been choking awhile as the resident's color had been purple and saliva had shot from his mouth. The staff member attempted the [MEDICATION NAME] in the wheelchair but could not perform the maneuver as the resident had been too big. The staff member instructed the staff present to get the DNS who immediately responded. The staff positioned the resident on the floor and the [MEDICATION NAME] was performed until the staff removed 3 pieces of corn dog. This was further described as 3 pieces that would have equaled one mini-corn dog but just the hot dog not the corn portion. When the pieces were removed, the resident began to exchange air so staff applied oxygen. Staff F stated the resident voiced he had his shoes on. Staff F stated 911 was called and the resident suctioned. The resident's vital signs remained stable with an oxygen saturation rate in the 70's ad 80's and climbing. The resident was talking when the ambulance crew arrived. On [DATE] at 12 p.m. the resident's spouse confirmed the facility staff told her the resident choked on a corn dog, turned blue, was given CPR (cardio [MEDICAL CONDITION] resuscitation) and the staff planned to send him to the emergency room . When the resident went to the local hospital the staff put a tube down his throat to get the hot dog out and they could not believe his oxygen level was at a 70 percent. The staff then put the resident on a ventilator and sent him to a hospital in Nebraska because of the aspiration of the corn dog into the lungs. When the resident went to a hospital in Nebraska, the staff could not dislodge the hot dog so they had to pluck it and pluck it little by little and they finally put in a balloon type device to remove the hot dog. The family member stated she was told the resident's oxygen levels to be at a ,[DATE] percent for hours. The next day the staff checked the resident's gag reflux and eventually removed the ventilator. Review of a typed statement by the DNS and titled Choking Incident of the resident on [DATE] identified the following information: The DNS was in a meeting in her office with a family member. The Activity Director interrupted and stated the resident choking in the chapel and needed now. DNS entered the chapel with the [MEDICATION NAME] in progress on the resident. The DNS requested staff to lower to the floor to receive more proficient abdominal thrusts. Staff F, Staff E, Certified Nursing Assistant (CNA) and the DNS lowered the resident to the floor. Staff F continued abdominal thrusts. The CNAs removed other residents out of the chapel. The DNS checked for a carotid and peripheral pulse during the abdominal thrusts. The resident sustained [REDACTED]. Staff F became tired so the DNS took over the abdominal thrusts. Staff F continued to get the crash cart which allowed staff to apply oxygen and to have suctioned the resident. The abdominal thrusts produced 1 hot dog piece and removed by a finger sweep. No air exchanged noted so abdominal thrusts continued and produced a 2nd piece of hot dog while air exchange noted. The resident moved to a recovery position, suctioned numerous times and vitals taken during the incident. Eventually the resident sat up with assistance and assessed. Vitals and oxygen obtained during the incident. The resident then moved to a wheelchair until the ambulance arrived. The first responder arrived and took over the cares. The DNA left when the resident became stable and the ambulance arrived. The resident then moved to a stretcher with the assistance of multiple staff members. When the resident moved to the stretcher he stated what now? As the resident left the chapel room he stated I got my shoes on. During an interview [DATE] at 2:55 p.m. Resident #6 indicated the choking incident as just horrible. The facility celebrated state fair week and that day they served mini corn dogs and there were 3 in each cup. When the resident received his cup of corn dogs he picked them up as fast and he could, chewed and chewed and then swallowed them in one big gulp. The resident then began to choke, cough, wheeze and turn blue and she could tell the resident was choking to death. The staff got the nurses who laid him down and she left. An Attestation form signed by a Physician [DATE] at 6:54 p.m. included the following: The resident was found with a saturation level in the 70's percent. The chest x-ray identified atelectasis (collapse of lung tissue) of the left lung. A [MEDICATION NAME] (scope of the lung bronchus) identified a large chunk of hot dog which occluded 80 percent of the distal trachea and lodged in the left main stem bronchus with a small lumen which gave visibility into part of the right main stem bronchus. The patient reportedly spoke with the ambulance to the emergency room with rapid decompensation of the respiratory status. Oxygen saturation levels remained in the low 60's with an eventual intubation performed. Food particles suctioned from the resident's mouth. A chest x-ray demonstrated near complete opacification (decrease in the ratio of gas to soft tissue in the lung) of the left hemi thorax concerning for obstruction. The resident emergently transported to another hospital for his acute hypoxic [MEDICAL CONDITION] due to the aspiration of food. Review of the facility Diet Type Report form dated [DATE] identified 13 of 66 residents required a ground diet. A Working with Residents with Special Dietary Needs form (revised ,[DATE]) directed the staff the purpose was to provide guidelines for activity staff members when working with residents with special dietary needs. The procedures included the following: Maintenance a current list of residents on special diets. An updated list should be obtained month or per location practice. Activity staff members and volunteers who distributed food items during activity function should have been made aware of each resident's diet restrictions. By [DATE], the facility had provided inservices to all employees. The inservice provided guidelines for activity staff members when working with residents with special dietary needs. The Activity Director would be provided a list of residents at nutritional risk. Activity staff members cannot assist residents with eating unless they are certified nursing assistants or have completed a state-approved Paid Feeding Assistant training Program.

Based on observation, record review, staff and family interviews and review of facility policy and procedures, the facility failed to ensure Resident #5 received adequate supervision to prevent self transferring without staff assistance. The sample consisted of 7 residents and the facility reported a census of 67 residents. Findings include: 1. An Admission Record form dated 12/15/17 identified Resident #5 had an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 had a Minimum Data Set (MDS) assessment with a reference date of 9/12/17. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15. A score of 7 represented a severe cognitive impairment. The MDS identified the resident required extensive assistance of 1 staff person with transfers, limited assistance of 1 staff person with ambulation and experienced 2 falls. A Care Plan with a focus area dated 8/10/15 identified the resident as a fall risk related to severe weakness as evidenced by extensive assistance required with transfers. The focus area revised on 11/13/15 that indicated the resident had activities of daily living (ADL) self-care performance deficit related to spinal ischemia. The Care Plan identified a focus area of limited physical mobility revised on 2/1/17 and a focus area of impaired cognitive function/dementia or impaired thought processes revised on 4/18/17. The approaches directed the staff to do the following: Keep the wheel chair and wheeled walker away from the resident, on the other side of the room or in the bathroom to prevent self-transfers. Transfers with a front wheeled walker and assistance of one staff member. A Falls Tool form dated 11/8/17 at 8:10 p.m. indicated the resident at a medium risk for falls. The Progress Notes form, with an entry dated 11/25/17 at 10:47 a.m. , identified the following documentation from Staff A, Licensed Practical Nurse (LPN): At 6:40 a.m. heard hollering from the resident's room. Entered room and found the resident as he sat on the bathroom floor with his legs out in front as he faced the door and the walker positioned in front of him. The staff member moved the walker to the side and asked him what he had been doing up by himself. The resident stated he tried to get to the wheelchair in the corner but could not get it out so he turned from the wheelchair, lost balance and sat down. The nurse asked him what he had been doing up on his own. The resident stated he told the CNA (certified nursing assistant), as he sat on the edge of bed, he ambulated independently so she left the resident. The resident then ambulated to the door to see if she came back and then ambulated to the bathroom. The LPN (licensed practical nurse) started to perform range of motion (ROM) and the resident voiced it hurt when the left leg had been moved. The LPN noted the leg as rotated out. Two staff with a total lift transferred the resident from the floor to the bed. The LPN asked the resident to stay there until she could get his hip checked out. The LPN called the ED (emergency department), physician and ambulance. The ambulance crew arrived about 7:45 a.m. An Emergency (ED) Provider Notes form dated 11/25/17 at 8:26 a.m. indicated the resident sustained [REDACTED]. A form titled Transition Orders And Information For The Continuation of Patient Care identified the resident as admitted to the hospital on [DATE] and discharged back to the facility on [DATE] with a left hip pin site wound and a weight bearing status of toe touch only. On 12/15/17 at 10:21 a.m. Staff C, Certified Nursing Assistant (CNA) was interviewed and stated she had worked in the therapy room when she heard a resident yell out for help. Staff C stated she responded and observed the resident on the floor in the bathroom leaning back on a wheelchair in a sitting position. The staff member moved the resident's wheelchair and sat behind him for support. Staff B, CNA entered the room along with Staff A (licensed practical nurse) who came to check vitals. The staff member indicated every time they moved the resident he called out in pain. The resident then held onto his leg and said the pain ran down his leg. Staff A performed a thorough assessment, then retrieved a Total Lift device and transferred the resident to bed while he continued to call out in pain. The staff member confirmed the resident was known to self-transfer and it had not been appropriate to leave him unattended on the edge of the bed. On 12/15/17 at 10:56 a.m. Staff A was interviewed and stated at about 6:30 a.m., during the time of giving treatments, she heard someone calling for help and observed Staff B and Staff C as they entered the resident's room. Staff A entered the room to check vital signs and observed the resident on the floor in the bathroom. The resident denied hitting his head but when she moved the resident's left leg, he called out in pain and the leg externally rotated so she halted movement and began to assess vital signs. The staff members retrieved a Total Lift device and transferred the resident with 2 staff persons from the floor to the bed. Staff A then began neurological checks. The staff member told the resident she planned to have his hip checked out and proceeded to call the physician, spouse and ambulance crew. The resident also told Staff A he told a CNA he could ambulate independently so she left the room. The resident then stood up and looked in the hallway for the CNA and did not see her so he went to the bathroom to get a wheel chair, turned to get out of the bathroom and lost his balance and fell . The staff member confirmed the resident known to self- transfer and not appropriate to leave the resident unattended on the edge of the bed. The staff member indicated when a resident falls it had been normal procedure to transfer them to bed via a Total Lift device however she understood about not moving a resident with an obvious injury because the ambulance crew could have just slid him/her onto a board. During an interview 12/15/17 at 10:43 a.m. Staff B indicated she heard someone as they yelled for help. She asked another resident what had been going on and that resident told her Resident #5 had fallen. The staff member then went to get a vital pole as Staff C went to the resident's room. When the staff member entered the resident's room she observed him/her on the floor in the bathroom with his/her feet located in the entrance of the bathroom and his/her body positioned in the bathroom laying down while Staff C held the resident's head. The wheel chair had been positioned outside of the bathroom with the walker inside. The resident stated he/she had been trying to get his/her machine which she assumed had been the wheel chair. Staff A then entered with her vital pole so Staff B went to get the agency staff member to see where she left the resident and the agency staff member said on the edge of the bed. When Staff B re-entered the resident's room Staff A said she could handle it from there. Staff B confirmed the resident kept saying he/she had to move his/her left leg because something had been wrong. The staff member also confirmed the resident had been known to self- transfer and it had not been appropriate to leave him/her unattended on the edge of the bed. During an interview 12/15/17 at 11:18 a.m. Staff D, CNA indicated she heard a resident call for help and when she responded Staff A, B and C had already been present so she went to retrieve the Total Lift device. When she returned to the room the resident complained of left hip pain when the area had been move. The staff members then transferred the resident from the floor to the bed while he/she moaned and stated it hurt. The staff member confirmed the resident had been known to self-transfer and it had not been appropriate to leave the resident unattended on the edge of the bed. The agency staff member provided the following written statement to the facility date 11/25/17: Assisted the resident that morning by helping him switch his catheter bag to a leg bag, put on ted hose, pants and shoes. The resident stood up and she assisted him and pulled up the pants. The resident sat back down and put on a shirt. The resident seemed alert and oriented as well as able to independently stand. She asked the resident if there had been anything else and he said no and placed his hearing aids. She then made sure the resident's walker was locked and call light in reach. She told the resident as she left the room that she would return to make the bed and the resident said OK, thank you. On 12/20/17 at 2 p.m., the resident was interviewed and stated he could not recall the fall that resulted in a fracture. The resident's family member was present and stated the resident broke his upper leg because a CNA left him setting on the edge of the bed and he got up and walked with a walker to his wheelchair in the bathroom and fell . According to a typed statement dated 12/22/17 at 2:39 p.m., a physician documented the following information: The physician did not think it was unreasonable to leave the resident at the edge of the bed but the resident did need at least verbal reminders to wait for assistance due to his extremely limited insight into his own physical limitations. The physician thought if someone had been present at the bedside, they could have redirected him more effectively before he stood, walked and fell . The physician stated he was unsure about the situation enough to know if the Hoyer was appropriate or not. In certain cases, it had been better to get the patient up than leave them down, and the resident would have been a challenging transfer. A form titled Fallen Or Injured Resident Clinical Skill Checklist (not dated) included the following directive to staff: The charge nurse needed to observe the resident and perform a full body exam to determine if there may have been a suspected injury and direct whether to have moved the resident. A form titled Fall Prevention and Management (revised 10/17) directed the staff to do the following: Do not move the resident. Cover the resident and have him/her lay quiet until help arrived. A nurse must have observed the resident and performed a full-body exam to determine if there had been a suspected injury and direct whether to have moved the resident. Do not attempt to move the resident if a spinal or [MEDICAL CONDITION] had been suspected.

Based on clinical record review and interviews, the facility failed to provide adequate supervision to protect Resident #1 from hazards during transfers for one (1) of four (4) residents. The resident's care plan intervention directed staff to assist the resident with transfers to reduce the risk of an accident. Staff interviews established Resident #1 required assistance with transfers & for staff to use a gait belt to stabilize his/her balance when walking. Interviews revealed when Resident #1 lost his/her balance and fell , the staff did not have ahold of the resident's gait belt during the transfer. Resident #1 sustained a left hip fracture from the fall and a laceration to his/her head. The facility identified a census of 71 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 4/10/15 Resident #1 had been diagnosed with [REDACTED]. The MDS identified the resident with a BIMS (brief interview for mental status) score of 2 which indicated his/her cognition severely impaired. The assessment revealed the resident had disorganized thinking that fluctuate and changed in severity. The MDS dated [DATE] revealed the resident required one person physical assistance for bed mobility, transfers and toilet use. The MDS identified the resident not steady & required staff assistance to stabilize his/her balance when walking, when moving from seated to standing position, when turning around and when facing the opposite direction. A Fall Risk Evaluation dated 2/24/15 revealed the resident had not had any recent falls. The resident had just recently discharged from hospice and ambulating more. Staff would continue to use alarms to alert them of the resident's movement. Review of the Physical Therapy (PT) Assistant Progress Update dated 3/3/15 revealed the resident required front wheeled walker and moderate assistance (from staff) for safe ambulation of 50 feet. The note directed staff to assist with bed mobility, functional transfers with contact guard assist and ambulation with a wheeled walker and contact guard assist. The caregiver training indicated the caregiver had been educated in precautions and able to recount 50% of the information with accuracy. Review of the Policy and Procedure titled Gait Belt dated 10/13 identified gait belts were to aid a resident in maintaining his/her balance; and gait belt's would avoid (reduce) injury to both residents and staff. The Gait Belt Procedure directed staff to explain to residents that gait belt device are used for stability and/or support during transfer or ambulation. The procedure directed staff to do the following: a. When holding the belt, an underhand grasp should be used. The belt should not be used for lifting. It is for support and stability only. b. Transfer or ambulate the resident and remove the belt. c. Do not use the pants/slacks belt as a gait belt. The care plan dated 3/6/15 identified the resident had limited physical mobility due his/her [DIAGNOSES REDACTED]. The care plan directed staff to assist the resident to ambulate a distance he/she can tolerate with front wheeled walker and contact guard assistance 3 to 6 times a week. Review of the Incident report written by Staff C, Licensed Practical Nurse/(LPN) dated 3/22/15 revealed Staff D, Certified Nurse Aide/(CNA) walked with Resident #1 to the room to get ready for bed and to use the bathroom. The report documented staff used a wheeled walker, gait belt and 1 staff assistance. The resident turned into the bathroom and lost balance, landing on his/her left side, hit the forehead on the doorframe of the bathroom door. The resident had a 2 centimeter (cm) laceration to the mid forehead close to the hairline. A minimal amount of blood had been noted. The resident complained of being dizzy, nauseous and sleepy. The nurse assessed the resident with the following vitals: BP (Blood pressure) 69/43, P (pulse) 58, R (respirations) 16, T (temperature) 96.6. The resident had clear speech and complained of their head hurting. At 9:30 p.m., the resident ' s vitals were: BP 89/58, P 71, R 18 and T 96.6 and the resident complained of the left leg hurting with no rotation noted. The resident had been sent to the emergency room and complained of the left leg when he/she moved. The Falls Investigation Form dated 3/22/15, written by Staff D documented around 9:15 a.m., she had been walking the resident to his/her room to use the bathroom and get ready for bed. When Staff D and Resident #1 got to Resident #1's room, Staff D told the resident to turn left. Staff D started to close his/her room door when Resident #1 started going down (falling). The resident lost his/her balance and fell . The late entry Progress Note dated 3/22/15, written by Staff C indicated no teaching need or training provided to any individual at this time. Review of the Progress Notes (written by Staff C) dated 3/22/15 at 11:18 p.m., revealed at 9:15 p.m., staff walked with the resident to his/her room to get ready for bed and to go to the bathroom. The resident used a wheeled walker, gait belt and assistance of 1 staff. The resident in the room and turned into the bathroom and lost balance and went to the floor landing on the left side and hit head on the door frame and caused a 2 cm laceration on the mid forehead close to the hairline. The resident complained of being dizzy, sleepy and nauseous. BP 69/43, P 58, R 16, T 96.6. At 9:30 p.m., BP 89/58, P 71, R 18, T 96.5 and the resident complained of the left leg hurting. Call placed to the emergency room at 9:35 p.m., to send the resident. At 10:30 p.m., the ambulance at the facility to transfer the resident. The resident joking around with staff and speech clear. The area cleaned and steri stripes applied to the forehead with minimal blood. When ambulance staff arrived, the resident complained of left leg pain when moved, no rotation noted and no more complaints of dizziness or nausea noted. Review of the Radiology Report dated 3/22/15 revealed the resident with impacted and mildly angulated left femoral neck fracture. The hospital Encounter notes signed 3/25/15 documented the resident underwent [REDACTED]. The resident would be returning to the nursing home on 3/26/15. The prosthetic right hip appeared unchanged from 2013. Review of the Major Injury Determination Form dated 3/23/15 revealed the injury sustained is a major injury. During an interview with Staff D, Certified Nurse Aide (CNA) on 5/5/15 at 10:00 a.m., she stated that she walked the resident to the bathroom and the resident lost his/her balance and fell . Staff D stated the resident required a gait belt and hands on assistance. Resident #1 had a gait belt on but she did not have hold of it. Staff D stated she had been trained by the facility on use of gait belts. During an interview with Staff C, Licensed Practical Nurse (LPN) on 4/28/15 at 11:15 AM she stated that she had been at the nurse's station and the CNA (Staff D, a certified nursing assistant)) walked the resident to the bathroom. She heard a thud and went to the resident's room. The resident turned left to enter the bathroom and went to the floor. She had to enter through the bathroom due to the resident being against the door and the door being shut. The resident's legs lay in front of the bathroom door. The resident awake and bleeding a small amount on the forehead. Resident #1 complained of being dizzy, sleepy and felt like s/he could vomit. The resident moved all extremities, could sit him/herself up and did not favor a side for pain. There had been no rotation or shortening. Staff used the gait belt to lift the resident into the wheelchair. She stated that she had not been aware of the policy to use a Hoyer lift to transfer a resident after a fall. During an interview with Staff B, LPN (licensed practical nurse) on 4/23/15 at 6:00 p.m. she stated that she usually ambulated the resident with a gait belt and 2 staff. The resident unreliable to transfer and staff always hang on to the gait belt. If a resident needed assistance, use a gait belt. During an interview with Staff E, CNA on 4/23/15 at 6:15 PM she stated that she used a gait belt on any resident that needed any type of assistance. During an interview with Staff A, PTA (physical therapy assistant) on 4/24/15 at 8:00 a.m., she stated Resident #1 had dementia that caused him/her to make poor decisions. If a resident had a need for a gait belt, or hands on assistance, (then) a gait belt was needed at all times. She further stated staff had been educated on gait belt use and had no previous problems. During an interview with the Director of Nursing (DON) on 4/23/15 at 3:30 PM she stated that they had looked at the cameras in the Dementia unit and she observed Staff D walking with Resident #1. Staff D had her arm under the resident's arm and did not have hold of Resident #1's gait belt. The gait belt had been on. She further stated that staff did not use the Hoyer lift to transfer the resident after the fall.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision to protect Resident #1 against hazards from self and the environment and failed to plan the nursing care and services so the resident ' s needs were met. The sample consisted of 5 residents and the facility reported a census of 68 residents. Resident #1 had not received care prior to bedtime (HS care) because staff did not know who was assigned to care for the resident. The resident was found sitting on the bathroom floor at 11:15 p.m., after a fall which resulted in a fractured rib and a lung contusion. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 6/26/14. The MDS identified the resident had [DIAGNOSES REDACTED]. The same assessment revealed a brief interview for mental status (BIMS) of 1. A score of 1 represented severely impaired cognition. Resident #1 also required extensive assistance of two staff persons for transfer and extensive assistance of one person for using the toilet, ambulating in his/her room and frequently displayed bladder incontinence. Review of the resident's Comprehensive Care Plan dated 5/28/14 identified the resident at risk for falls due to confusion, weakness, mobility impairment, history of hip fracture and Alzheimer's disease with memory impairment. The Care Plan approaches, to prevent falls are included: a. extensive assistance of 1-2 for bed mobility, b. dressing and grooming, c. toileting every 2-3 hours and as needed, d. transfers with many verbal cues. Review of the Incident Details report dated 6/17/14 at 2315 (11:15 PM) revealed the staff found Resident #1 on the bathroom floor with his/her legs straight out in front of him/her. The wheelchair had an alarm fastened on it and there had been no sound from the alarm. Staff completed an assessment and range of motion to all extremities. Staff transferred the resident to bed using a gait belt and the assistance of two staff persons and placed a personal alarm on the resident. The staff documented the presence of a questionable injury related to a flush colored area on the left outer thigh and a red raised area to the left side of the resident's back following the fall. The resident had no complaints of pain at that time. The incident report revealed the facility had two aides working the west hall; they were new and had not discovered the resident until they found the resident on the floor. Neither had provided HS (bedtime) cares. The same report revealed Resident #1 required follow-up care the next morning and x-rays revealed a cracked 9th rib. The radiology report included and revealed the resident had a fracture of the right ninth rib and right mid lung infiltrate which may be due to pulmonary contusion or pneumonia. The Patient Discharge Instruction revealed the Physician Assistant Certified (PAC) ordered the resident to receive liquid Morphine (narcotic analgesic) for pain as needed and ice to the area for 20 minutes 3 to 5 times a day for 3 days. The Medication Administration Record revealed Resident #1 could receive 5-20 milligrams of Morphine P.O. (by mouth) as needed (PRN). The Interdisciplinary Progress Notes (IPN) dated 6/18/14 at 1:00 p.m. revealed the resident returned to the facility. The facility Medication Administration Record revealed the resident received .25 milliliters (5 milligrams) of Morphine on 6/18/14 at 3:30 p.m. and 9:00 p.m., 6/19/14 at 6:40 a.m. and noon and 6/20/14 at 3:30 a.m. and 3:30 p.m. On 8/11/14 at 2:10 p.m. Staff G (certified nursing assistant) was interviewed and stated she had found the resident in the bathroom on the floor sitting. The resident ' s wheelchair did not have the wheels locked and the alarm hung from the wheelchair instead of from the resident so the alarm had not sounded. Staff G stated she had not been assigned to the resident but since there was only 3 staff instead of 4, she should have checked on the resident. Staff G stated the resident was fully dressed and wore shoes when she found him/her. Staff G stated the last time she saw the resident was around 7:00 p.m. or 8:00 p.m. at the television area and sitting in the wheelchair. On 7/31/14 at 10:00 AM, Staff B, LPN (licensed practical nurse) stated she worked the evening of 6/17/14. She stated that she was orientating a nurse that had been off of work for 5 months and just back for her second night. She was then pulled (from nurse duties) to work as an aide to cover the west hall. Staff B stated she did not know she was to cover the center hall, where Resident #1 lived, until 2 days later. She stated she had never worked as an aide before and had no instruction and the other staff working did not offer any assistance or questioned why Resident #1 had still been up with no HS (hour of sleep) cares. She stated she should not assume and should have asked what her assignment covered. She stated the aides are expected to do a walk through report and she had not done that either that night when Resident #1 had been found on the floor. On 7/31/14 at 9:35 AM, Staff A, LPN stated that was her 2nd night back after being off of work for 5 months. She stated she did not know the routine of Resident #1 so she had not questioned anyone. It was an unusual circumstance, no one knew to check on this resident and assure the resident received assistance to go to bed that night. She stated it was a lesson learned and she now knows how important it is to do rounds and check all residents at change of shift. She stated the last time that she saw Resident #1 was at around 8 PM and she did not see the resident after this time. Staff A stated she had been called to the resident ' s room when Resident #1 fell . The resident was fully dressed and wore shoes. Staff A stated she assessed the resident several times throughout the night and the resident never complained of pain. The resident remained in bed for the remainder of the night. During an observation of Resident #1 on 7/29/14 at 3:50 PM, the resident was in his/her room with an alarm fastened low on the resident's back. The resident displayed confusion. The resident did not remember falling and stated she/he just gets up when ready to go and would not fall. During an observation of Resident #1 on 7/31/14 at 10:55 AM, two aides assisted the resident from the wheelchair over into the recliner. Staff E, CMA (certified medication aide) assisted with a gait belt around his/her waist, then Staff E and Staff F, CNA (certified nursing assistant) transferred the resident into the recliner. Staff placed an alarm low on the middle of the resident's back, provided a call light and offered the resident a drink before exiting the room.

Based on observation, record review, resident, physician, family and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment when transferring Resident #3 with an EZ Stand and transporting a resident in a wheelchair (Resident #1). The sample consisted of 4 residents and the facility identified a census of 59 residents. Resident #3's legs gave out while in the EZ stand which caused the resident to go down with his/her bottom 4 to 6 inches from the floor. As the resident hung in this position, one staff went out to get a nurse while the other staff stood at the bathroom entrance. When the staff returned from getting the nurse, the resident went out of the lift the rest of the way causing skin injury to the arms and hitting head on some plastic drawers in the bathroom. The facility had the resident transported to the emergency room for examination and was admitted with [DIAGNOSES REDACTED]. Resident #1 sustained a sprained ankle when staff transported him/her in the wheelchair without foot pedals on the wheelchair. The resident tumbled forward from the chair when the resident lowered feet onto the floor. Observation of the EZ stand transfer of Resident #4 revealed staff did not follow protocol by failing to tighten the EZ stand strap/belt when they raised the resident to an upright position with the lift. Findings include: 1. Resident #3 had a Minimum Data Set (MDS) assessment with an assessment date of [DATE]. The assessment identified the resident with a brief interview for mental status score of "6" (severe cognitive impairment). The resident required extensive assistance of 2 staff with bed mobility, transfers, ambulation in room, wheelchair locomotion on unit and toileting. The resident was occasionally incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The resident had occasional pain that limited day to day activities. The MDS did not identify falls since the previous assessment. The resident weighed 265 and measured 63 inches tall. A "transfer lift assessments for residents form" dated [DATE] and [DATE] revealed the resident did not need a lift used for transfers. A falls data collection tool dated [DATE] identified the resident with a score of "16". A score of 12 or above equals high risk. An incident details form dated [DATE] at 10 p.m. documented the resident fell when one staff ambulated the resident and the resident's right knee gave out. The resident fell to the right side on the floor. As the resident ambulated to the recliner, the right knee gave out and the resident leaned into the recliner and the recliner moved away. The resident slipped down to the floor. The resident sustained [REDACTED]. bruise to the right elbow with a 1.5 cm. skin tear also on the right elbow. The intervention following the fall was: assist of 2 and new arm protectors due to "the other ones slip down all the time". Staff also notified maintenance to brace the recliner so it would not move after the fall. Interdisciplinary progress (IDP) notes dated [DATE] at 8 p.m. identified staff now uses the EZ stand (sit/stand) to transfer the resident due to weakness in legs. IDP notes dated [DATE] at 1 p.m. stated the resident voiced concerns regarding lift. Resident reassured that staff utilized lift for resident's own safety and staff would not use the commode anymore. At 9 p.m. the resident continued to use the sit/stand. Some complaints about lift but understand its use. IDP notes dated [DATE] at 9 p.m. stated the resident voiced dislike of the EZ stand. Staff educated the resident. The resident voiced understanding but would like to ambulate during the day. IDP notes dated [DATE] at 6:00 a.m. and written by Staff J (Registered Nurse) stated the resident fell while using the EZ stand. When Staff J arrived to the room, she observed the resident lying on the bathroom floor with back against drawers with eyes closed and gasp breathing. The resident opened his/her eyes to verbal stimuli but did not verbally respond. The resident appeared lethargic. Observation revealed the backs of both hands bleeding with gaping skin tears. Staff applied pressure to the areas. Staff observed a large bruise to the left breast. The resident stated he/she did not know what happened when questioned. Staff called the emergency room (ER) and received orders to transport the resident to the ER IDP notes documented on the same date at 11 a.m. that the resident admitted to the hospital. The hospital emergency department nursing records dated [DATE] identified the resident's chief complaint as lower back pain and dry heaves. The nursing home reported the resident fell out of the EZ lift and hit head on a drawer. The resident complained of chest pain at the facility with no chest pain on arrival. The Emergency department nursing record documented the resident with very thin skin and skin tears on the right dorsum and forearm and multiple bruises to both arms. Laboratory blood work performed on [DATE] revealed the resident's hemoglobin as 8.7 (low) potassium 7.9 (critically high) CO2 34 (high), blood urea nitrogen 75.4 (high) and creatinine 2.9 (high) CPK 214 (high). A CT of the head, performed [DATE] did not show gross abnormality. A CT of the lumbar spine performed on [DATE] identified a limited examination due to obesity and patient motion. No gross displaced fracture or evidence of acute subluxation. A hospital history and physical dated [DATE] identified the resident's chief complaints for hospital admission as "Hyperkalemia, acute low back pain, general weakness and impaired functional status". A hospital discharge summary dated [DATE] stated the resident received Kayexalate to decrease potassium level and at discharge the potassium level read 5.0. At admission the resident complained of low back pain. Some was believed as chronic pain but seemed worse since the fall from the EZ lift at the nursing home. The resident received oral hydrocodone (narcotic) for the pain which helped. During hospitalization the back pain waxed and waned. On the day of transfer the resident complained more of shoulder pain than back pain. The resident transferred to a swing bed at the hospital. IDP notes dated [DATE] at 4 p.m. identified the resident returned to the facility. The Wound flow sheets dated [DATE] identified the area to the back of the right hand as measuring 3.5 cm. by 7.5 cm. and the back of the left hand measured 1.4 cm. by 4 cm. The Daily Skilled Notes dated [DATE] at 12:30 p.m. identified the following skin areas: left and right back of hands abraded, scattered aged bruising noted along length of left arm mid to upper knuckles, left knee light purple 3.5 cm. by 2.5 cm., arch of left foot light purple 1.5 cm. by 1.5 cm., 6 aged bruises noted right upper arm extending along breast, side and around to back. The resident denied pain at any site. A pain management review form dated [DATE] revealed the resident identified pain as "always there" in the leg. The resident denied pain interfered with sleep or activity and rated it as severe at times. The resident utilized as needed Tylenol (analgesic) for pain. The physician orders [REDACTED]. Reenactment with Staff Involved in the [DATE] incident: On [DATE] at 10:03 a.m. Staff F (nurse aide) and Staff G (nurse aide) identified themselves as the staff involved in the EZ lift transfer on [DATE]. Staff applied the harness (dated [DATE]) and the waist and leg belts while the resident remained seated in the chair. Staff then lifted the resident out of the chair via EZ stand. The resident's legs remained slightly bent. The belt around the waist was not re-tightened and appeared loose. Staff then maneuvered the resident into the toilet room by backing the resident into the bathroom. Neither staff went in the bathroom at the time of the backing into the bathroom. At this time, the resident's legs gave out and the resident let go of the hand grips. The harness and waist belt kept the resident's bottom about 4 to 6 inches off the floor and the resident's arms were up and the belt and harness appeared higher up on the chest area. Staff F then left the room to get the nurse and Staff G remained outside the bathroom door. The resident remained as described previously (4 to 6 inches from the floor and upper torso dangling from the harness and belt) Staff F estimated the time he was gone as 30 to 40 seconds. He arrived back to the room, and when he arrived, the resident fell through the harness/waist belt to the floor hitting the back of his/her head on a plastic drawer. The resident's arms went through the waist belt and harness to the floor and the resident's bottom made contact with the floor Staff Working When the Incident Occurred: On [DATE] at 10:30 a.m. Staff F (nurse aide) stated he thought they used a size medium harness for the transfer and it fit the resident. He stated they used the waist and the leg straps as well as the harness for the transfer. They tightened the waist strap immediately after application and also when the resident stood up. He did not tighten it when the surveyor observed during the reenactment but stated he was sure he did on the day of the incident because it is "automatic". He stated the resident's legs gave out and the resident "chicken winged" (elbows came up with hands lower at center of body). He stated the resident's legs did not give out in the past. The resident did not "chicken wing" in the past. He stated after the resident went down, he went out of the room to get the nurse. At that time, the strap and harness still held the resident up about 4 inches from the floor. He returned and then the resident went all the way out of the straps and harness onto the floor. The resident hit his/her head on the plastic drawers behind the resident. Staff F stated prior to the incident, he thought the resident was safe to use the EZ stand. When asked why he got the nurse instead of getting the resident in a safe position, he stated the resident was 4 inches off the floor and he wanted more people down there because the resident would need plenty of help to get him/her lifted up. He stated he knew if the resident slid out that the resident wasn't high enough off the floor that he/she would get hurt. When asked if in retrospect, he would have done anything different he stated if he would have known the resident's legs would give out that he would not have used the EZ stand. On [DATE] at 10:15 a.m. Staff G (nurse aide) denied any prior problems with transferring the resident with the EZ lift. She thought the resident was safe in the EZ stand. She stated she stood outside the bathroom until the nurse came and when the nurse came, they got sheets and assisted the resident. She stated she did not know why she did not go in the bathroom and attempt to secure the resident prior to the nurses ' arrival. On [DATE] at 6:33 p.m. Staff D (Licensed Practical Nurse) stated she worked the night shift prior to the incident and was still at the facility in report with the day shift nurse (Staff J) She stated prior to the EZ stand, the resident ambulated but the resident's knees would get weak and the one knee would give out and wobble so they switched the resident to the EZ stand. Staff D stated the resident did not like the EZ stand because it pulled the resident's arms. Staff D told the resident he/she could use the Hoyer mechanical lift if it bothered his/her arms and the resident refused. Staff D stated the nurse aides started saying the resident's legs were weak. When that happened, they would tell the resident to stand tall. They then began using the commode instead of taking the resident into the bathroom because using the commode shortened the distance of the transfer. The resident then complained staff wouldn't assist him/her to the bathroom so staff discontinued the use of the commode. Staff attempted therapy and the resident refused. Following report of the fall on [DATE], Staff D went to the room and observed the resident with cuts on both sides of the arms. The resident did not seem to respond well and seemed shaky. The nurse aides stated they had applied all the straps and harness. Staff D looked at the straps and saw flesh on the straps. Staff D stated that reassured her staff did have the straps in use when the fall occurred. Staff D stated, at the time, she thought the resident may have suffered a heart attack. After returning to the facility, Staff D asked the resident what happened when the fall occurred and the resident stated he/she "was dropped" on the floor. Staff D stated prior to the incident she saw the resident start to "chicken wing" and, when cued, then the resident would put his/her legs down and stand. If cued, the resident would stabilize self. On [DATE] at 1 p.m. Staff J (Registered Nurse) stated she was in report when staff informed her resident fell out of the EZ stand. Upon entering the room, Staff J observed the resident with back to sink and skin injuries to both hands. The resident appeared confused, sleepy and then awake and not making much sense. Staff sent the resident to the emergency room for evaluation. She stated she examined the lift and belts. It appeared the resident caught his/her arms on the belt and that resulted in the skin injuries to the hands. She also examined the harness and did not note anything abnormal. Staff J stated prior to the fall the resident's family had concerns with the lift but the resident was not safe to walk. Staff J felt the resident was safe to use the lift because the resident bore weight and followed directions. She stated no staff informed her of the resident "chicken winging" or not bearing weight in the lift. Staff J stated the resident's physician stated the resident's high potassium had nothing to do with the fall but she thinks it may have contributed to it. Staff J stated the belt was still snapped and when examined appeared very small and she wondered how it could have even fit around the resident (meaning it was tight). Interview with EZ stand representatives on [DATE] at 11:25 a.m. identified that in order for a resident to qualify for using the EZ stand they must be able to do three things: 1. follow verbal commands 2. bear weight 3. there must be 4 points of contact on the lift i.e. 2 hands and 2 feet The exception may be 3 points of contact. The EZ stand is designed so a resident cannot slip through and fall, if belts and harness are on and secure. After putting the resident in an upright position, staff needs to re-tighten the belt around the waist because when upright the resident gets a little thinner. They recommend replacing harnesses yearly or at the first sign of fraying. If a resident goes limp, the harness and belt strap should catch the resident. They said they could not say for sure but it sounded like the belt was not tight enough around waist/ chest area. If the harness and strap are tightened appropriately it is very difficult to come out of it-you must wiggle to get out of it. Other staff: On [DATE] at 11:50 a.m. Staff E (nurse aide) identified the resident as getting weaker and unable to follow instructions and the resident's legs didn't always support him/her. Because of this, Staff E suggested the Hoyer lift to other nurse aides and nurses, who said they would check into it. The resident would try and hold onto the lift but just did not have the strength. Staff E stated he did not think the EZ stand was safe for the resident and that is why he suggested the Hoyer lift. On [DATE] at 9:50 a.m. Staff H (Director of Nursing) stated she visited with the resident ' s primary physician about the resident's high potassium which can cause nausea, confusion and weakness. The physician stated that had nothing to do with the fall. She then visited with the medical director who said the high potassium indirectly probably had something to do with it. On [DATE] at 6:03 p.m. Staff C (nurse aide) stated when the resident first began using the EZ lift, he/she did well but towards the end the resident didn't hold on right and didn't stand right. The resident refused to stand up straight. The resident would let go of the bars and his/her knees would give out. When this happened staff would sit the resident back down. Staff C stated nurses and management knew this information but if staff sat the resident down for a few minutes and tried again the resident would then perform the EZ stand transfer correctly. On [DATE] at 5:45 p.m. Staff B (nurse aide) stated sometimes transferring the resident with the EZ stand did not go well because the resident would not stand and the resident's legs would buckle. The resident would sometimes take his/her arms out of the harness or "chicken wing". The nurses knew this information. When the resident's knees buckled staff would set the resident back in the chair. Staff B stated the only way to prevent the incident would be to use the Hoyer. On [DATE] at 9:15 a.m. Staff A (certified occupational therapy aide) stated if someone shows they can ' t hang on, staff would change the transfer method. The resident used a total Hoyer lift transfer upon return from the hospital. Staff A stated the resident would be unable to make reasonable safety decisions. On [DATE] at 10:55 a.m., the resident's durable power of attorney for health care stated no one asked her about switching the resident from the EZ stand to the Hoyer lift or about not using the bathroom instead of the commode. She stated the resident would not be able to make reasonable safety decisions. On [DATE] at 10:49 a.m. the resident's primary physician stated the [DATE] fall resulted in the resident's admission to a higher level of care and as a major injury. He stated if the resident wasn't holding on and getting weaker in the EZ stand that staff should have reassessed the use of the stand. He stated he was unclear how the fall could have happened. He stated the fall did not contribute to the resident's death. The resident died of kidney failure and the fall did not make that any worse. 2. Resident #1 had an MDS assessment with a reference date of [DATE] which identified the resident with a brief interview for mental status score of "15" (cognitively intact). The MDS reflected the resident required extensive assistance of two staff with transfers. The resident did not ambulate and utilized a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The MDS identified one fall with injury since the previous assessment. On [DATE] at 1:30 p.m., observation revealed Resident #1 in bed. The resident stated he/she fell forward out of the wheelchair in therapy. The resident stated he/she got a leg hurt in the fall. An incident details report dated [DATE] at 9 a.m. documented the resident went head first out of the wheelchair. A physical therapy aide pushed the resident to the parallel bars in the wheelchair without pedals. The resident's left foot touched the floor and twisted. The resident went face first out of the wheelchair to the floor. The resident received a 2 centimeter (cm.) scratch to the corner of the left eye and complained of pain to the left ankle. The physician orders, dated [DATE] indicated the physician wanted the resident examined in the emergency room if having pain and swelling. The emergency room (ER) discharge instructions, dated [DATE] diagnosed the resident with an ankle sprain. The orders were to apply ice four times a day for 2 days 20 minutes per time, elevate extremity and rest. The ER documentation identified that an ankle sprain occurs when the ligaments that hold the ankle joint together stretch or tear. Sometimes it is called a "twisted" ankle. Review of the care plan dated [DATE] identified the resident utilized a wheelchair and transferred with a sit to stand lift or pivot transfer. The care plan did not direct staff to use foot pedals on the wheelchair during transport of resident. On [DATE] at 12:35 p.m. Staff H (Director of Nursing) was interviewed and stated it is facility policy to have foot pedals on the wheelchair during transport of resident. There is no written policy but verbal that has been in place for years. Staff H stated the physical therapy aide is not employed by the facility but works at the facility through contract with facility and Rehab Care. Review of the ReHab Care contract with the facility, indicated the employees should follow policies of the facility. On [DATE] at 9:18 a.m. Staff A (certified occupational therapy aide and Salem Lutheran program director) stated she is employed by ReHab Care which has a contract with the facility. She stated foot pedal use varies from facility to facility. She stated she did not know the Salem Lutheran policy for foot pedal use. She stated if she is working with someone and is going to push them, she puts foot pedals on. On [DATE] at 9:22 a.m. Staff M (physical therapy aide) stated the resident stood with her and the walker and said he/she needed to sit down. Because of this, Staff M thought they needed to use the parallel bars so she told the resident to hold his/her feet up and pushed the resident to the parallel bars approximately 10 feet away. Just as Staff M moved the wheelchair, the resident dropped his/her feet down and went out of the wheelchair. Staff M stated she knew she should have applied the foot pedals but didn't because it was such a short distance away. She stated the policy at the facility is to use foot pedals on the wheelchair during transport. 3. On [DATE] at 10:28 a.m. Staff O (Registered nurse and Quality Assurance) supplied the surveyor with a competency checklist as facility policy for use of the EZ stand. Part 2 e) indicated staff should keep constant tension on the seat belt of the harness during the raising of the resident. Observation revealed on [DATE] at 1:35 p.m. Staff K (nurse aide) and Staff P (nurse aide) transferred Resident # 4 from the wheelchair with the EZ stand. Observation revealed staff did not tighten the belt when they raised Resident #4 up out of the wheelchair.

Based on record review and staff interviews, the facility failed to maintain an environment free of accident hazards and provide adequate supervision to ensure against hazards from self, others, or elements in the environment for 2 of 5 residents sampled (Resident # 4 and # 5). The facility reported a census of 60 residents. Findings include: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/12/12 which identified [DIAGNOSES REDACTED]. The MDS documented the resident had short and long term memory loss and moderately impaired cognitive skills for decision making. The resident required extensive assistance of 2 or more staff for transfers and bed mobility and had unsteady balance with all activities. The assessment documented Resident # 4 fell on ce without injury since admission or the prior assessment. Review of the Comprehensive Care Plan, dated 10/5/12, revealed the resident had a problem/ need/ and or concern of an alteration in mobility related to cognitive loss with the inability to safely transfer self or be mobile in wheelchair. Plans and approaches directed staff to: a. transfer assist of 2 staff to ensure safety. b. Physical and occupational therapy as ordered. c. Fall prevention: Chair and bed alarm on at all times d. Anti-roll backs on wheelchair. e. Special equipment/ devices: lap buddy as needed when in wheelchair. d. Gripper socks to bed with clip alarm to one sock and end of bed. e. Ambulate with front wheel walker and assist of 2 staff. Review of the Transfer Lift Assessment for Residents dated 9/21/12 revealed the resident could safely perform > or = 50 % lift/ transfer and required no lift. Review of the Falls Data Collection Tool, dated 9/21/12 revealed a score of 23; a score of 12 or more equals a high risk for falls. Review of the Interdisciplinary Progress Notes dated 11/6/12 at 5:30 AM revealed an alarm sounding. Staff entered the room and found Resident # 4 sitting on his/her knees between the wall and bed. Review of the Incident Details report dated 11/6/12 at 5:30 AM revealed the resident found on the floor between the wall and bed, facing the bed. Contributing factors included the Certified Nursing Assistant (CNA) forgot to lock the bed after changing and repositioning the resident. The resident obtained a bruise/contusion measuring 2 centimeter (cm) x 1 cm. On 11/26/2012 at 2:30 PM, Staff F (Licensed Practical Nurse) was interviewed and revealed rounds were completed with the resident. She stated Staff G (Certified Nursing Assistant-CAN) and she changed the resident. She stated the resident is a restless resident and difficult to keep in one spot. Staff F stated the resident had climbed out of bed several times and had 2 alarms in place. Staff F found the resident on the floor between the bed and wall. She did not believe the CNA locked the bed in place prior to leaving the room; Staff F had left the room before the CNA left the room. Staff F stated the resident had no injuries. An interview with Staff G on 11/27/12 at 3:25 PM revealed the resident as frequently restless and tries to climb out of bed and requires alarms for fall prevention. Staff G stated they (Staff F and her) had completed cares with the resident and forgot to lock the bed back into position. 2. Review of the MDS assessment dated [DATE] for Resident # 5 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status score of 13 which signified the resident had an intact cognition. The resident required extensive assistance with bed mobility and transfers and did not walk. Resident # 5 had unsteady balance with all activities. The resident had 1 fall with no injury since admission or the prior assessment. Review of the Comprehensive Care Plan dated 10/31/12 revealed the resident had a potential for injury related to congestive heart failure, renal failure, diabetes mellitus, and mental status change. The resident was non- ambulatory and used a wheelchair. The plan directed to transfer the resident with the assist of 1-2 staff and the use of a sit to stand lift. The plan also directed staff to clip the resident's call light to their gown or shirt while in the room and to use a clip alarm when up; a bed alarm when in bed and to remind the resident to ask for and wait for assistance. Review of the Falls Data Collection Tool dated 10/23/12 revealed a score of 19 which signified the resident at high risk for falls. Review of the Incident Details report revealed: a. On 10/18/12 at 2:30 AM staff found the resident on the floor laying on his/her left side with their head on the blankets and eyes closed. The resident had no injuries and corrective action included to place bed alarms/clip alarm on the resident. b. On 10/26/12 at 5:45 AM, staff found the resident on the floor. The resident stated he/she slid out of bed. Resident # 5 had a small amount of blood on both arms from old skin tears. The bed alarm did not sound until staff pulled the cord and the call button lay on the floor. The immediate intervention to prevent the accident from reoccurring included to change the bed alarm pad and instruct staff to pin the call light on the resident's shirt. On 11/26/2012 at 1:40 PM Staff A (Licensed Practical Nurse) was interviewed and revealed staff found resident on the floor in the Hospice room at the foot of the bed. The alarm box at the head of the bed was connected to the pad in the bed. The alarm should have sounded when the resident moved but it did not sound to alert the staff the resident fell out of bed. At 7:00 AM the restorative aid changed the pad on the bed alarm. On 11/26/2012 at 1:45 PM Staff B (CNA/Restorative Aid) was interviewed and revealed she came to work and staff told her the alarm did not work for Resident # 5 at the time of the fall. She stated she changed the pad on the bed alarm. She also stated they checked the alarms on a weekly basis. Some of the pads would not last the full month of use and the resident's alarm should have been due to be changed.