Every finding on record at Silver Oak Nursing and Rehabilitation Center LLC

Based on observation, clinical record review, facility investigation, and staff and resident interviews, the facility failed to ensure residents remained free from resident to resident sexual abuse for two of three residents reviewed (Resident #2 and Resident #3). Resident #2 showed her breasts to Resident #3, and Resident #3 exposed his penis in front of Resident #2. On 8/16/26, the facility staff self-reported the incident to the Department of Inspections, Appeals, and Licensing. The facility fully corrected the deficient practice by taking the following steps: -When staff were made aware of the incident involving Resident #2 and Resident #3, staff immediately separated and assessed the residents.-Notification of the the physician and Resident #2 and Resident #3's emergency contacts on 8/16/26-Close monitoring of the residents and a room change for increased supervision.-Notification to the police department on 8/16/26. -Staff Education regarding the situation and interventions. The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment, transferred and ambulated without staff assistance, had no behaviors and could understand others. The MDS reported the resident had diagnoses including diabetes, hypertension and depression.The facility self-report dated 8/16/2026 revealed a nurse was informed that Resident #2 reported Resident #3 exposed and touched himself inappropriately while seated across from her in the South dining room. Resident #2 described the behavior as gross.Following the incident, a nurse approached Resident #3 and told him Resident #2 did not appreciate him exposing himself to her and that the behavior was inappropriate. Resident #3 did not deny the reported conduct and nodded his head in understanding when educated regarding appropriate behavior in public areas and around other residents. Both residents were interviewed by the police. Each provided the same story to the officer: Resident #2 first lifted up her shirt, exposing her breasts, followed by Resident #3 pulling down his pants, and touched himself inappropriately in front of Resident #2. Upon the receipt of that information, the facility began 15 minute checks on Resident #2 as well for safety, behavior and distance from Resident #3. The facility revised each resident's Care Plan to include interventions to prevent future recurrence. Each resident stated they would not do this again.The residents were immediately separated, and Resident #3 was instructed not to approach Resident #2 or enter her room. Resident #3 received 15 minute checks with direct staff supervision while in common areas or near other residents. Staff were instructed to closely monitor his location and interactions, prevent contact with Resident #2, and immediately report any further inappropriate behavior. Staff assessed Resident #2 for injury, pain, emotional distress, and any indication of physical contact. A complete skin assessment was completed by the skin nurse. No injuries, skin abnormalities, pain or signs of emotional distress were identified. The physicians and responsible parties for both residents were notified. Resident #3's physician reviewed his medication and possible medical causes for the escalation in sexual behavior.Review of Resident #2's ICF Progress Note by the Nurse Practitioner (NP) dated 6/25/26 revealed the resident had severe memory loss and was unable to make any decisions. Resident #2's Care Plan included the focus: Resident has history of lifting her shirt exposing self to other residents, initiated on 08/18/2026. Goal: Resident will have appropriate attire in public areas at all times. The Care Plan instructed staff to redirect the resident to her room if attire not in place and remind the resident to keep clothes in place in public areas.In a progress note dated 8/16/2026 at 1:41 PM (late entry) revealed, Staff F, LPN (Licensed Practical Nurse) documented Resident #2 reported male resident had exposed himself to her. Further investigation determined she showed her breasts. Staff completed a full skin assessment and provided 15 minute checks, and kept separate from make resident. The physician received notification with no new orders.Review of a Witness Statement Form completed by Staff I, Housekeeping dated 8/16/26 regarding Resident #2 revealed, When came in to the south dining room [Resident #2] told me that [Resident #3] showed her his privates and she said it was really gross. She don't know why he did that. Observation on 8/24/2026 at 8:15 a.m. revealed Resident #2 seated at the South dining room table visiting with Staff E, Registered Nurse (RN). Resident #2 said she ate breakfast and it was good. She persistently questioned Staff E about her marital status. At 11:50 a.m. the resident ambulated independently with her walker to the dining room with the Physical Therapist by her side.On 8/25/2026 at 7:45 a.m. Resident #2 sat at the dining room table, same table as the previous day. At 5:30 p.m. the resident sat in a chair near the entrance. She appeared calm and observed others in the area.On 8/25/2026 at 4:00 p.m., interview with Resident #2 revealed the following: When asked did the police come and talk to you, the resident responded, No, about what? When queried if anyone exposed themselves to the resident, the resident denied. When queried if a man pulled his pants down in front of the resident, the resident denied. When queried if she lifted up her shirt, the resident denied. When queried if she felt safe [at facility], Resident #2 responded she did. 2. The MDS dated [DATE] revealed Resident #3 had intact cognitive function, ambulated with a walker and without staff assistance. The MDS revealed no resident behaviors. The resident had diagnoses including stroke, hypertension, and diabetes.Resident #3's Care Plan reported he had impaired ability to comprehend/interpret and react appropriately to social cues, initiated 8/18/2026. The Goal initiated on 8/18/26 revealed, Resident will refrain in sexual communication in public. Interventions dated 8/18/26 revealed, Staff will identify and have awareness to resident cues, and Staff will redirect to private area for sexual needs.The Care Plan also included the following focus area dated 8/18/26: Engages in voluntary consensual sexual activities with another resident. Interventions dated 8/24/26 revealed, The resident initiating the sexual activity must get permission to do so. and Educate resident that consent for one form of sexual activity does not automatically imply consent to other forms of sexual activity.Review of the resident's ICF Progress Note dated 7/16/26 revealed Resident #3 had deficits in memory, insight, and judgement consistent with prior stroke. The resident had done well on fluoxetine with no charting ordered in the past 60 days for any sexual comments. In a Progress Note dated 8/16/2026 at 9:20 a.m., Staff G documented the South hall nurse reported that other resident stated this resident (Resident #3) showed himself to her. The Progress Note dated 8/16/26 at 12:18 p.m. revealed Resident #3's physician ordered an increase in his Fluoxetine (antidepressant). Staff informed the resident of the new dose.On 8/24/2026 at 8:15 a.m., Resident #3 sat at a South dining room table eating breakfast independently and alone. Resident had his walker nearby. Staff E, RN sat nearby at another table with Resident #2 and Resident #5. At 11:35 a.m. the resident sat alone at the same dining room table, in the same chair, near the entry, eating independently with staff present. At 1:00 p.m. the resident sat near the South nurses station observing staff and residents. At 4:00 p.m. the resident ambulated towards the lounge with his walker.Interview with Resident #3 revealed the following: When asked if the police came and talked to Resident #3 recently, Resident #3 responded, You mean about [Resident #2 first name]? The resident was asked yes, what happened? Resident #3 responded, she flashed me and I flashed her. When queried what he did, Resident #3 motioned that he pulled down his pants and said he pulled his pants down. When queried if he pulled his underwear down too, Resident #3 denied. When queried if he would do that ever again, Resident #3 denied.On 8/24/2026 at 8:50 a.m., Staff A, DON (Director of Nursing) indicated staff was always present when residents ate in the South dining room. Resident #2 could eat wherever she wanted, in any dining room. The incident occurred after the meal, and after it was clear of residents. There was a television in the South dining room that played movies all day. Resident #2 also liked to sit in the common area. She liked to be out of her room and people watch. Resident #3 resided in the facility for about 2 years, and Resident #2 for 3 years. This was the first time anything between them had occurred. She exposed herself first. She admitted it to the police. She lifted up her shirt, then he lowered his pants. He was standing, she was sitting. She said it was gross. She came out and told staff I, Housekeeper. Staff I reported it to Staff J, Registered Nurse (RN). Staff called the Administrator, police, and got statements. The on-call nurse came in. The police interviewed the residents separately. They moved Resident #3's room close to the South nurse's station. Staff did 1:1 supervision with Resident #3 and 15 minute checks for 72 hours. They explained to both residents that they cannot do that. It did not seem to bother either one of them during the interview. They both have a flat affect. Resident #2 shared with the police that she exposed herself first. They completed a pharmacy review and the physician increased Resident #3's fluoxetine. He had no previous history and Resident #2 had never shown any interest in men. She participated in activities, liked to watch people and was able to walk around. It was her home. Staff received education, discussed the incident, what to do and what triggers to look for. It will be reviewed again at the all staff meeting Thursday, August 27. South hall had a lot more activity and supervision with PT (Physical Therapy) and the nurse's station. This was the first time Resident #2 had ever done anything, and staff were surprised. Both residents had a SLUMS (St. Louis University Mental Status) exam, (a screening tool to detect signs of dementia) and updated care plans.On 8/24/2026 at 1:00 p.m., Staff F, Licensed Practical Nurse (LPN) reported she got a call that morning around 9:00 a.m. The East hall nurse called and said Staff J, the South nurse told her that Resident #2 said Resident #3 pulled down his pants and exposed himself to her. Staff F directed her to separate the residents, get statements, and call the Administrator. She said she would complete a State report and call the police. Staff F completed a skin assessment on Resident #2 and found no concerns. She reached out to the Resident #3's physician and he increased his fluoxetine. The police came and spoke with the residents. He said that Resident #3 admitted that he exposed himself and that Resident #2 exposed her breasts first. He went down and spoke to Resident #2 who admitted she showed Resident #3 her breasts and he showed her his penis. Staff F updated the Administrator. Staff initiated 15 minute checks on both residents. They had already initiated the checks on Resident #3, and when Resident #2 said she initiated it, they added the checks on her. We did room changes so they were both closer to nurse's station where there was more eyes. In the past, Resident #2 had a girlfriend at the facility, but it fizzled out. They sat together and they were both cognitively intact. They enjoyed spending time together but it never went any farther. Staff A had a talk with him at that point about appropriateness. The police officer questioned Resident #3's cognition. Staff F felt Resident #3 had a bit of a deficit. He was able to voice his needs and concerns. He typically liked to sit in the dining room or outside of his room, by the nurse's station now that they had moved his room.On 8/24/2026, Staff E, RN reported she did not work at the time of the incident but was made aware of the incident. Staff was keeping an eye on them; monitoring them both. Resident #2's baseline, and usually the only thing she says is it's about time you got it right. She typically did not ask about marriage. That morning at the dining room table when Staff E sat at her table, she kept bringing up the subject. Staff E had told her that she had gone to a wedding over the weekend and that got her going. The South dining room is always supervised. That was a first for both of them. Staff E reported she never observed any sexual behaviors from them. Resident #3 had his fluoxetine increased. He always appeared quiet, never inappropriate, and never touched another resident. Staff E was surprised to hear Resident #2 acted in that way. Staff E contacted the Nurse Practitioner to let her know that Resident #2 was focused on her getting married that morning at the breakfast table, and could not redirect the resident's attention from it. On 8/25/2026 at 10:15 a.m., Staff C, LPN reported working the weekend of the incident involving Resident #2 and Resident #3, but on another hall. Resident #3 had his medications increased. No residents had reported inappropriate behaviors. He ate in the supervised dining room. Staff C reported staff received education. On 8/25/2026 at 10:55 a.m., Staff H, Nurse Practitioner (NP) reported Resident #2 was not a reliable historian, and Resident #3 was not the most reliable person either. Resident #3 had cognitive impairment secondary to stroke. He would not have the insight to understand what the police were asking him. He agreed to everything that Staff H asked him. Per the NP, could phrase questions two different ways and get two different answers. Per the NP, Resident #2 was very pleasant but very demented. She joked a lot and has very superficial responses. Cognitively she cannot remember, she would not have the cognitive ability to understand. Staff H saw Resident #2 earlier for a routine visit. Both residents had a lot of mobility, but they both had cognitive limitations. The NP explained BIMS (Brief Interview for Mental Status) tests were fairly easy, and there was a big difference between BIMS and insight. Neither one were reliable. Anything they said would have to be thoroughly investigated. Resident #2 would be zero reliable.On 8/25/2026 at 1:05 p.m., Staff I, Housekeeper reported worked at the facility for two years. On August 16, when she went to clean the dining room, Resident #2 looked at her and said that guy over there showed me his privates and I thought it was gross. He was not there any longer, she just pointed to where he sat. Staff I did not see him leave the dining room. It was just Resident #2 and another resident, Resident #5. After Resident #5 got up and left, Resident #2 reported it as Staff I wiped down the table. Resident #5 never said anything when she walked out. Staff I had no observations of Resident #3 being inappropriate or enter another resident's room. Staff I never witnessed any sexual behaviors from either one of them.On 8/25/2026 at 1:10 p.m., Resident #5 sat in her room in a recliner. When questioned, she had no recall of ever witnessing inappropriate behavior or anyone exposing themselves. Resident #5's MDS dated May, 2026 revealed she had moderate cognitive impairment.On 8/25/2026 at 1:15 p.m., Staff L, Medication Aide, Bath Aide reported that she never witnessed any sexual behaviors from Resident #3. She never observed him touch anyone or enter another resident's room. In the past Resident #3 and another female resident would walk together and go to the dining room together. Resident #2 is very interested in the lives of staff. She wanted to know what was going on in their lives. No residents had reported any issues with either of them.The police report entered 08/16/2026 at 12:06 p.m. included: Male resident exposed himself to a female resident Spoke with nursing staff here who reported a female resident (Resident #2) approached them and stated a male (Resident #3) had exposed his penis to her. I was able to speak with Resident #3 who appeared to have cognitive issues and he admitted to exposing himself. He stated Resident #2 had exposed her breast first which prompted him to reveal himself. I also spoke with Resident #2 who admitted to exposing her breasts to Resident #3 which caused him to show his penis to her. It should be noted [Resident #2] suffers from cognitive issues as well. The facility Abuse, Neglect and Exploitation policy revised 4/22/2025 included: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.The Prevention of Abuse, Neglect and Exploitation section revealed, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:a Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This ay include identifying when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.

Based on clinical record review, staff interviews and facility policy review, the facility failed to administer medication as the physician ordered for one of three residents reviewed (Resident #4).The facility reported a census of 71 residents. The facility fully corrected the deficient practice per past non-compliance on 5/21/26 by taking the following steps: -Nurses, Medication Aides and Certified Nursing Assistants (CNAs) received education and training regarding medication administration at a staff meeting on May 21, 2026.-Staff D, Registered Nurse (RN), the nurse involved in the medication error, received immediate education when Staff C identified the error.-The facility made the pharmacy aware of the incident and the pharmacy added clearer labeling on the medication. Findings include: The 4/28/2026 Minimum Data Set (MDS) revealed Resident #4 had intact cognitive skills for daily decision making, used a wheelchair for locomotion, and required staff assistance for hygiene and dressing. The MDS reported the resident had diagnoses including heart failure, diabetes, chronic respiratory failure, and renal insufficiency.On 9/11/2025 the physician ordered Mounjaro Subcutaneous Solution (for blood sugar control) Auto-injector 5 milligrams (MG)/0.5ML (milliliter), inject 7.5 mg subcutaneously one time a day every Friday related to Type 2 Diabetes Mellitus with diabetic Chronic Kidney Disease and morbid obesity.In a note dated 3/26/2026, the resident's Nurse Practitioner noted the resident had physical deconditioning due to morbid obesity and respiratory illness with weight slowly trending down. Weight loss desirable, helps with oxygen needs and large hernia. Tolerating Mounjaro well.The May 2026 Medication Administration Record (MAR) revealed Staff D, RN initialed the record, indicating she administered Mounjaro 5 MG/0.5 ML, 7.5 mg to Resident #4 on May 8, 2026.In a Progress Note dated 5/9/2026 at 2:25 PM, Staff C, LPN (Licensed Practical Nurse) documented Resident #4 received the wrong dosage of Mounjaro from the other day. Resident's current order states that she is to get 5mg/0.5 ml when she had gotten 15mg/0.5ml. In a Risk Management note dated 5/12/2026, Staff B, LPN, ADON (Assistant Director of Nursing) documented the medication error occurred on 5/9/2026. The nurse did not check the rights of medication pass. Treatment required - assessment and monitoring. Interventions put into place - nurse education. Physician notified/response: 5/9/2026 at 2:44 p.m. Resident/Responsible party: self.On 8/25/2026 at 9:45 a.m., Staff D, RN reported the medication error occurred when she was asked to help administer resident insulin medications on South hall. She removed the Mounjaro from the refrigerator and administered it to Resident #4. She learned later that she gave the wrong dose and administered another resident's Mounjaro. On 8/25/2026 at 10:10 a.m., Staff C, LPN revealed she found the issue with the Mounjaro. Staff D gave the wrong dose. The resident had no adverse reactions. Staff notified the physician and followed instructions to monitor the resident. On 8/25/2026 at 12:05 p.m., Staff A, DON (Director of Nursing) indicated the resident had no adverse effect from receiving the wrong Mounjaro dose. The resident received double the dose and Staff C found it on May 9th. Staff D received education. The physician prescribed it and it had been working for her. When staff notified the physician about the incorrect dose administration, he instructed staff to observe her. There were two residents on the same hall receiving the same medication, just different doses. The pharmacy delivered the pens, not individually labeled. Now each pen is labeled. They did a risk analysis on the error and communicated to the pharmacy that they needed better labeling.The facility Medication Administration policy included: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, review of the facility Quality Assurance and Performance Improvement (QAPI) documentation, QAPI policy review, and staff interview the facility failed to implement effective quality assurance processes to address deficient practices with F658 Services Provided Meet Professional Standards, F725 Sufficient Nursing Staff, and F880 Infection Prevention and Control, resulting in deficient practices previously identified in 2025 also identified on the facility's current survey. The facility reported a census of 75 residents.Findings include: A review of the CMS CASPER reports revealed the following deficiencies had been cited as follows: a. F658 Services Provided Meet Professional Standards in 2021,2022,2024, and 2025. b. F725 Sufficient Nursing Staff in 2025.c. F880 Infection Prevention and Control in 2025.Deficient practices were identified with F658, F725, and F880 during the facility's most current survey, conducted 4/20/26-4/23/26. A review of the facility QAPI Plan revealed the following: The Governing Body: Reviews QAPI data, findings, and trends, oversees corrective actions and performance improvement activities, ensures adequate staffing, training and resources and supports regulatory compliance and quality outcomes the QAPI/QAA Committee is responsible for the implementation, coordination, and ongoing monitoring of the facility's Quality Assurance and Performance Improvement (QAPI) program and Performance Improvement Projects (PIPs), 4. Feedback, Data Systems, and Monitoring: The following methods will be used to monitor care and services that draw data: Quality indicator reports, CASPER reports, Resident concerns/ grievances, audit tools, monthly facility tracking and trending reports, self-reports, Survey results Department of Inspections and Appeals (DIA) 2567.In an interview on 4/23/26 at 12:45 PM, the Administrator reported concerns were brought to the QA Committee from audits, grievance forms. The QA Committee decided which issues to work on based on what was needed, what was urgent, and what was required. The Administrator was responsible for providing updates to the Council on a monthly basis or as requested.

Based on observation, staff and resident interviews, facility document review and facility policy review the facility failed to answer call lights timely for 4 out of 6 residents reviewed (Resident #1, Resident #26, Resident #50,and Resident #80). The facility reported a census of 75 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. The MDS also documented diagnoses of complete traumatic amputation above the knee of left lower extremity, anxiety, depression, and the need for assistance with personal care. The MDS revealed Resident #26 required partial/moderate assistance with toileting hygiene. The Care Plan focus area dated 2/14/25 revealed the resident was at risk for or has actual impaired ability to independently toilet. The intervention for Resident #26 dated 5/22/25 instructed when toileting, the resident can complete both the transfer and hygiene tasks independently. Check in with the resident early in the shift to be sure the resident isn't requiring more assistance than usual. On 4/20/26 at 11:28 AM, Resident #26 reported having to wait 45 minutes for staff to answer the bathroom call light to assist with wiping while she was sitting on the toilet. 2. The MDS assessment for Resident #50 dated 3/17/26 documented a BIMS score of 15 out of 15, which indicated intact cognition. The MDS reflected the following diagnoses of spondylosis, chronic pain syndrome, Fibromyalgia, osteoporosis, and muscle weakness. The assessment indicated Resident #50 was dependent on staff for toileting, dressing upper and lower body, and required substantial assistance for chair/bed to chair transfers. On 4/20/2026 at 11:00 AM, Resident #50 verbalized she had waited up to 40 minutes for assistance but said it was getting better, only had to wait 20-25 minutes now. 3. The Minimum Data Set (MDS) assessment for Resident #1 dated 4/05/26 listed diagnoses of end stage renal disease, high blood pressure, diabetes mellitus (DM). The MDS reflected a BIMS score of 15 out of 15, which indicated intact cognition. The MDS reflected Resident #1 required partial/moderate assistance to sit up in the bed, sitting to lying on the bed, from sitting to standing, and with toileting hygiene. The Care Plan intervention for Resident #1 dated 4/6/26 directed keep call light within reach and encourage the resident to use it, if not cognitively impaired, for assistance as needed. On 4/20/26 11:01 AM Resident #1 reported he'd waited 40 minutes for staff to come help him. Resident#1 stated the weekends were worse, felt not enough staff on the weekends. 4. The MDS for Resident #80 dated 4/13/26 listed diagnoses of heart failure, diabetes mellitus (DM), and respiratory failure. The BIMS listed a score of 15 out of 15, which indicated intact cognition. The MDS reflected Resident #80 was dependent on staff for toileting hygiene, lower body dressing, rolling to the left and right, sit to standing and bed to chair transfer. The MDS showed Resident #80 required substantial/maximal assistance for upper body dressing and bath/shower. The Care Plan intervention for Resident #80 dated 9/1/2023 revealed, call light within reach and encourage the resident to use it, if not cognitively impaired, for assistance as needed. On 4/23/26 at 7:27 AM, the Call light Monitor on the wall at the North nurses station read Resident #80's room number on 26 minutes. Staff K, Certified Nurse Aide (CNA) sat the nursing station. On 4/23/26 at 7:29 AM, the Staffing Scheduler/CNA went into the Resident #80's room to see what the resident needed. Staff K went into the room. The call light turned off after 28 minutes. Resident #80 reported the staff were checking and changing her. On 4/23/2026 at 10:02 AM, Resident #80 reported her call light on for sometime before the staff came to help her. On 4/23/26 at 1:07 PM the Director of Nursing (DON) reported she expected call lights answered in 15 minutes. The Resident Council notes dated 1/12/26 identified call lights not being answered. The Resident Council notes dated 1/29/26 identified call lights not being answered timely. The Resident Council notes dated 2/9/26 identified call lights not being answered timely. The Resident Council notes dated 4/13/26 revealed resident has to wait an hour for CNA to come help them. The facility provided a policy titled Call Lights: Accessibility and Timely Response dated 12/1/25 reflected the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Based on observation, record review, staff interviews, resident interviews, and policy review the facility failed to follow Physician's Orders when applying topical medication for 1 of 5 residents reviewed (Resident #50). The facility reported a census of 75 residents.The findings include: The Minimum Data Set (MDS) assessment for Resident #50 dated 3/17/26 documented a BIMS (Brief Interview for Mental Status) score of 15/15, which indicated intact cognition. The MDS reflected the following diagnoses of arthritis, chronic pain syndrome, fibromyalgia (disorder causing pain, fatigue, sleep disturbances and cognition issues), osteoporosis, and muscle weakness. The resident's Care Plan focus area dated 8/31/23 revealed the resident had potential for pain related to knee pain, fibromyalgia, chronic pain syndrome, hx (history) skin cancer of face, thoracic spondylosis (spinal osteoarthritis). Interventions dated 8/31/23 included:a. Anticipate resident need for pain relief, to evaluate the effectiveness of pain interventions.b. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.On 4/20/26 at 11:00 AM, Resident #50 stated her Voltaren cream (for pain) and hydrocortisone cream (for rash) were not applied like ordered. A document titled Treatment Administration Record (TAR) for March 2026 lacked documentation that the resident received her scheduled Voltaren gel for 16 out of 93 applications, and Hydrocortisone cream for 2 out of 62 doses.A document titled Treatment Administration Record (TAR) for April 2026 lacked documentation that the resident received her scheduled Voltaren gel for 7 out of 67 doses, and lacked documentation for Hydrocortisone cream for 4 out of 45 doses.On 4/22/26 at 1:00 PM, the Director of Nursing (DON) confirmed her expectation that staff were to sign off on treatments once completed, and if staff did not complete a treatment, they wrote a progress note and notified the physician. A document titled Medication Administration Policy last revised 4/9/25 stated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy explanation and compliance guidelines included, Sign MAR after administered.

Based on resident interview, staff interview, and clinical record review the facility failed to notify the Long-Term Care Ombudsman of discharge and transfers as required for 1 of 1 resident reviewed for hospitalizations (Resident #13). The facility reported a census of 75 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 13 relayed the resident entered the facility from the hospital. The Care Plan initiated 11/14/2024 for Resident #13 relayed resident has altered respiratory status, difficulty breathing, chronic obstructive pulmonary disease, heart failure and chronic hypoxic respiratory failure. Resident #13's Electronic Record listed multiple hospitalizations:-hospitalized on [DATE] and returned on 6/3/25 -hospitalized on [DATE] and returned on 11/13/25-hospitalized on [DATE] and returned on 12/24/25-hospitalized on [DATE] and returned on 1/16/26 On 4/20/26 at 11:17 AM, Resident #13 confirmed recent hospitalizations, contributed to breathing issues.On 4/22/2026 at 11:15 AM, the Administrator reported had believed the Social Services interim staff had notified the Ombudsman appropriately. On 4/22/26 at 11:30 AM, Social Services, Staff B relayed had not been trained correctly regarding reporting to the Ombudsman, could not provide documents that indicated notification of Resident #13's transfers, and agreed processes needed improved for correct Ombudsman report submission. The Administrator relayed on 4/23/26 at 9:30 AM had a report that tracked admission and discharges and thought social services was reporting to the Ombudsman. Per the Administrator, would ensure training and correct the processes. The Transfer and Discharge policy revised 7/14/25 directed the Social Services Director, or designee, would provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for contents of the such notices.

Based on clinical record review, staff interview, and policy review the facility failed to ensure assessments were completed before and after dialysis and ensure ongoing coordination between the facility and dialysis center for 1 of 1 resident reviewed for dialysis (Resident #1). The facility reported a census of 75 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #1 dated 4/5/26 revealed a diagnosis of renal insufficiency/End Stage Renal Disease (ESRD). Per the MDS assessment, the resident received dialysis. The resident's Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15, which indicated intact cognition. The Care Plan initiated 4/2/26 documented Resident #1 received dialysis three times weekly, and the intervention dated 4/6/26 directed to monitor vital signs pre and post dialysis and as needed. The Electronic Record for Resident #1 Titled Dialysis Communication, included the dialysis communication tool assessment and facility communication tool assessment for April 1, 3, 6, 10, 14, 16, 18, and 21. A Dialysis Communication Tool dated 4/1/26 revealed Section 2 titled Dialysis Center Communication was blank.A Dialysis Communication Tool on 4/3/26 revealed Section 2 titled Dialysis Center Communication was blank.A Dialysis Communication Tool on 4/16/26 revealed Section 2 titled Dialysis Center Communication was blank.A Dialysis Communication Tool dated 4/18/26 revealed Section 2 titled Dialysis Center Communication was blank.A Dialysis Communication Tool dated 4/21/26 revealed Section 1 titled Facility Communication was incomplete on the shunt exam section. During an interview on 4/21/26 at 2:30 PM, Staff C, Licensed Practical Nurse relayed the pre-dialysis assessment was completed by the facility nurse before Resident #1 left the facility, and the post-dialysis assessment was completed at the dialysis center. The information relayed by the dialysis center was supposed to be sent back with the resident and entered into the facility assessment documents. Staff C relayed was not sure why some assessments were missing. During an interview on 4/22/26 at 3:10 PM with the Director of Nursing (DON), the DON explained an assessment should be done before dialysis and after dialysis by the facility. The DON relayed would ensure an improved process to ensure dialysis assessments are completed before and after dialysis procedures. The facility policy titled, Hemodialysis revised 12/2/24 documented the facility will assure ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.

Based on staff interviews, employee files, facility document review, and facility policy review the facility failed to check the licensure for 1 of 1 nurse before hire, and failed to obtain clearance from the Department of Criminal Investigation (DCI) before 1 out of 5 staff were hired. The facility reported a census of 75 residents.Findings include:1. The employee timecard for Staff H, Certified Nurse Aide (CNA) showed the employee was rehired on 9/29/2025.The Employee Master Form dated 10/1/25 revealed a requested rehire 9/29/25. The Employee file for Staff H failed to hold a background check dated 9/29/25 or within 30 days before hire. The Division of Criminal Investigation (DCI) advised on 10/2/25 more information needed.The Submission Status/Results Summary dated 1/29/26 showed Criminal History pending further research. 2. The Employee File for Staff I showed the SING completed 6/26/25. The SING failed to show a nurse licensure verification.The facility completed Staff I's licensure verification on 4/2/26. On 4/23/26 at 8:00 AM the Administrator reported the facility verified Staff I's nursing License in 1/2026. The Administrator reported she expected the licensure verification completed before hire. On 4/23/2026 at 10:45 AM the Administrator confirmed the facility failed to have a copy of the clearance for Staff H to work before the hire date of 9/29/25. The Administrator reported these need completed before hire. The Facility provided a blank new hire check list that directed License/Certification Copy AND Verification as part of Pre-Hire, as well as SING Results & May Work Letter (required for anyone with and un-clean SING report) as part of pre-hire.The facility provided a policy titled Abuse, Neglect and Exploitation dated 4/22/25 revealed the following per the Screening section:A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.2. Screenings may be conducted by the facility itself, third-party agency or academic institution.3. The facility will maintain documentation of proof that the screening occurred.

Based on observation, staff interviews, and facility policy review the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 3 residents reviewed (Resident #6 and Resident #11). The facility reported a census of 75 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #6 dated 3/20/26 listed diagnoses of Atrial Fibrillation (irregular heart beat), acute respiratory failure, and gastrostomy tube (feeding tube) status. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicated intact cognition. The gray box on Resident #6's room door held Personal Protective Equipment (PPE) that included gowns, gloves and face masks. The sign on the box that held the PPE read EBP. Everyone must clean their hand before entering and before leaving the room. Providers and Staff must also: Wear gloves and gown for the following activities. Dressing, bath/shower, transferring, changing linens, providing hygiene changing briefs or assisting with toileting, Device care or use: central lines, urinary catheter, feeding tube. On 4/23/26 at 8:25 AM, Staff F Wound Nurse checked the order for the tube feeding (TF) and water flush. Staff F completed hand hygiene applied gloved. Staff F flushed the tube feeding and set up the feeding per the physician's order. Staff F failed to use gown and mask with the TF. On 4/23/26 at 9:46 AM upon entering Resident #6's room, Staff C Licensed Practical Nurse (LPN) and the Speech therapy (ST) were in the room. ST directed Resident #6 to work on swallowing exercises. Staff C wore a pair of gloves and failed to wear other EBP. The feeding tube was unconnected from Resident #6. Staff C removed her gloves, left the room. Staff C reported she needed to find the Director of Nursing (DON).On 4/23/26 at 9:52 AM, Staff C completed hand hygiene, put a gown, mask and gloves on, and administered Resident #6's medication through the feeding tube. On 4/23/26 at 10:15 AM, Staff F reported she failed to wear the gown and mask (EBP) when she hooked up Resident #6's TF. On 4/23/26 at 10:37 AM, Staff C reported she failed to put the gown, mask on and when she went into Resident #6 room to flush her TF after her feeding completed. Staff C acknowledged she only wore only gloves for that care. 2. The MDS assessment for Resident #11 dated 3/20/26 listed diagnoses of retention of urine, and need for assistance with personal care. The MDS included a BIMS score of 15 out of 15, which indicated intact cognition. The MDS revealed the resident had an indwelling urinary catheter.The Care Plan for Resident #11 dated 4/17/26 identified an indwelling foley catheter related to retention of urine. The Intervention dated 4/20/26 directed EBP.On 4/20/26 at 1:00 PM, 4/21/26 at 9:30 AM, and 4/22/26 at 8:05 AM, Resident #11's room door failed to hold an EBP Sign or box with PPE. The Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated 4/2026 directed indwelling Foley catheter 16 French 15 milliliters (ml) per Urology physician for urine retention. On 4/23/26 at 8:46 AM, Resident #11 and Staff E, Certified Nurse Aide (CNA) walked out of the shower/bath room across the hall from Resident #11's room. Staff E reported she just completed bathing for Resident #11.Staff E said she failed to need EBP for a bath. Staff E said CNAs did the catheter care but they only needed to use gloves for her cares, no gown or other PPE. Resident #11's room door failed to hold an EBP sign or PPE.On 4/23/26 at 10:30 AM, Staff C reported the CNA needed to wear the EBP when they did things with Resident#11's catheter bag. She said if the staff didn't move the bag or wash her, they don't need to use EBP. On 4/23/26 at 10:35 AM Staff E reported she told Resident #11 to wash herself during the shower. Staff E revealed she just wore gloves with Resident #11's shower. On 4/23/26 at 10:35 AM, the Infection Preventionist (IP) said EBP was needed when entering the room for catheter care handling of urine. All need an EBP tray holder on the door and the sign. The IP confirmed staff were expected to use EBP for residents with tube feedings. On 4/23/26 1:08 PM, the Director of Nursing (DON) reported she expected the staff to use the EBP as directed on the signage with high contact activities. The facility provided a policy titled Enhanced Barrier Precautions dated 9/9/25 which revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.The Implementation of Enhanced Barrier Precautions section revealed, a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .4. High-contact resident care activities include:a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline cathetersh. Wound care: any skin opening requiring a dressing.5. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room, and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.

Based on clinical record review, resident interviews, staff interviews, training documentation, personnel files, and policy review the facility failed to ensure 2 of 5 residents received respectful dignified care that protected their right to privacy (Residents #2 and #8). An Activity Assistant walked into Resident #2's room while a Certified Nurses Aide (CNA) was providing personal cares, and into Resident #8's room while she was dressing and using the restroom. The facility reported a census of 70 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #2 dated 7/6/25 documented diagnoses of cancer, multiple sclerosis, and schizophrenia. Her Brief Interview for Mental Status indicated she was cognitively intact with a score of 15/15. Section GG revealed she was dependent on staff for hygiene, dressing, transfers, and bed mobility.A progress note titled Psychosocial Note dated 10/2/25 at 1:00 PM documented the resident was receiving cares when the Activity Assistant came into the room without knocking. The CNA stated the Activity Assistant saw the resident exposed and that caused the resident distress. She was uncomfortable that the staff entered the room, and very upset by the belief that the staff member would be fired. She spoke with the Director of Nursing about the incident.Investigation documentation titled Questions - Alert and Oriented Residents dated 10/3/25 revealed Resident #2 told the facility that Staff D, Activities Assistant had entered her room twice without knocking and that it made her feel uncomfortable.During an interview on 10/22/25 at 10:14 AM Resident #2 confirmed Staff D entered her room without waiting for the CNA taking care of her (Staff A, CNA) to announce that she was providing care. She stated she was naked and the CNA was providing peri care. The resident stated she mostly felt embarrassed at the time and she told Staff A she was upset. She reported Staff D apologized later and she was no longer upset.During an interview on 10/22/25 at 11:46 AM Staff A confirmed the resident's account of the incident and stated the resident was very upset when it happened. She reported the incident to the nurse and Director of Nursing for follow up. Staff A did not think most staff entered rooms without knocking but other residents had commented about the Activity Assistant not knocking and not waiting for a response.2. The most recent submitted MDS for Resident #8 dated 9/21/25 revealed diagnoses of bipolar disorder, osteoarthritis, and polyneuropathy (damage or disease affecting nerves on both sides of the body).A facility Assessment Scoring Report dated 7/20/25 to 10/20/25 documented the resident scored 11/15 on the BIMS assessment which indicated moderate cognitive impairment.The Care Plan (CP) for Resident #8 dated 10/12/23 revealed she had risk for or actual impaired ability to transfer independently related to musculoskeletal impairment, and the intervention dated 8/26/24 revealed the resident could usually transfer independently. A current Care Plan intervention dated 8/26/24 revealed the resident could independently complete both toilet transfers and hygiene. Staff were directed to check in with the resident to be sure she didn't require more help.Investigation documentation titled Questions - Alert and Oriented Residents dated 10/3/25 and 10/6/25 revealed Resident #8 told 2 employees that Staff D, Activities Assistant had entered her room without knocking too many times to count and that it made her uncomfortable.During an interview on 10/22/25 at 10:30 AM Resident #8 reported that Staff D had come into her room without knocking or without waiting for her to answer his knock many times. She provided examples that included asking him to get out while she finished dressing, asking him to come back in 10 minutes when she heard him open the door and call out while she was in the bathroom, and opening the door when she was trying to get in bed. She did not think he was trying to hurt her, but she didn't feel like he thought about her privacy while he was doing his job. She stated residents at resident council had reported the same concerns.During an interview with the facility's Corporate Nurse on 10/22/25 at 12:19 PM she confirmed that the incident with Resident #2 and the concerns brought forward by Resident #8 were not the first time Staff D had entered resident rooms without knocking.At 12:22 PM on 10/22/25 the Administrator stated Staff D had been educated and re-educated regarding the correct way to enter a resident room. This included teach back training where she demonstrated her expectations to him and he then performed the task. At 12:47 PM the Administrator provided disciplinary action reports dated 8/12/25 and 9/9/25 for Staff D regarding similar incidents. Training records provided did not include documentation of all staff training regarding dignity and privacy.On 10/22/25 at 1:22 PM Staff D confirmed he entered Resident #2's room during cares and stated he took full responsibility for that. He reported that he knocked and said who he was, didn't hear them, and then opened the door. He said his voice was soft and they might not have heard him. When asked if he waited for a response to open the door he said no. When asked if there were incidents where he entered a resident's room without waiting for a response he said no.A policy titled Resident Rights revised 3/4/25 indicated residents had the right to personal privacy which included medical treatment, visits, and personal care.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies form, the facility Quality Assurance and Performance Improvement (QAPI) Plan, and staff interviews the facility failed to carry out Quality Assurance activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 76 residents. Findings include:The CMS 2567, dated 4/9/2025 reflected deficiencies identified for failure to report an allegation of abuse. The current complaint survey, conducted 9/8/2025 - 9/15/2025 also identified the above concern. During an interview on 9/15/2025 at 11:31 a.m. with Staff D, Administrator and Staff C, DON, Staff D explained the QAPI team met at least quarterly to discuss Performance Improvement Projects (PIP). The next committee meeting is scheduled for October 6 with administration, heads of departments and the medical director. Issues are discussed in the morning meetings, and those issues are carried over to QA (Quality Assurance). Data is collected via PCC (Point Click Care), grievance forms, and any relevant vender notes such as pharmacy. Staff can leave notes or texts and they can call the compliance line anonymously. The committee decides which issues to work on by ranking them in order with which affect the residents first. Administration held a nurse's meeting regarding the failure to report. Staff were given an opportunity to voice some of the things they reported to prior administration. Things they felt should have been reported but were not. Staff were told they could put notes under the administrator's door if they had a concern. The facility Quality Assurance and Performance Improvement (QAPI) implemented 7/17/2023 included: Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data drivenQAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. The QAPI plan will address the following elements:a. Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions.b. Policies and procedures for feedback, data collection systems, and monitoring.c. Process addressing how the committee will conduct activities necessary to identify and correctquality deficiencies. Key components of this process include, but are not limited to, the following:i. Tracking and measuring performance.ii. Establishing goals and thresholds for performance improvements.iii. Identifying and prioritizing quality deficiencies.iv. Systematically analyzing underlying causes of systemic quality deficiencies.v. Developing and implementing corrective action or performance improvement activities.vi. Monitoring and evaluating the effectiveness of corrective action/performance improvementactivities and revising as needed.d. A prioritization of program activities that focus on resident safety, health outcomes, autonomy,choice, and quality of care, as well as, high-risk, high-volume, or problem-prone areas as identifiedin the facility assessment that reflects the specific units, programs, departments, and uniquepopulation the facility serves. The facility must also consider the incidence, prevalence, andseverity of problems or potential problems identified.e. A commitment to quality assessment and performance improvement by the governing body and/orexecutive leaders.f. Process to ensure care and services delivered meet accepted standards of quality. The facility QAPI Plan received from the administratoron 8/25/2025

Based on clinical record review, staff interviews and facility policy review, the facility failed to report an allegation of resident to resident abuse,(Resident #3 and Resident #4). The facility reported a census of 76 residents. Findings include:The MDS (Minimum Data Set) dated 7/26/2025 revealed Resident #4 had severe cognitive impairment, ambulated independently and had a history of physical behaviors. The resident had diagnoses including dementia, depression and mood disorder. The Care Plan indicated the Resident #4 had behaviors including physical aggression towards others. It instructed staff to administer medications as ordered, monitor and document behaviors and intervene as needed. The resident's Progress Notes dated 6/21/2025 at 1:59 p.m. revealed staff heard a resident yell help in the dining room. Resident #4 slapped another resident's face (Resident #3), knocking her glasses off. The other resident also reported Resident #4 pulled her hair. The MDS dated [DATE] revealed Resident #3 had severe cognitive impairment, ambulated independently, and had diagnoses including seizure disorder and dementia. Progress Notes dated 6/21/2025 at 1:59 p.m. revealed staff heard a resident yell help in the dining room, a CNA entered the room, Resident #3 received a slap to her face, knocking her glasses off. On 6/21/2025 at 10:16 p.m. staff documented the resident had a small scratch on her face. On 6/27/2026, Staff B, Nurse Practitioner saw the resident concerning an intact blister on her face and ordered an antibiotic for seven days. On 7/1/2025, staff documented the resident continued on an antibiotic for a left outer eye abscess. Staff B saw the resident on 6/27/2025. In her Progress Note, Staff B documented staff report the recent development of a blister, which has been increasing in size and causing discomfort. The blister is located at the corner of her left eye but does not involve the eye lids or eye lashes. She has attempted to alleviate the discomfort by applying a warm washcloth. An Incident Report dated 6/21/2025 at 1:59 p.m., revealed Resident #4 slapped Resident #3. Staff A, LPN (Licensed Practical Nurse) documented staff heard a resident yell help in the dining room. A CNA (Certified Nurse's Aide) entered the room and Resident #3 reported she received a full slap to her face, knocking her glasses off. The resident also reported Resident #4 pulled her hair. Staff immediately separated the residents. On 9/15/2025 at 8:12 a.m., Staff B, ARNP reported the resident had an infected abscess at the bottom of her left eye, it did not involve the eye lid, it was not a stye, and it cleared up with antibiotics. Staff began notifying her a couple of days prior to her visit on 6/27/2025. Staff B indicated the abscess could have been a result of trauma. Nursing staff failed to inform Staff B of the resident to resident incident at the time of the visit. On 9/15/2025 at 9:10 a.m., Staff D, Administrator and Staff C, Director of Nursing both indicated the incident involving Resident #3 and Resident #4 on 6/21/2025 should have been reported to the state. According to their abuse policy, it should have been reported. On 9/10/2025 at 9:40 a.m., Staff A, LPN reported on 6/21/2025, Resident #4 entered the dining room, came up behind Resident #3 and slapped her. The two residents do not get along and staff try to keep them apart. Staff A verified she documented the incident. The facility Abuse Policy implemented March, 2022 and revised 9/2025 included: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure sufficient staff in order to provide bathing and/or grooming assistance for 8 of 13 residents reviewed for activities of daily living assistance (Residents #2, #10, #13, #30, #46, #49, #71, & #231). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS stated the resident required substantial/maximal assistance with bathing and listed her Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Nursing Services and Sufficient Staff, revised 2/5/25, stated the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility policy Activities of Daily Living, dated 12/4/24, stated staff would assist residents with baths, dressing, and oral care. A 2/19/25 Care Plan entry stated Resident #2 usually required assistance to provide supervision, verbal cues, and touching/steadying or contact assistance with bathing. The entry stated the resident required assistance with washing her back and hair. On 3/31/25 at 10:36 a.m., Resident #2 stated she only received one bath per week because the facility was short-staffed. Review of the resident's Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers between her admission on 2/11/25 and 4/2/25: 2/22/25 shower documented on paper Resident Bath/Shower Sheet 3/1/25 shower documented on paper Resident Bath/Shower Sheet 3/8/25 shower documented on March 2025 Documentation Survey Report V2 3/12/25 shower documented on March 2025 Documentation Survey Report V2 3/15/25 Resident Bath/Shower Sheet was blank 3/19/25 Resident Bath/Shower Sheet stated the resident did not want to shower and requested if she could shower tomorrow 3/22/25 shower documented on paper Resident Bath/Shower Sheet 3/29/25 shower documented on paper Resident Bath/Shower Sheet The facility lacked documentation of additional tub baths or showers received during the above time period including between 2/12/25 and 2/22/25, a span of 9 days, between 2/22/25 and 3/1/25, a span of 7 days, between 3/1/25 and 3/8/25, a span of 7 days, and between 3/22/25 and 3/29/25, a span of 7 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. 2. The MDS assessment tool, dated 1/5/25, listed diagnoses for Resident #10 which included non-Alzheimer's dementia, seizure disorder, and mild intellectual disabilities. The MDS stated the resident was dependent of staff for personal hygiene including combing hair. The MDS listed the resident's BIMS score as 7 out of 15, indicating severely impaired cognition. A 10/18/23 Care Plan entry stated the resident was depended on staff for combing hair. On 3/31/25 at approximately 1:00 p.m., Resident #10 walked down the East hall and her hair was disheveled and sticking up in the back. On 4/2/25 at 9:00 a.m., the resident ate breakfast in the dining room. The resident's hair was in a head band but her hair was sticking up on both sides and was matted at the crown of her head. 3. The MDS assessment tool, dated 1/20/25, listed diagnoses for Resident #13 which included severe obesity, anxiety, and depression and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 10/12/23 Care Plan entry stated the resident required partial to moderate assistance for bathing. On 3/31/25 at 1:11 p.m., Resident #13 stated she was supposed to receive a bath twice per week but that did not happen. Review of the resident's February and March 2025 Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers during the period of 2/1/25 and 4/2/25: 2/17/25 partial bed bath or wash up at sink documented on February Documentation Survey Report V2 2/20/25 shower documented on paper Resident Bath/Shower Sheet 2/22/25 shower documented on paper Resident Bath/Shower Sheet 3/3/25 shower documented on March 2025 Documentation Survey Report V2 3/13/25 The paper Resident Bath/Shower sheet was blank. 3/27/25 shower documented on March 2025 Documentation Survey Report V2 3/31/25 The resident refused according to the March Documentation Survey Report V2. The facility lacked documentation of additional tub bath or showers received or offered during the above time period including between 2/1/25 and 2/17/25, a span of 15 days, between 2/22/25 and 3/3/25, a span of 8 days, between 3/3/25 and 3/10/25, a span of 6 days, and between 3/17/25 and 3/27/25, a span of 9 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. 4. The MDS assessment tool, dated 1/20/25, listed diagnoses for Resident #46 which included heart failure, non-Alzheimer's dementia, and depression and listed the resident's BIMS score as 11 out of 15, indicating moderately impaired cognition. A 10/12/23 Care Plan entry stated the resident required assistance of staff for washing her back and hair and to provide assistance transferring into the tub or shower. On 03/31/25 at 11:12 a.m., Resident #46 stated she went three weeks with no bath. Review of the resident's February and March 2025 Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers during the period of 2/1/25 and 4/2/25: 2/7/25 shower documented on February Documentation Survey Report V2. 2/25/25 shower documented on February Documentation Survey Report V2. 2/28/25 shower documented on February Documentation Survey Report V2. 3/21/25 documentation of resident refusal of shower on March 2025 Documentation Survey Report V2 3/28/25 shower documented on February Documentation Survey Report V2. The facility lacked documentation of additional tub baths or showers received or offered during the above time period including between 2/1/25 and 2/7/25, a span of 6 days, between 2/7/25 and 2/25/25, a span of 18 days, between 2/28/25 and 3/21/25, a span of 20 days, and between 3/21/25 and 3/28/25, a span of 6 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. 5. The MDS assessment tool, dated 3/14/25, listed diagnoses for Resident #71 which included cellulitis (infection of the tissue) of the left lower limb, heart failure, and obesity and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. Review of the resident's Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers between her admission on 3/7/25 and her discharge on 3/25/25: 3/12/25 shower documented on March 2025 Documentation Survey Report V2 3/13/25 shower documented on March 2025 Documentation Survey Report V2 3/15/25 bed bath documented on paper Resident/Bath/Shower Sheet and stated the resident did not want shower due to her leg dressings 3/24/25 shower documented on Resident Bath/Shower Sheet. The facility lacked documentation of additional tub baths or showers received during the above time period including between 3/7/25 and 3/12/25, a span of 4 days and between 3/15/25 and 3/24/25, a span of 8 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. On 4/7/25 at 10:31 a.m., Staff C Certified Nursing Assistant (CNA) stated Resident #71 needed a shower and she felt like the facility needed to pay attention to how they sent residents out to appointments. She stated she remembered the resident going to dialysis and her hair was matted. On 4/8/25 at 2:38 p.m., the Director of Nursing (DON) stated residents should receive at minimum two baths per week and she had a plan to remedy the concern moving forward. She stated staff should comb a resident's hair before leaving the room. 6. The MDS for Resident #30 dated 3/21/25 documented diagnoses of heart failure, weakness, seizure disorder, and anxiety. The MDS included a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition. It reported the resident needed assistance with set up for oral care and was dependent for toileting hygiene, sit to stand, and chair/bed transfers. The MDS further documented tub/shower transfers and bathing were not attempted in the look back period. On 3/31/25 at 11:16 AM observed the resident asleep in her recliner. From the door of her room, her hair appeared oily and there was a musty urine odor outside of her room. On 04/01/25 at 07:49 AM the resident was observed in her room, asleep in nearly same position as the day before and wore the same plaid nightgown. Her hair remained oily and tight to the side of her head. During an interview on 04/01/25 at 07:54 the resident reported certified nursing assistants (CNAs) told her she had to go (urinate and defecate) in her brief due to 'spells' she had in the bathroom. The resident reported an instance when she sat with poop half in and half out all night. She also reported staff did not regularly comb her hair, change her clothes, help her brush her teeth, or bathe her. She did not think the facility had enough staff to take care of the residents. Review of the resident's March 2025 Documentation Survey Report V2 indicated the resident received 1 bath in March on 3/11/25 and refused a bath on 3/7/25. The facility was unable to provide bath/skin sheets to supplement missing days or document additional efforts to offer the resident a bath. Additional documentation in the V2 report for March 2025 indicated the resident was not assisted with oral hygiene, hair care, shaving, or washing hands and face the following mornings: 3/4, 3/10, 3/11, 3/13, 3/14, 3/15, 3/16, 3/18, 3/19, 3/22, 3/23, 3/30, and 3/31. 7. The MDS for Resident #49 dated 3/16/25 included diagnoses of atrial fibrillation, neurogenic bladder, and fibromyalgia and a BIMS of 15/15 indicating intact cognition. Section GG revealed the resident required substantial to maximal assistance with transfers, toileting, bathing, dressing, and personal hygiene. During an interview on 03/31/25 at 01:40 PM the resident reported she received 1 bath per week and she didn't want a bed bath to replace her showers. She wanted staff to take the time to dry her well after bathing so she didn't get sores under her breasts. She stated it was hard to get a CNA to find the Administrator or Director of Nursing (DON) when she wanted to talk about her concerns. A document titled Monthly Grievance log contained an entry dated 10/21/24 from Resident #49 that she was not receiving showers. It documented the issue was resolved the same day. Review of the resident's Documentation Survey Report V2 and bathing/skin sheets for March 2025 revealed the resident received a shower on 3/7/25, 3/21/25, and 3/28/25. Facility documentation in Progress Notes and bathing sheets did not include documentation that the resident refused any baths/showers. 8. The MDS assessment for Resident #231 dated 2/15/25 listed diagnoses of heart failure, renal failure, and non-Alzheimer's dementia and indicated the resident was unable to complete the BIMS assessment due to short and long term memory problems. The resident's Care Plan with an admitted [DATE] recorded the need for the assistance of two helpers with bathing due to impaired cognition and weakness. On 03/31/25 at 1:40 PM Resident #231's former roommate reported the resident went weeks without a bath, and she thought that was because Resident #231 couldn't speak up for herself like she could. Facility documentation titled South Hall shower schedule listed Resident #231 was scheduled to receive a bath/shower on Mondays and Thursdays. No shower sheets with skin assessments were completed for the resident between 2/1/25 and 3/14/25. Review of the resident's February and March 2025 Documentation Survey Report V2 revealed the resident received 2 showers from 2/1/25 through 3/14/25, on 2/17 and 2/27. The facility did not have documentation that staff communicated missed baths/showers or approached the resident on a different day. During an interview with the DON on 4/7/25 at 9:22 AM she stated the nurses should be checking daily to ensure dressing and toileting were done, and that every contact with the resident was an opportunity to ensure cares were done, including oral care morning and night. She indicated residents had complained to her about bathing and linen changes. She did not think there was currently enough staff for all of the needs residents had. On 4/7/25 at 11:08 AM Staff G, LPN reported acuity impacted completion of tasks, and that call ins affected how much they could get done in a day. She stated every resident could have better oral care. She expected staff to help with oral cares and other activities of daily living, and stated there was a [NAME] effect when there were not enough staff.

Based on facility policy and staff interview, the facility failed to carry out a system of surveillance to track and address infections and potential infections in the facility. The facility reported a census of 74 residents. Findings include: On 4/8/25 at 11:41 a.m., the Regional Director of Nursing (DON) stated infection control had not been completed well at the facility but they had a new person starting soon. She stated it was her expectation they carry out such activities such as mapping out infections and completing skills fairs. The facility lacked documentation of an infection control surveillance system designed to identify possible communicable diseases or infections before they could spread to other persons in the facility such as: a. systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors. b. an ongoing system of surveillance designed to identify possible communicable diseases c. a system for surveillance based upon national standards of practice and the facility assessment, including the resident population and the services and care provided. d. routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility policy Infection Surveillance, revised 6/2024, stated a system of infection surveillance served as a core activity of the facility's infection prevention and control program. The purpose was to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Data to be collected, including how often and the type of data to be documented, included: a. the infection site, pathogen (type of bacteria or virus) (if available), signs and symptoms, and resident location. b. summary and analysis of the number of residents (and staff, if applicable) who developed infections. c. observations of staff including the identification of ineffective practices, if any. d. the identification of unusual or unexpected outcomes, infection trends and patterns. e. how the data would be used and shared and with appropriate individuals to ensure that staff minimize the spread of the infection or disease.

Based on observation, record review, resident interviews, staff interviews, and policy review the facility failed to treat 3 of 7 residents reviewed with dignity and respect while providing care and services (Residents #30, #49, and #51). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #30 dated 3/21/25 documented diagnoses of heart failure, weakness, seizure disorder, and anxiety. The MDS included a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition. It reported the resident needed assistance with set up for oral care and was dependent for toileting hygiene, sit to stand, and chair/bed transfers. The resident was marked as touch assistance for toileting transfers with the MDS further documenting tub/shower transfers and bathing were not attempted in the look back period due to medical condition or safety concerns. The Care Plan for Resident #30 included interventions dated 7/10/24 to transfer the resident to her wheelchair at night for toileting, as well as to encourage participation in activities that promote exercise and physical activity for strengthening and improved mobility. An intervention dated 10/12/24 indicated the resident used XXL disposable briefs and directed staff to change or offer toileting every 2 hours and PRN (as needed). On 3/31/25 at 11:16 AM the resident was noted to be asleep in her recliner wearing a red plaid nightgown. From the door of her room, her hair appeared oily and there was an odor outside of her room. On 04/01/25 at 07:49 AM the resident was observed in her room, asleep in nearly the same position as the day before. She was wearing the same plaid nightgown as the day before. Her hair remained oily and tight to the side of her head. During an interview on 04/01/25 at 07:54, when asked about staff treating her with dignity and respect, the resident reported certified nursing assistants (CNAs) had told her she had to go (urinate and defecate) in her brief due to 'spells' she had quite a while ago in the bathroom. She said she felt 'nasty' going in her brief, which caused trouble getting it out and constipation. They told her to finish going and call them when she was done. She stated it had happened more than once in the past week, mostly at night. The resident reported an instance when she sat with poop half in and half out all night. She also reported staff did not regularly comb her hair, change her clothes, help her brush her teeth, or bathe her. She reported she had been wearing the current clothing for 3 days. A Progress Note dated 7/12/24 at 8:19 PM documented the resident became upset waiting to use the restroom. She told the nurse she would need to use the toilet versus 'going in the brief' that night. Documentation indicated that would be passed on to the night shift. It did not include that it was passed on to the Director of Nursing or the Administrator to discuss why she thought she had to go in her brief. On 04/01/25 at 07:25 PM observed Staff E, CNA walk into Resident #30's room without knocking or announcing herself. Between 7:25 PM and 8:11 PM Staff E entered and exited resident rooms 7 times without knocking or announcing herself. 3 of the rooms were dark with residents sleeping and the noise Staff E made could be heard in the hallway. During a follow up interview with Resident #30 on 04/01/25 at 08:16 PM she reported she'd had a shower after dinner. The resident stated the briefs they put her in afterwards were too tight. The surveyor observed the open package of briefs on the bed were XL. The resident stated she needed XXL and staff told her they didn't have any. She reported they were 'cutting' in to her front and back. She further stated the evening shift CNAs changed her brief but would not take her to the bathroom. She confirmed using the bathroom was her preference. On 04/03/25 at 02:50 PM Staff I, Licensed Practical Nurse (LPN), stated she was aware of staff refusing to take the resident to the bathroom at night. She thought the CNA was disciplined and didn't think that person worked there anymore. An interview with Staff G, LPN on 04/07/25 at 11:08 AM revealed the resident needed the wheelchair and 2 CNAs to take her to the bathroom and to change her brief. She stated the resident had told her about concerns with 2nd shift staff not taking her to the bathroom. She did not know if that had been reported to anyone. While interviewing Staff H, CMA/CNA on 04/07/25 at 10:46 AM she stated Resident #30 required pretty much full care. She reported the resident had been upset some mornings when she arrived because the resident said staff at night made her go to the bathroom in her brief. She stated the resident did have 'little episodes' but if staff stayed with her in the bathroom it was fine. 2. The MDS for Resident #49 dated 3/16/25 included diagnoses of atrial fibrillation, neurogenic bladder, and fibromyalgia. It documented a BIMS of 15/15 indicating intact cognition. Section GG revealed the resident required substantial to maximal assistance with transfers, toileting, bathing, dressing, and personal hygiene. The resident's Care Plan with an admitted [DATE] indicated the resident used an electronic tablet to assist with communication due to hearing deficit. Interventions included anticipating and meeting needs and monitoring for non-verbal signs of distress and frustration. Focus areas included risk for developing pressure ulcers, bowel and bladder incontinence, risk for falls, and fragile skin. On 03/31/25 at 01:19 PM observed the resident's roommate and a guest who opened and closed the curtain dividing the room. Resident #49 asked to speak with the surveyor somewhere private because she felt her roommate listened to everything. At 01:40 PM the resident was transferred to her wheelchair to move to a private area. She reported she was only getting one bath a week, she had to ask repeatedly to get up in the morning, her medications were often late and her pain cream was missed some days. She stated that on 3/4/25 at 11:50 AM a CNA came in and turned off her call light without helping her leading to a 2.5 hour wait to get changed. When asked if she felt staff were respectful she stated she didn't think having to ask the CNAs to make sure she was clean after going to the bathroom, missing showers, or making residents wait so long for care was respectful at all. Resident #49 also reported staff did not provide appropriate daily care for false teeth and it was sometimes hard to get her clothes changed in the morning unless her significant other helped and shut the door. On 04/03/25 at 2:50 PM Staff I, Licensed Practical Nurse (LPN) stated the resident probably had missed showers due to staffing issues. She was not aware of missing denture cleaning. Staff H, Certified Nursing Aide (CNA), during an interview 04/07/25 at 10:46 AM, indicated residents often complained about missing baths, mostly second shift. Staff H stated oral cares should be provided at least every morning. She stated this resident had spoken to her about her care before. On 04/07/25 at 11:08 AM Staff G, LPN reported Resident #49 had expressed concerns about showers, medications, and staff who have told her to wait and then not returned. She addressed it the times she was there but that was only part time. She thought the facility was short staffed for the care residents needed in the building. 3. The MDS for Resident #51, dated 2/9/25, included diagnoses of multiple sclerosis, neurogenic bladder, anxiety, and depression. The resident scored 15/15 on the BIMS indicating intact cognition. He was dependent on staff for oral hygiene, toileting hygiene, and chair/bed transfers. He required substantial/maximal assistance for toilet transfers and dressing. The Care Plan for Resident #51 with an admitted [DATE] included focus areas, goals, and interventions related to multiple sclerosis care, depression, anxiety, mood, and medication monitoring. On 03/31/25 at 11:30 AM the resident reported he was generally happy with his care. During a follow up interview with the resident on 04/08/25 at 9:05 AM he revealed that sometimes he was confused and embarrassed about some of the things he heard. When asked to explain that, he reported he had heard staff in the building talking about about him and a former employee. He stated he did feel safe but also felt 'under duress.' On 4/7/25 at 11:08 AM Staff G, LPN reported staff had talked about the resident and former employee when they still worked at the facility. On 4/9/25 at 9:47 AM Staff H, CNA confirmed that she had talked about the resident, employee, and possible medication issues with other staff. On 4/9/25 at 9:18 AM Staff F, CNA confirmed that she had talked about possible incidents with other staff and heard rumors among staff about a potential relationship. On 4/7/25 at 9:22 AM the Director of Nursing was asked about resident dignity concerns and stated she expected nurses to check in with residents daily to make sure dressing, toileting, bathing, overall care was being completed and that every resident contact was an opportunity to ensure good care. She stated residents had complained to her about issues related to dignity such as bathing, timeliness, and staffing. She expected staff to knock before entering a room and that CNA's would help with oral care twice a day. On 4/7/25 at 5:06 PM the Administrator reported the facility was continuing their investigation into Resident #51 concerns. She expected staff to remember this was a resident's home and didn't know staff had been talking about this incident. A policy titled Resident Rights revised 3/4/25 revealed the resident had the right to a dignified existence. The resident had the right to be treated with respect and dignity. The resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. The resident had a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care. The resident had a right to personal privacy and confidentiality of his or her personal and medical records.

Based on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to provide bathing and/or grooming assistance for 8 of 13 residents reviewed for activities of daily living assistance (Residents #2, #10, #13, #30, #46, #49, #71, #231). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS stated the resident required substantial/maximal assistance with bathing and listed her Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Activities of Daily Living, dated 12/4/24, stated staff would assist residents with baths, dressing, and oral care. A 2/19/25 Care Plan entry stated the resident usually required assistance to provide supervision, verbal cues, and touching/steadying or contact assistance with bathing. The entry stated the resident required assistance with washing her back and hair. On 3/31/25 at 10:36 a.m., Resident #2 stated she only received one bath per week because the facility was short-staffed. Review of the resident's Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers between her admission on 2/11/25 and 4/2/25: 2/22/25 shower documented on paper Resident Bath/Shower Sheet 3/1/25 shower documented on paper Resident Bath/Shower Sheet 3/8/25 shower documented on March 2025 Documentation Survey Report V2 3/12/25 shower documented on March 2025 Documentation Survey Report V2 3/15/25 Resident Bath/Shower Sheet was blank 3/19/25 Resident Bath/Shower Sheet stated the resident did not want to shower and requested if she could shower tomorrow 3/22/25 shower documented on paper Resident Bath/Shower Sheet 3/29/25 shower documented on paper Resident Bath/Shower Sheet The facility lacked documentation of additional tub baths or showers received during the above time period including between 2/12/25 and 2/22/25, a span of 9 days, between 2/22/25 and 3/1/25, a span of 7 days, between 3/1/25 and 3/8/25, a span of 7 days, and between 3/22/25 and 3/29/25, a span of 7 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. 2. The MDS assessment tool, dated 1/5/25, listed diagnoses for Resident #10 which included non-Alzheimer's dementia, seizure disorder, and mild intellectual disabilities. The MDS stated the resident was dependent of staff for personal hygiene including combing hair. The MDS listed the resident's BIMS score as 7 out of 15, indicating severely impaired cognition. A 10/18/23 Care Plan entry stated the resident was depended on staff for combing hair. On 3/31/25 at approximately 1:00 p.m., Resident #10 walked down the East hall and her hair was disheveled and sticking up in the back. On 4/2/25 at 9:00 a.m., the resident ate breakfast in the dining room. The resident's hair was in a head band but her hair was sticking up on both sides and was matted at the crown of her head. 3. The MDS assessment tool, dated 1/20/25, listed diagnoses for Resident #13 which included severe obesity, anxiety, and depression and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 10/12/23 Care Plan entry stated the resident required partial to moderate assistance for bathing. On 3/31/25 at 1:11 p.m., Resident #13 stated she was supposed to receive a bath twice per week but that did not happen. Review of the resident's February and March 2025 Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers during the period of 2/1/25 and 4/2/25: 2/17/25 partial bed bath or wash up at sink documented on February Documentation Survey Report V2 2/20/25 shower documented on paper Resident Bath/Shower Sheet 2/22/25 shower documented on paper Resident Bath/Shower Sheet 3/3/25 shower documented on March 2025 Documentation Survey Report V2 3/13/25 The paper Resident Bath/Shower sheet was blank. 3/27/25 shower documented on March 2025 Documentation Survey Report V2 3/31/25 The resident refused according to the March Documentation Survey Report V2. The facility lacked documentation of additional tub bath or showers received or offered during the above time period including between 2/1/25 and 2/17/25, a span of 15 days, between 2/22/25 and 3/3/25, a span of 8 days, between 3/3/25 and 3/10/25, a span of 6 days, and between 3/17/25 and 3/27/25, a span of 9 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. 4. The MDS assessment tool, dated 1/20/25, listed diagnoses for Resident #46 which included heart failure, non-Alzheimer's dementia, and depression and listed the resident's BIMS score as 11 out of 15, indicating moderately impaired cognition. A 10/12/23 Care Plan entry stated the resident required assistance of staff for washing her back and hair and to provide assistance transferring into the tub or shower. On 03/31/25 at 11:12 a.m., Resident #46 stated she went three weeks with no bath. Review of the resident's February and March 2025 Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers during the period of 2/1/25 and 4/2/25: 2/7/25 shower documented on February Documentation Survey Report V2. 2/25/25 shower documented on February Documentation Survey Report V2. 2/28/25 shower documented on February Documentation Survey Report V2. 3/21/25 documentation of resident refusal of shower on March 2025 Documentation Survey Report V2 3/28/25 shower documented on February Documentation Survey Report V2. The facility lacked documentation of additional tub baths or showers received or offered during the above time period including between 2/1/25 and 2/7/25, a span of 6 days, between 2/7/25 and 2/25/25, a span of 18 days, between 2/28/25 and 3/21/25, a span of 20 days, and between 3/21/25 and 3/28/25, a span of 6 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. 5. The MDS assessment tool, dated 3/14/25, listed diagnoses for Resident #71 which included cellulitis (infection of the tissue) of the left lower limb, heart failure, and obesity and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. Review of the resident's Documentation Survey Report V2 and paper bath sheets revealed the resident received the following baths or showers between her admission on 3/7/25 and her discharge on 3/25/25: 3/12/25 shower documented on March 2025 Documentation Survey Report V2 3/13/25 shower documented on March 2025 Documentation Survey Report V2 3/15/25 bed bath documented on paper Resident/Bath/Shower Sheet and stated the resident did not want shower due to her leg dressings 3/24/25 shower documented on Resident Bath/Shower Sheet. The facility lacked documentation of additional tub baths or showers received during the above time period including between 3/7/25 and 3/12/25, a span of 4 days and between 3/15/25 and 3/24/25, a span of 8 days. The facility lacked documentation staff re-approached the resident on a different day after a refusal. On 4/7/25 at 10:31 a.m., Staff C Certified Nursing Assistant(CNA) stated Resident #71 needed a shower and she felt like the facility needed to pay attention to how they sent residents out to appointments. She stated she remembered the resident going to dialysis and her hair was matted. On 4/8/25 at 2:38 p.m., the Director of Nursing (DON) stated residents should receive at minimum two baths per week and she had a plan to remedy the concern moving forward. She stated staff should comb a resident's hair before leaving the room. 48452 6. The MDS assessment for Resident #231 dated 2/15/25 listed diagnoses of heart failure, renal failure, and non-Alzheimer's dementia and indicated the resident was unable to complete the BIMS assessment due to short and long term memory problems. The resident's Care Plan with an admitted [DATE] recorded actual skin impairment, risk of pressure ulcer development, nutritional problems, incontinence, and the need for the assistance of two helpers with bathing due to impaired cognition and weakness. On 03/31/25 at 1:40 PM Resident #231's former roommate reported the resident went weeks without a bath, and she thought that was because Resident #231 couldn't speak up for herself like she could. Facility documentation titled South Hall shower schedule listed Resident #231 was scheduled to receive a bath/shower on Mondays and Thursdays. No shower sheets with skin assessments were completed for the resident between 2/1/25 and 3/14/25. Review of the resident's February and March 2025 Documentation Survey Report V2 revealed the resident received the following baths or showers from 2/1/25 through 3/14/25: 2/10/25 #1 documented, which indicated the resident had a partial bed bath. 2/17/25 shower documented. 2/27/25 shower documented. 3/03/25 #1 documented. The facility did not have documentation that staff communicated missed baths/showers or approached the resident on a different day. 7. The MDS for Resident #49 dated 3/16/25 included diagnoses of atrial fibrillation, neurogenic bladder, and fibromyalgia and a BIMS of 15/15 indicating intact cognition. Section GG revealed the resident required substantial to maximal assistance with transfers, toileting, bathing, dressing, and personal hygiene. The resident's Care Plan with an admitted [DATE] included focus areas for risk of developing pressure ulcers, bowel and bladder incontinence, risk for falls, and fragile skin. During an interview on 03/31/25 at 01:40 PM Resident #49 reported receiving 1 bath per week and she didn't want a bed bath to replace her showers. She wanted staff to take the time to dry her well after bathing so she didn't get sores under her breasts. She stated it was hard to get a CNA to find the Administrator or Director of Nursing (DON) when she wanted to talk about her concerns. She added regular bathing was important because 3 CNA's didn't get her completely clean, and sometimes she had to use wipes to clean herself. A document titled Monthly Grievance log contained an entry dated 10/21/24 from Resident #49 that she was not receiving showers. It documented the issue was resolved the same day. Review of the resident's Documentation Survey Report V2 and bathing/skin sheets for March 2025 documented: 3/3/25 #1 which meant washed up, sink bath, or partial bed bath. No shower/skin sheet. 3/5/25 #1. No shower/skin sheet. 3/7/25 shower documented. No shower/skin sheet. 3/10/25 blank. No shower/skin sheet. 3/12/25 #1. No shower/skin sheet. 3/14/25 blank, skin sheet documented a shower 3/17/25 #1. No shower/skin sheet. 3/19/25 blank. No shower/skin sheet. 3/21/25 shower documented, bathing sheet confirmed 3/24/25 not applicable documented. No shower/skin sheet. 3/26/25 #1. No shower/skin sheet. 3/28/25 shower documented. No shower/skin sheet. Facility documentation in Progress Notes and bathing sheets did not include documentation that the resident refused any baths/showers. 8. The MDS for Resident #30 dated 3/21/25 documented diagnoses of heart failure, weakness, seizure disorder, and anxiety. The MDS included a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition. It reported the resident needed assistance with set up for oral care and was dependent for toileting hygiene, sit to stand, and chair/bed transfers. The MDS further documented tub/shower transfers and bathing were not attempted in the look back period. The Care Plan for Resident #30 included interventions dated 7/10/24 to transfer the resident to her wheelchair at night for toileting. An intervention dated 10/12/24 directed staff to change or offer toileting every 2 hours and PRN (as needed). On 3/31/25 at 11:16 AM observed the resident asleep in her recliner. From the door of her room, her hair appeared oily and there was a musty urine odor outside of her room. On 04/01/25 at 07:49 AM the resident was observed in her room, asleep in nearly same position as the day before and wore the same plaid nightgown. Her hair remained oily and tight to the side of her head. During an interview on 04/01/25 at 07:54 the resident reported certified nursing assistants (CNAs) told her she had to go (urinate and defecate) in her brief due to 'spells' she had in the bathroom. She said she felt 'nasty' going in her brief, which caused trouble getting it out and constipation. The resident reported an instance when she sat with poop half in and half out all night. She also reported staff did not regularly comb her hair, change her clothes, help her brush her teeth, or bathe her. She reported she had been wearing her current clothing for 3 days. Review of the resident's March 2025 Documentation Survey Report V2 indicated the resident received 1 bath in March on 3/11/25 and refused a bath on 3/7/25. The facility was unable to provide bath/skin sheets to supplement missing days or document additional efforts to offer the resident a bath. Progress Notes for Resident #30 did not document additional baths given, alternate attempts after refusals, or offers of alternate interventions. Additional documentation in the V2 report for March 2025 indicated the resident was not assisted with oral hygiene, hair care, shaving, or washing hands and face the following mornings: 3/4, 3/10, 3/11, 3/13, 3/14, 3/15, 3/16, 3/18, 3/19, 3/22, 3/23, 3/30, and 3/31. During an interview with the DON on 4/7/25 at 9:22 AM she stated the nurses should be checking daily to ensure dressing and toileting were done, and that every contact with the resident was an opportunity to ensure cares were done, including oral care morning and night. She indicated residents had complained to her about bathing and linen changes. She did not think there was currently enough staff for all of the needs residents had. The DON confirmed staff had refused to take the resident to the bathroom at night. Staff had been re-educated 3 weeks before. She was not aware it was still happening. On 4/7/25 at 11:08 AM Staff G, LPN reported acuity impacted completion of tasks, and that call ins affected how much could get done in a day. She stated every resident could have better teeth care here. She expected staff to help with oral cares and other activities of daily living, and there was a [NAME] effect when there was not enough staff.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to carry out wound assessments and/or wound treatments for 3 of 6 residents reviewed for non-pressure wounds (Residents #63, #71, and #232). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 11/5/24, listed diagnoses for Resident #63 which included left foot drop, muscle weakness, and abnormal posture. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A 7/30/24 Care Plan entry stated the resident had actual impairment to skin integrity related to a left foot surgical wound. An 8/1/24 surgical note stated the resident had a left fourth toe amputation and had a diagnosis of osteomyelitis(infection of the bone). A 12/20/24 Order Note requested the discontinuation of a betadine (an iodine solution used to treat wounds) treatment to the left foot due to the area long since healed. A 12/28/24 Order Note stated the facility received a verbal order for betadine to the left second and third digits. The facility lacked documentation of an assessment of the left foot and a reason for the betadine order. A 1/3/25 Weekly Skin Observation lacked documentation of a current wound. A 1/10/25 Weekly Skin Observation stated the resident had a left foot mark and scar but lacked any further assessment of the foot. A 1/14/25 surgical note stated the resident had a wound on the left second and third toes which he stated began a couple of weeks prior. The facility lacked further documentation of left foot assessments including a description of the wound and wound measurements from the date of the order on 12/28/24 until the 1/14/25 surgical appointment. 2. The MDS assessment tool, dated 3/14/25, listed diagnoses for Resident #71 which included cellulitis (an infection of the tissues) of the left lower limb, heart failure, and obesity. The MDS stated the resident had two venous or arterial ulcers and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 3/3/25 hospital note stated the resident had non-healing bilateral lower extremity wounds and had lower left extremity black eschar (a thick, dry, leathery, and often dark-colored (black, brown, or tan) tissue that formed on a wound, typically after a burn or other severe injury) and erythema (redness) with purulent (referring to pus) drainage. A 3/7/25 hospital Summary of Care report listed current medications including silver sulfadiazine 1% cream (used to treat and prevent infections) and [NAME] oxide (used to protect skin) to bilateral lower legs and feet twice daily. A 3/7/25 Health Status Note stated the resident arrived at the facility from the hospital. A 3/7/25 Nursing Admission/Readmission Assessment, documented the resident had vascular wounds to the right and left lower legs. A 3/7/25 Weekly Skin Observation documented the resident had left and right lower leg necrosis (referring to dead tissue), a right foot ulcer measuring 3 centimeters (cm) x 2 cm, and a left upper leg ulcer measuring 3 cm x 5 cm. Care Plan entries, dated 3/8/25, stated the resident had potential/actual impairment to the skin integrity of the right and left legs and directed staff to carry out weekly documentation including measurements, tissue type, and other notable changes or observations. The March 2025 Treatment Administration Record (TAR) included the following orders: a. Silver Sulfadiazine Cream 1%, apply to bilateral lower extremities and feet topically every shift, cleanse wound with soap and water, apply zinc oxide paste to peri-wound skin, apply thick layer like frosting of sulfadiazine on 4x4 gauze and apply to wound, cover with abdominal pads, wrap with kerlix (a type of gauze bandage) and secure with 2 inch paper tape. b. Silver Sulfadiazine Cream 1%, apply to left medial (referring to the middle portion) lower leg topically every shift, cleanse wound with saline and gauze, loosely fill wound with sulfadiazine moistened packing strip, cover with an abdominal pad, wrap with Kerlix, and secure with paper tape. c. Zinc Oxide External Paste 40%, apply to legs and feet per orders. The following entries were blank and lacked staff initials to indicated the completion of the above treatments: 3/8/25 6:00 a.m. dose, 3/11/25 night dose, 3/12/25 morning dose, 3/22/25 night dose. The 3/9/25 morning dose documented a 9 which directed to Progress Notes. 3/9/25 eMAR Administration Notes stated the facility waited for the resident's Silver Sulfadiazine Cream 1% and zinc oxide from the pharmacy. A 3/14/25 Nurse Practitioner note stated the resident had cellulitis of the lower extremities with non-healing ulcers and stated the dressings were intact and per nursing, the wounds were stable with no acute signs of infection. A 3/14/25 Weekly Skin Observation sheet stated the resident had vascular wounds to the bilateral lower legs. The document contained no other assessments or measurements of the wounds. A 3/21/25 Health Status Note stated the resident's wounds to the left lower extremity were worsening and the redness extended to mid-thigh bilaterally. A 3/21/25 Weekly Skin Observation stated the resident had pressure ulcers to the right and left heels. The sheet lacked documentation of an assessment to the legs. A 3/21/25 Order Note stated the resident's bilateral lower legs weeped with a moderate amount of serosanguinous(bloody, watery) drainage. The wound beds vary with slough (a yellow, white, or tan, stringy, or thick substance, that overlayed a wound bed and hindered healing) and necrotic areas with surrounding redness noted. The facility lacked further assessments of the residents legs during the time of her admission until her 3/25/25 discharge. A 3/25/25 Progress Note stated the resident received orders to discharge. The facility policy Nurse Services and Sufficient Staff revised 2/5/25, listed nursing duties to include: assessing, evaluating, planning, and implementing resident care plans and responding to resident needs. The facility policy Notification of Changes, revised 10/21/24, stated the facility would promptly consult the resident's physician when there was a change requiring notification. On 4/7/25 at 9:22 a.m., the Director of Nursing (DON) stated staff should carry out treatments and should complete skin assessments weekly. On 4/8/25 at 2:38 p.m., the DON stated they did not locate anything additional for Resident #71 but were still working on it.

Based on observation, facility cleaning schedules, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 kitchen observations. The facility reported a census of 74 residents. Findings include: The initial kitchen tour, conducted on 3/31/25 at 9:33 a.m., revealed the following concerns: a. a thick layer of dust buildup on the back of the ice machine b. dust particles suspended from the 3 spigots of the fire suppression system located above the stove burners. A follow-up kitchen tour, conducted on 4/1/25 at 10:23 a.m., revealed the following concerns: a. dust particles remained suspended from the 3 spigots of the fire suppression system located above the stove burners. b. a shelf to the right of the three compartment sink covered with a film of dust and hairs, located directly over steam table lids. c. the ceiling above a prep area where staff wrapped silverware had strings of dust hanging down approximately 3 inches in length. d. a thick layer of dust hung from the sprinkler above the prep sink. e. dust particles suspended from the ceiling panels above the steam table and covering a vent above the right hand side of the steam table. The undated facility Weekly Cleaning List directed staff to clean ceiling vents biweekly and clean shelves weekly. On 4/2/25 at 12:57 p.m., the Dietary Manager stated she expected kitchen vents and the ceiling to be clean and stated some of the ceiling panels needed replaced.

Based on clinical record review, facility policy review, and staff interview, the facility failed to offer influenza vaccines to 4 of 5 residents reviewed for immunizations (Residents #2, #8, #10, and #63). The facility reported a census of 74 residents. Findings include: The facility policy Influenza Vaccination, dated 6/14/23, stated the facility would offer residents annual immunizations against influenza. 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS stated the resident required substantial/maximal assistance with bathing and listed her Brief Interview for Mental Status (BIMS) status as 15 out of 15, indicating intact cognition. 2. The MDS assessment tool, dated 4/1/25, listed diagnoses for Resident #8 which included diabetes, seizure disorder, and low back pain and listed her BIMS score as 9 out of 15, indicating moderately impaired cognition. 3. The MDS assessment tool, dated 1/5/25, listed diagnoses for Resident #10 which included non-Alzheimer's dementia, seizure disorder, and mild intellectual disabilities. The MDS listed the resident's BIMS score as 7 out of 15, indicating severely impaired cognition. 4. The MDS assessment tool, dated 11/5/24, listed diagnoses for Resident #63 which included left foot drop, muscle weakness, and abnormal posture. The MDS listed the resident's BIMS score as 14 out of 15, indicating intact cognition. The facility lacked documentation they offered influenza vaccines to the above residents during the 2024-2025 influenza season. On 4/8/25 at 2:38 p.m., the Director of Nursing (DON) stated residents should be up to date with their vaccinations. On 4/9/25 at 8:10 a.m., the Regional DON stated she could locate no additional influenza vaccine documentation.

Based on clinical record review, facility policy review, and staff interview, the facility failed to offer a Covid-19 vaccine for 1 of 5 residents reviewed for vaccinations (Resident #2). The facility reported a census of 74 residents. Findings include: The facility policy Covid-19 Vaccination reviewed 11/4/24, stated the facility would offer residents the Covid-19 vaccine. 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS listed her Brief Interview for Mental Status (BIMS) status as 15 out of 15, indicating intact cognition. The resident's clinical record lacked documentation the facility offered the resident a Covid-19 vaccination. On 4/8/25 at 2:38 p.m., the Director of Nursing (DON) stated residents should be up to date with their vaccinations. On 4/9/25 at 8:10 a.m., the Regional DON stated she could locate no additional Covid-19 vaccine documentation.

Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to complete accurate evaluation, failed to implement interventions and failed to prevent a staff member from allowing an exit seeking cognitively impaired resident from leaving the facility at 5:40 AM, walking down the street around the corner, down a main road 0.3 miles (1584 feet) and being outside in below freezing temperatures for 20 minutes. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The Facility reported a census of 67 Residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on February 19, 2024 on February 20, 2024 at 10:45 a.m. Facility staff corrected the Immediate Jeopardy on February 20, 2024 through the following actions: a. All residents were re-evaluated for elopement risk and Care Plans reviewed. b. Resident #67 placed on 1:1 until sent to the hospital for other placement per prior agreement. c. Staff education on elopement risk and procedures; elopement triggers; elopement response plans; not allowing resident/visitors out of the door until verified by a nurse or management staff on 2/20/24. d. Dietary employee provided education on 2/19/24 and 2/20/24. e. All staff were educated on 2/20/24 on the facility protocols for elopement and the requirement to validate with nurse or management who an individual is, if unsure, before helping them exit the facility. f. Root Cause Analysis completed with Quality Assurance (QA) team on 2/20/24. -Dietary staff failed to follow prior education. -Resident admission elopement risk failed to be accurate. -The baseline Care Plan failed to address the risk of elopement. -Wander alert device not placed. The scope was lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: The Admission Record for Resident #67 dated 2/19/24, reflected an admitted [DATE]. The Admission Record listed diagnoses of dementia with other behavioral disturbances, pneumonia and osteoarthritis. The Brief Interview for Mental Statues (BIMS) dated 2/16/24, reveal a score of 1, severe cognitive impairment. The Elopement/Wandering Risk Evaluation dated 2/16/24, showed a score of 22, moderate risk. The evaluation failed to mark Resident #67's dementia diagnoses and failed to reflect behavioral disturbance The Baseline Care Plan for Resident #67 dated 2/16/24, failed to identify the risk for elopement. Failed to place a wander alert device. The Order Summary dated 2/19/24, failed to include a Wander Alert Device. The General Note for Resident #67 dated 2/17/24 at 5:37 AM, reflected overnight Resident#67 entered other residents room and attempting to evacuate the building. Resident#67 removed all of his belonging out of his room. Resident became aggressive with nursing staff that attempted to redirect. The Behavior Note for Resident #67 dated 2/17/24 at 5:13 PM, identified Resident #67 wandered throughout the facility, often gathered his belonging and of his peers, distributing them randomly throughout the facility. Multiple attempts at re-direction were made and unsuccessful. The Electronic Medication Administration Record (EMAR) Administration Note for Resident #67 dated 2/19/24 at 4:38 AM, reflected Resident #67 declined to allow staff to take his vital signs. Resident #67 awake and wandered in the halls as he expressed a desire to leave and wondered why no one else is up yet. The Behavior Note dated 2/19/2024 at 5:00 AM, revealed Resident #67 awake and at intermittent times throughout the night he wandered in the hallways. Staff reported repetitively re-directed the resident to return to his room. At 4:38 a.m. Resident#67 at the North nurses station asking where everyone was and indicated he had wanted to leave. Staff re-directed him to return to his room and monitored him while he ambulated back down the hall. The Health Statues Note for Resident #67 dated 2/19/22 at 5:40 AM, included Staff H, Certified Nurses Aid (CNA) reported to Staff K, Registered Nurse (RN) she failed to locate Resident#67. Staff H stated she saw him within the last 5 minutes as he sat in the lounge area by the dining room and talked to another resident. The note reflected the nurse saw him ambulate in the the hall at approximately 5:30 AM. Staff H and Staff I, CNA searched the facility for Resident #67. Staff determined Resident#67 self-removed his wander guard device and exited the facility while A.M. staff arrived at work. The note identified Resident#67 dressed in shirt, jeans, brown shoes, a blue coat and a baseball style cap. The note continued Staff K and Staff I left the campus to search for Resident #67. Staff K called 911 and alerted the other staff in the building of Resident #67's elopement. Staff reported Resident #67 located and returned to the facility. Resident #67 ambulated with a steady gait & balance. His speech was clear, he denied pain and was free of any signs/symptoms of injury. Resident#67 indicated he went looking for his wife, whom he hadn't seen for 3 weeks. A Notification Preference for Staff G, Cook dated 1/16/23, reflected: The front doors are to remain locked at all times, unless the reception is posted at the front door. For anyone exiting the facility you must ask them if they are a resident or a visitor. If you are unsure, or they cannot answer your question do not let them exit the facility and notify the nurse or management immediately. All resident's exiting the facility must sign out in the sign out binder/book that is blue and located on the front desk by the front door. A Disciplinary Action Form for Staff G, dated 2/20/24, identified she must not let any person out the front door or any other door without verifying they are not a resident. Verification must be conducted with a nurse or management. The Timecard for Staff G, Cook dated 2/19/24, revealed the punch in time of 5:38 AM. Review of the facility video surveillance dated 2/19/24 at 5:38 AM, showed Resident #67 approached Staff G, Cook they appeared to talk to each other. Staff G pushed buttons on the door alarms, opened the door for Resident #67 and he exited the facility. The video surveillance showed Resident #67 walked back in the building on 2/19/24 at 6:00 AM. On 2/21/24 at 9:26 AM, Staff G stated she got in at 5:40 AM on 2/19/24. Staff G reported she knew the resident that sat in the wheelchair (w/c) and a man that sat next to her in a regular chair. Staff G revealed the man wore a coat and shoes, a visitor she thought. Staff G revealed he told her he wanted to be let out. Staff G indicated she failed to see other staff in the area. Staff G confirmed she punched in the door codes and assisted Resident #67 to exit the building. Staff G stated a short time later Staff H, CNA asked if she let Resident # 67 out of the building. Staff G reported she went outside with Staff H and looked for Resident #67. Staff G revealed Staff H found Resident #67 on the other side of the hotel. Staff G confirmed the facility provided additional education after the incident. On 2/21/24 at 5:36 PM, Staff K, Registered Nurse (RN) stated at about 20 minutes to 6 AM on 2/19/24 Staff I, CNA told her she failed to know the location of Resident #67. Staff K reported staff last saw him about 5:30 AM. Staff K indicated she called to the other staff in the back to call 911 and the Administrative staff. Staff K revealed alarms failed to sound alerting them of an elopement. Staff K revealed the night before Resident #67 wandered the halls. Staff K reported none of Resident #67's chart told her he used a wander alert device. Staff K reported staff found a cut wander alert device on Resident #67's bed, but failed to find a cutting device. On 2/21/24 at 6:09 PM, Staff H, CNA stated Resident #67 wandered all night. She said he sat by the fireplace at 5:15 AM, at 5:40 she noticed she didn't hear him anymore, and didn't see him. She said she looked in all the rooms with Staff I, CNA. Staff H reported Staff I told her she heard a dietary staff at the door earlier. Staff H revealed Staff I went to the kitchen and asked about Resident #67. Staff G told Staff I he looked like a visitor and the resident next to him confirmed that. Staff H confirmed she, Staff I and Staff G looked outside for Resident #67. Staff H revealed she called out for him and he stopped on the far side past the hotel on the side of the roundabout. Staff H reported he came back to the facility without further incident around 6 AM. On 2/21/24 at 6:33 PM, Staff I reported Resident #67 wandered the hall most of the night. She stated she saw him about 5:30 AM he sat in the lounge and listened to the radio. She reported she noticed he wasn't in the lounge she went and looked for him. Staff I confirmed Staff G revealed she let a man out the front door. Staff I reported after reporting to the nurse, they all went outside to look for him. She stated Staff H found him over by the coffee shop past the hotel. On 2/22/24 at 2:12 PM, the Director of Nursing (DON) reported a sign on the front door directed staff to be aware of who is coming in and out of the building before this elopement occurred. The DON confirmed the staff training's almost completed. The DON revealed she cut a wander alert device off a resident and it sat at the nurses station. She stated Resident #67 must have picked it up from the nurses station and taken it to his room. She reported staff failed to place a wander alert on Resident #67. The DON confirmed one staff completed the Elopement assessment and another nurse completed the Baseline Care Plan and there was a lack of communication between them to get things in place. She stated at the time she reviewed the admissions the next day she worked and well Monday morning Resident #67 left. The DON reported if a resident wore a wander alert device the MAR directed the nurses to check the placement and the function of the alarm. On 2/22/24 at 3:22 PM, the Administrator reported education completed for Staff G. She stated the staff searched the building and went outside and found him. She reported she's thankful he lacked injury from the incident. She confirmed some additional parts of the admission process needed addressed. She reported she thought staff knew not to let people out the door without verifying who they are. The facility provided a list of cognitively impaired mobile residents dated 2/20/24, the list included nine residents. The facility provided a policy titled Elopement Policy and Procedure undated, Elopement: When a patient or resident who is cognitively, physically, mentally, emotionally and/or chemically impaired wanders away, walks away, runs away, escapes or otherwise leaves a care giving facility or environment unsupervised, unnoticed and/or prior to their scheduled discharge. a. Identify residents who may be at risk of eloping. b. Perform Risk Assessment. Once a resident has been identified as moderate or high risk to elope, share the information with all staff, not just nurses and other direct care providers via elopement binders. Missing Resident Protocols a. Initiate a systematic search of resident care units and other immediate areas: rooms, closets and stairwells, even those areas that are normally locked, along with the roof if there is roof access. b. Make a thorough search of the grounds. Alert staff of potential hazards, such as parking areas, adjacent roadways or bodies of water, such as lakes or ponds. c. Notify management, family members and physician(s). d. Notify local police to request their assistance. e. Document all actions taken either at the time of the incident or immediately after. f. Once resident is found obtain a complete medical evaluation to identify potential injuries and provide necessary treatment. Also notify any previously contacted individuals (managers, family, physician, etc.) of the residents; return. g. Conduct an investigation to determine how the elopement occurred in order to correct any underlying contributing factors. NOTE: Elopement Binders are located at each Nurses Station, Reception Desk, DON & amp; ADMIN Offices

Based on clinical record review, observation, and staff interviews, the facility failed to adequately provide supervision to keep one of three residents safe from an accident with injury (Resident #6). While providing care to a resident in bed who required extensive assistance of two persons with bed mobility, they completed the task with only one person. As they rolled Resident #6, he fell out of bed, and received a hip fracture. In addition, the facility failed to lock the medication cart while unsupervised. During the time the lock remained unlock, at least one resident sat need the medication cart. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #5 required extensive assistance from two persons to transfer and bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). He required assistance from one person for dressing, eating, and hygiene. Resident #3 did not ambulate and used a wheelchair for mobility. The MDS included diagnoses of non-traumatic brain dysfunction (impaired thought process not caused by an injury), dementia, anxiety, depression and hydrocephalus (a condition in which fluid accumulates in the brain, sometimes causing brain damage). The MDS indicated Resident #6 fell in the two to six months prior to admission with no falls since admission. The Care Plan Focus dated 5/17/23 indicated that Resident #6 had a self-care performance deficit related to cognitive impairment, dementia, hydrocephalus, polyneuropathy (damage to multiple peripheral nerves), and physical deconditioning. The Interventions included: a. Initiated 5/17/23: Bed Mobility - Resident #6 required extensive assistance by two staff to turn and reposition in bed. b. Initiated 6/10/23. Transfer - dependent on two staff and use of a total lift. The Morse Fall Scale dated 5/4/23 listed a score of 55, indicating a high risk for falls. The Care Plan Focus dated 5/17/23 indicated that Resident #6 had a moderate risk for falls related to his cognitive impairment, dementia, hydrocephalus, and physical deconditioning. The Interventions instructed the following: a. Dated 8/7/23: Staff received reeducation about having two staff present for all activities of daily living (ADLs) with Resident #6. b. Dated 8/14/23: The staff received education on bed mobility and Kardex (simplified Care Plan). The Kardex dated 8/14/23 described Resident #6 as non-ambulatory, used a wheel chair with extensive assistance of one person, assist of two with bed mobility, and used a total lift for transfers with two staff. Resident #6's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderately impaired cognition. He transferred with total dependence from two persons. He needed extensive assistance from two persons for bed mobility and did not ambulate. The MDS reported the resident had a fall since admission with a major injury (bone fracture, joint dislocation, closed head injury with altered consciousness, subdural hematoma). The Initial Federal Report dated 8/7/23 reflected that Resident #6 had a fall in his room while receiving care by Staff H, CNA. On 8/7/23 at approximately 9:15 AM the facility received notification that Resident #6 had a hip fracture. The Immediate Correction/Protection Actions taken listed that the facility started an investigation and pulled Staff H from the floor and schedule pending the investigation. The Final Report Findings detailed that on Friday, August 4, 2023 at approximately 9:20 PM, Staff I, Registered Nurse (RN) / Assistant Director of Nursing (ADON), received a call from Staff G, RN, regarding a resident's fall. She reported that as Staff H, CNA, provided cares to Resident #6 in bed, she assisted him to lay on his side. When she rolled him to the side, he rolled off the bed, and landed on the floor. Upon the nurse's initial assessment, Resident #6 complained of pain of 10 out 10 to his lower back. Staff I received instruction to call the physician to get orders to send Resident #6 to the hospital due to the inability to get X-rays after hours. Around 9:25 PM after contacting the Administrator, the DON called the facility to see if they received an order to send Resident #6 to the hospital. Staff G reported that the physician did not call back yet. At that time, the DON call the afterhours number and spoke with the physician and obtained orders to transfer Resident #6 to the hospital for evaluation and treatment. The DON contacted the facility to let them know they had orders and ensured the facility sent the resident out to the hospital. Around midnight Staff G call to report that the hospital admitted Resident #6 with hypoxia (low blood oxygen levels) and pneumonia. On August 7, the facility reviewed the hospital notes, which indicated that Resident #6's x-rays on August 5th indicated a right hip fracture. At the time, the hospital did not communicate the findings with the nursing home staff. Resident #6's son chose not to pursue a surgical option to repair his right hip at that time. Additionally, during the hospital stay, Resident #6 received a diagnosis of a third degree AV (atrial ventricular) block and received a pacemaker. Prior to the accident, Resident #6 did not walk and required extensive assistance with activities of daily living (ADLs) and transfers. Staff H received education related to the level of care and assistance needed by the residents on her assignment prior to resident contact on her agency shift that included a COVID outbreak status. Resident #6 required extensive assistance with ADL's, including bed mobility and transfers at the time. He could verbalize and could make his needs known to the staff. Staff H helped Resident #6 with bed repositioning to his right side when he rolled off the bed and landed on the floor. The Incident Report dated 8/4/23 at 9:00 PM completed by Staff G, Registered Nurse (RN), indicated that a CNA call the nurse to Resident #6's room because he fell out of bed to the floor. Upon arrival, the nurse observed him lying on the floor in a supine (on his back) position, with his head towards the television, his feet under the bed, and his urinary catheter to the left of him. Resident #6 had a pillow under his head and another under his hip. The nurse preformed a head-to-toe assessment, took his vitals, and completed a neurological (check the functions of the brain) assessment. Resident #6 at first said he had no pain, but while assessing his back and hip, he screamed from pain in his lower back. The nurse call and notified the physician of the situation. The physician gave an order to send him to the hospital. The nurse removed the CNA from the room and instructed them not to go into his room. The Hospital Impression and Plan document dated 8/5/23 included Hospital Problems of acute hypoxic respiratory failure secondary to bilateral COVID-19 pneumonia with possible superimposed bacterial pneumonia and right parapneumonic effusion. Resident #6 received an order to admit to the intensive care unit (ICU). The report continues to indicate that Resident #6 had an acute third-degree AV block with RBBB and prolonged QT interval, and an acute fall at the nursing home, most likely secondary to COVID-19 pneumonia and the third-degree AV block combination. The Hospital Impression and Plan document dated 8/13/23 listed that Resident #6 had an unstable acute close right hip fracture. The document included an order for Resident #6 to be nonambulatory for one year and is bedbound. No surgical intervention at that time per the physician. The orthopedics department called the nursing station and let them know that Resident #6 could be weightbearing as tolerated with a follow-up with them in six weeks. The undated typed statement completed by Staff A, previous Director of Nursing (PDON) indicated that on Friday, August 4, 2023 at approximately 9:20 PM, Staff I, Registered Nurse (RN) / Assistant Director of Nursing (ADON), received a call from Staff G, RN, regarding a resident's fall. She reported that as Staff H, CNA, provided cares to Resident #6 in bed, she assisted him to lay on his side. When she rolled him to the side, he rolled off the bed, and landed on the floor. Upon the nurse's initial assessment, Resident #6 complained of pain of 10 out 10 to his lower back. Staff I received instruction to call the physician to get orders to send Resident #6 to the hospital due to the inability to get X-rays after hours. Around 9:25 PM after contacting the Administrator, the PDON called the facility to see if they received an order to send Resident #6 to the hospital. Staff G reported that the physician did not call back yet. At that time, the PDON call the afterhours number and spoke with the physician and obtained orders to transfer Resident #6 to the hospital for evaluation and treatment. The PDON contacted the facility to let them know they had orders and ensured the facility sent the resident out to the hospital. Around midnight Staff G call to report that the hospital admitted Resident #6 with hypoxia (low blood oxygen levels) and pneumonia. On August 7, the facility reviewed the hospital notes, which indicated that Resident #6's x-rays on August 5th indicated a right hip fracture. At the time, the hospital did not communicate the findings with the nursing home staff. In a written statement dated 8/4/23, Staff H, CNA, reported that she entered Resident #6's room at approximately 9:00 PM on 8/4/23 to provide perineal care. As Staff H finished his cares, she proceeded to change Resident #6's sheets. She turned him onto his left side and began tucking the sheets under him. When she turned him onto his right side, he rolled too far, falling off the bed, and onto the floor, landing on his back with his head on the legs of his bedside table. Resident #6 requested that she place a pillow under his head and left hip. The XR Hip Right 2 Views Portable report dated 8/5/23 at 6:26 PM included the findings of an acute fracture of the right femoral neck (upper portion of the hip) which appears subcapital (fracture line extends through the junction of the head and neck of the femur) in location. There is associate coxa [NAME] angulation (deformity of the hip where the femoral neck-shaft angle is decreased less than 120 degrees). On 10/3/23 at 11:30 AM Staff K, Advanced Registered Nurse Practitioner (ARNP) reported that she knew Resident #6 for over a year. She explained that he resided in multiple facilities prior to his admission to that nursing home. The facility informed Staff K that Resident #6 fell from bed due to a staff member failing to use two staff during care. Resident #6 fractured his hip but was not a candidate for surgery. He was not ambulatory prior to the surgery and would never walk again. Staff K asked the facility to place something in the resident's room that explained the assistance they required. On 10/2/23 at 12:04 PM, Staff D, Administrator, reported that Staff F, CNA an agency aide, worked at the facility on 8/4/23 on the second shift. The off-going day shift aide gave report to the oncoming shift and explained the level of care each resident required. The agency staff have access to the Kardex if they have questions. On 8/4/23, during a COVID outbreak, the facility staffed two agency aides and one agency nurse on the south and north halls. Resident #6's Care Plan directed staff to use two persons for bed mobility before his fall. After his fall from bed, the facility educated the staff regarding the use of the Kardex. During the facility investigation, the staff reported they typically used one staff with cares and two staff to transfer the resident since he used a Hoyer mechanical lift. On 10/2/23 at 12:50 PM, Staff I explained that on the evening of 8/4/23, she took the initial call from Staff G, Agency Nurse, who stated Resident #6 rolled out of bed and complained of pain. Staff G obtained a physician's order to send Resident #6 to the emergency room (ER). Resident #6 admitted to the hospital with hypoxia and COVID. Initially, the hospital did a chest x-ray but did not do hip x-rays. On Monday, Staff I read that Resident #6 had a fractured hip and then they began the investigation. The facility educated all the CNA's on bed mobility and reviewed the Care Plans for accuracy. The CNA's fluctuated between the level of care that Resident #6 required based on his ability to assist. Resident #6's Care Plan indicated he required extensive assistance. The facility also completed a skills assessment for all CNA's. On 10/2/23 at 1:10 PM, Staff B, CNA, reported that Resident #6's level of alertness fluctuated. On his alert days, Staff B could provide cares for him without another staff member present. The Kardex stated the resident required two staff for transfers with the full body mechanical lift (Hoyer lift) and bed mobility. Staff B gave shift to shift report to the two oncoming aides on 8/4/23 at approximately 2:00 PM He went room to room and told Staff H that he required a Hoyer lift and two staff. Staff H did not receive any type of cheat sheet and the rooms did not have resident reference sheets explaining the level of care. After Resident #6 fell , the staff received education about the need to read the Kardex. On 10/2/23 at 1:40 PM Staff E, CNA, explained that Resident #6 required assistance of two staff to transfer with the use of a Hoyer lift. The resident always turned over in bed without any problems for Staff E, therefore she could provide cares without other staff present. Resident #6 could turn over in bed, could move his legs, but he just could not stand. The facility removed grab bars from the beds of residents who require extensive assistance of two staff. The staff received education after Resident #6 fell from his bed. On 10/2/23 at 2:20 PM, Staff F, agency CNA, reported that she worked on 8/4/23 on second shift, primarily on a different hall than Resident #6's. The other aide went in to provide cares for Resident #6. That evening, they were the only two aides assigned to that area and the other aide never worked at the facility. Staff F reported that she never received report at the change of shift, and nobody went room to room with her. The nurse told her she had the middle hall and the other agency aide had the COVID wing. Staff H knew that the residents had COVID and knew the assistance they required for transfers. Resident #6 fell from bed while Staff F provided his care, not during a transfer. On 10/3/23 at 10:00 AM, Staff A, former DON, reported that Staff I took the call on the evening of 8/4/23. Staff D investigated the fall and determined the day shift aide should have gave the oncoming agency aide a walking tour. The staff do not receive resident reference sheets, but they do access to the Kardex. On 10/5/23 at 10:30 AM, Staff J, Certified Occupational Therapy Assistant (COTA) explained that therapy evaluated Resident #6 on 6/22/23. At that time, they determined that Resident #6 required partial/moderate assistance with bed mobility. The resident had pneumonia, COVID, a significant decline that required increased physical assistance. The Fall Management policy revised 7/19/23 instructed that it is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The policy defines a fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not because of an overwhelming external force (e.g. resident pushed by another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. 19126 2. On 9/26/23 at 1:22 PM observed the medication cart unlocked in the south hall. At the time, four residents sat in wheelchairs near the unlocked medication cart, with no facility staff present in the area. The surveyor notified Staff I to secure the medication cart. On 9/26/23 at 1:22 PM Staff I stated she always expected the staff to keep the medication carts locked when they are not at the medication cart. On 9/26/23 at 1:32 PM witnessed the east medication cart unlocked without staff present. At the time, the medication cart had one male resident near. Staff N, Agency Licensed Practical Nurse (LPN) walked to the cart and locked the medication cart at the time. On 9/26/23 at 2:53 PM noted the east hall medication cart unlocked without staff in the area. The Surveyor informed the LPN of the unsecured medication cart, they locked the medication cart. On 9/26/23 at 3:00 PM Staff N stated that she thought it was okay to leave the cart unlocked while she gave a resident their medications inside a resident's room. She did admit that she could not continuously see the medication cart while in a resident's room. The Medication Administration Policy revised 9/19/23 directed that medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by a physician and in accordance with professional standards of practice.

Based on clinical record review, observations, staff and resident interviews the facility failed to provide pain medications for 1 of 10 residents reviewed (Resident #3). Resident #3 missed 14 doses of fentanyl (pain medication) patch. The documented assessments revealed that she had an increase in pain from not every day and mild to everyday and moderate. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment. Resident #3 required extensive assistance with dressing and total assistance for transfers, personal hygiene, and bathing. The MDS indicated that Resident #3 did not walk and utilized a wheelchair to move about the facility. The MDS included diagnoses of heart failure, major depressive disorder, stroke, fibromyalgia, pain to right and left shoulders and extreme morbid obesity. The Care Plan Focus dated 10/18/22 reflected that Resident #3 had chronic pain due to fibromyalgia. The Interventions directed the following: a. Administer pain medications as ordered b. Anticipate the resident's needs for pain relief c. Evaluate the effectiveness of the pain medication regime d. Notify the resident's physician as needed for increased pain. The Monthly LTC Note dated 6/10/23 at 10:18 PM described Resident #3's pain as occurring less than daily, with the highest level as mild. The pain does not interfere with her daily functioning. The Progress Note written by Resident #3's Advanced Registered Nurse Practitioner (ARNP) on 6/23/23 included orders for the following: a. Oxycodone oral tablet 5 milligrams (mg) immediate release tablet. Take one tablet every 6 hours for pain as needed. b. fentanyl 25 mcg per hour 72-hour patch. Place one patch onto the skin every third day. Resident #3's July 2023 MAR included an order for fentanyl Patch 72-hour 25 mcg per hour. Apply one patch every 72-hours for pain, rotate site, and remove per schedule. The documentation on the 9th, 12th, 15th, 18th, 21st, 24th, 27th, and 30th listed a 9, indicating other / see progress notes, indicating she did not receive her fentanyl patch. The Psych Note dated 7/6/23 at 3:31 PM the ARNP documented that Resident #3 reported that she does not sleep good at night due to pain in her legs. Resident #3's August 2023 MAR included the fentanyl order. The documentation to indicate administration listed a 2 on the 2nd, 5th, and 8th, indicating drug refused. On the 11th, 14th, and 17th the MAR list a 9, indicating other / see progress notes. The MAR indicated that those days, Resident #3 failed to receive her fentanyl patch to relieve her pain. The Monthly LTC Note dated 8/11/23 at 3:05 AM indicated that Resident #3 had daily pain with her highest pain level rated as moderate. The Pharmacy Note dated 8/15/23 at 7:25 AM recorded the facility contacted the pharmacy regarding Resident #3 having no fentanyl patch for two weeks. The pharmacy responded that they needed a new script and they would contact the doctor. The Incident Report dated 8/15/23 at 2:00 PM indicated that Resident #3 did not have her scheduled pain medication available for more than two weeks. The Immediate Action Taken reflected that the nurse assessed Resident #3 for pain and contacted the pharmacy. The pharmacy responded that Resident #3 needed a new prescription to refill her medication. The nurse notified the physician that Resident #3 did not have her fentanyl, how long she did not have her fentanyl, her pain assessment findings, and that they needed a prescription. The nurse interviewed all staff who administered medication to Resident #3 and received education on the process of refilling medication timely, on-going communication with the on-coming and off-going nurse to ensure medication is received timely. The nurse conducted an audit on all residents who receive narcotic pain medication, to ensure availability and timeliness of the medication. The local pharmacy delivery record from 6/17/23 to 9/15/23 for Resident #3 revealed the pharmacy failed to deliver fentanyl patches for her from 6/23/23 - 8/16/23. On 10/2/23 at 12:40 AM Staff B, Certified Nurse Aide (CNA), stated Resident #3's pain comes and goes. When she has pain she will not get out of bed in the morning. Staff B reported that this happens on average about 12 days a month. Resident #3 frequently complained of pain to her shoulders. On 10/2/23 at 10:45 AM, Resident #3 explained that she always had pain but reported it is manageable with her medications. On 9/27/23 at 2:00 PM, Staff I, Registered Nurse (RN) / Assisted Director of Nursing (ADON), said she knew about Resident #3 missing her fentanyl patches for an extended period. Staff I acknowledged that Resident #3 missed at least 14 doses of her pain medication from June 2023 to August 2023.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to provide adequate nursing assessments for two of three residents reviewed (Residents #2 and #6). On 12/21/22, when Resident #2 admitted to the facility. On 12/23/22, Resident #2 discharged to the hospital. Between Resident #2's admission and discharge, the facility failed to complete and document assessments on his condition at the time. When Resident #2 discharge from the facility to the hospital, he got admitted to the ICU. On 1/20/23, Resident #6 dropped hot chocolate with an unknown temperature on her abdomen and thigh resulting in second to third degree burns. Following the incident, the staff reported that Resident #6 had complained of pain. The review showed that Resident #6 only received pain medication right after the incident and not again for another seven days despite her reports of pain. The facility reported a census of 52 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] indicated an admitted [DATE] from an acute hospital. The MDS indicated that on 12/23/22, Resident #2 discharged unplanned from facility to an acute hospital without a return anticipated. The MDS identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Resident #2 required extensive assistance of one to two staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS listed that Resident #2 did not walk and required the total assistance of one person with eating. Resident #2 received their nutrition from a feeding tube. The Care Plan initiated 12/22/22 indicated that Resident #2 had an activities of daily living (ADL) self-care deficit related to muscle weakness, decreased mobility, altered cardiovascular status, encephalopathy, peg tube (feeding tube), and a urinary catheter. The interventions listed that Resident #2 required extensive assistance with bathing/showering, bed mobility, dressing, personal/oral hygiene, toilet use, and transfers. Resident #2 required tube feeding and full assistance with the management of it. The Fall Incident Report dated 12/21/22 at 6:04 PM documented that Resident #2 fell in his room. The staff observed Resident #2's upper body on the floor with his legs on the bed. Resident #2 bled from his G-tube, (gastrostomy tube) a tube used to provide nutrition into the stomach. Resident #2's G-tube and urinary catheter were pulled from their insertion locations. When the staff attempted to provide range of motion (ROM), Resident #2 complained of pain. Staff A, LPN (Licensed Practical Nurse), notified the physician and transferred Resident #2 to the emergency room . Staff A also notified Resident #2's next of kin and the Administrator. On 1/24/23 at 12:05 PM, Staff B, CMA (Medication Aide), reported that they worked on 12/21/22, 12/22/22, and 12/23/22 from 6 o'clock AM until 6 o'clock PM. When Resident #2 fell on [DATE], Staff B already left for home but did hear that his feeding tube and urinary catheter got dislodged when he fell . On 12/22/22 around breakfast time, Staff B observed Resident #2 on the floor in his room, after falling from the bed. Staff B and Staff C, LPN, responded. Staff C provided an assessment and found Resident #2 did not have an injury. They transferred him to a high back wheelchair and brought him to the nurses' station for closer observation. Staff B indicated that Resident #2 had a change in condition on 12/23/22. At that time, Staff H, Registered Nurse (RN)/ADON (Assistant Director of Nursing), assessed him and transferred him to the emergency room (ER). On 1/24/23 at 2:00 PM, Staff C explained that on 12/22/22, Resident #2 rolled out of bed. Staff C assessed the resident and found no injury, so they brought him to the nurses' station. Resident #2 had restless behaviors and did not want to stay in his bed. Staff C said the progress note should have included a post-fall assessment. Resident #2's clinical record lacked progress notes from 12/21/22 - 12/27/22. The clinical record lacked an admission assessment and a skilled assessment from 12/21/22 - 12/23/22. The clinical record lacked any documentation related to Resident #2's condition prior to his discharge to the hospital on 12/23/22. On 1/24/23 at 12:30 PM, Staff G, RN, reported that the facility did not have a room available closer to the nurse's station at the time, so they kept Resident #2 at the nurses' station during the day and frequently checked on him during the night. On 12/23/23, Staff G reported that she assessed Resident #2 and found that he had a change in condition with no verbal responses. After this, Staff G sent him to the ER. On 1/24/23 at 12:30 PM, Staff H verified that Resident #2's clinical record included no admission assessment, skilled assessments, and included only one Incident Report for the fall on 12/21/22. The Hospital Emergency Department (ED) records dated 12/23/22 documented that Resident #2 presented with altered mental status, unable to follow commands, had respiratory distress, septic shock, and pneumonia. The ED staff admitted Resident #2 to the intensive care unit (ICU) for further evaluation and management of symptoms. 2. The MDS assessment dated [DATE] identified that Resident #6 had a BIMS score of 14, indicating intact cognition. Resident #6 required supervision with setup help only with eating. The MDS included diagnoses of diabetes mellitus, multiple sclerosis, and arthritis. The Burn Incident Report dated 1/20/23 at 12:30 PM indicated that Resident #6 received hot chocolate from a staff member in the dining room with the warning that it was hot. Resident #6 picked up the cup by herself and spilled it on herself. Staff took her to a room and assisted to her bed. Upon assessment the staff noted a 4.5 by (x) 3 inches of redness to her RLQ (Right Lower Quadrant) of her abdomen and 7 x 3 inches of redness with blisters. The facility reported the incident to Staff J, ARNP (Advanced Registered Nurse Practitioner). Staff J gave a new order to apply silvadene to her burn areas BID (two times a day), until healed. The staff notified Resident #6's daughter by phone and left a message. The Dietary staff who witnessed the spill wrote a statement. Resident #6 could not provide a description of what happened. In 1/20/23 written statement provided by Staff S, Dietary Aide, Staff S documented she gave the resident hot chocolate and warned the resident it was hot. After they turned around the resident spilled it on her lap, about three minutes later. They pulled her pants away from her skin and cleaned what spilled. Then Staff S quickly got Staff O, CNA and the DON. The Weekly Skin Observation - V2 - V3 completed by Staff L, LPN, on 1/23/23, documented an open blister on the abdomen that measured 4.5 inches by 3 inches, and an intact blister on her right thigh that measured 7 inches by 3 inches. The assessment included documentation that Resident #6 indicated that the burn hurts a little bit. The Monthly LTC Note dated 1/25/23 at 3:33 PM documented by Staff L, LPN, Resident #6 had daily moderate pain. The Wound Evaluation and Management Summary dated 1/27/23 listed Resident #6's chief complaint listed multiple wounds. The Focused Wound Exam of the burn wound of the right upper thigh full thickness indicated that the wound measured 6.5 x 30 x not measurable centimeters (CM). The wound had 90% granulation tissue with 10% skin and a fluid filled blister. The Focused Wound Exam of the Burn Wound of the Anterior Abdomen Full Thickness indicated the wound measured 8.5 x 10.8 x not measurable CM. The wound had 100% granulation tissue and a fluid filled blister. The Focused Wound Exam burn wound of the lower abdomen full thickness listed a measurement of 2.5 x 13 x not measurable CM. The wound had 100% granulation tissue and a fluid filled blister. The Advanced Care Planning Note dated 1/27/23 completed by Staff K indicated that Resident #6 rested in bed and generally she is in the chair for breakfast. The nurse informed Staff K that the resident had not been getting in the chair since she experienced a burn, after she received extremely hot chocolate and she accidentally dumped it causing it to burn her abdominal skin as well as the skin on her right lateral (outside) leg/thigh. Resident #6 appeared confused and had a difficult time telling Staff K what happened but did report it was better than it had been. The staff reported that the resident had not been getting out of bed for the last week because she has too much pain. Per the Medications Administration Record (MAR), Resident #6 received a dose of Tylenol on 1/20/23 but has not been getting pain medications. There are no nursing concerns at this time, their report confirms the patient is stable. The note included the following orders to schedule Tylenol 500 milligrams (MG) three times a day and Lortab 5/325 MG twice a day for one week. The note included diagnoses of a third degree burn of her abdominal wall with loss, initial encounter, and burn of her abdominal wall, second degree burn, initial encounter. On 1/30/23 at 8:30 AM observed Resident #6 in bed, fully dressed, and lying on the Hoyer (full-body mechanical lift) sling (material used to lift the resident safely with the Hoyer). Staff H removed Resident #6's clothing to allow for observation and treatment application. Resident #6's skin appeared waxy white with partial sloughing (skin falling away), with pink tissue underneath in some areas. Staff H measured the following wounds: 1. Right upper quadrant abdomen - 11 x 8 CM 2. Right upper thigh - 13 x 2.5 CM and an adjacent area measured 2 x 1.5 CM 3. Right outer thigh - 6.5 x 6.5 CM and an adjacent area measured 1.5 x 1.5 CM. 4. Waistband - 10 x 1 CM. Staff H explained that the Wound Clinic Physician observed the wounds on 1/27/23 and ordered a new treatment. Resident #6 had random, nonsensical speech during the observation. When the surveyor asked the resident if she had pain, she responded inappropriately. During an interview on 1/30/23 at 3:40 PM, Staff K indicated burns can be very painful and when she visited the resident on 1/27/23, the resident began crying, indicating that she had pain, and nobody listened to her. Staff K revealed that Resident #6 remained in bed since the incident, that she experienced pain, and that they had reported it. The facility failed to inform Staff K of the extent of the injury. The leadership did not know the extent of the injury either. Staff H observed the wounds for the first time on 1/27/23 as well. Staff K had concerns regarding the lack of pain medication and assessment of her pain. The resident had an order for a lidocaine patch to her hip daily for osteoarthritis. Resident #6's January 2023 MAR reviewed on 1/30/23 indicated that she received Tylenol 500 MG on 1/20/23 at 12:66 AM and not again until 1/27/23 at 12:03 PM. The MAR included an order to evaluate/monitor for pain every shift and as needed for pain monitoring. The MAR indicated that Resident #6 had a pain score of 10, severe pain on 1/20/23. The MAR listed that Resident #6 only had pain at night on 1/23/23, 1/24/23, and during the day on 1/24/23 until 1/28/23. The documentation showed that Resident rated her pain as a 0, indicating no pain on the other days from 1/20/23 until 1/28/23. Resident #6's January 2023 Treatment Administration Record (TAR) reviewed on 1/30/23 included an order for Silver Sulfadiazine Cream 1 % Apply to RLQ and right thigh topically every shift for burn until healed. The TAR lacked documentation of application of Silver Sulfadiazine Cream for the following a. 1/24/23 at Night b. 1/25/23 at 6:00 AM c. 1/26/23 at Night d. 1/27/23 at 6:00 AM During an interview on 1/30/23 at 9:25 AM with the DON (Director of Nursing) reported that on 1/20/23 during lunch, Resident #6 went to drink her hot chocolate and dropped it on her lap. Resident #6 did not require adaptive dining equipment and ate independently. At the time of the incident, Staff M, Dietary Aide, worked in the dining room. Resident #6 never really yelled out, the Certified Nurse Aides (CNA's) took her to her room and Staff L, LPN, assessed her. The provider ordered Silvadene cream, she never complained of pain, and on 1/28/23 she started receiving scheduled pain medication, Hydrocodone/Acetaminophen 5/325 mg, two times a day and Tylenol 500 mg three times a day. The Wound Clinic Physician saw her on 1/27/23 and ordered her a new treatment. The Administrator reported that she notified DIA (Department of Inspections and Appeals) on 1/27/23. The Medical Director's nurse instructed her to report it due to the staff failing to check the temperature of the hot water prior to serving it. On 1/30/23 at approximately 11:00 AM, the DON reported on 1/20/23 she was nearby speaking to another resident and witnessed the resident spilling the hot chocolate on her lap along with Staff M, Dietary Aide. The DON informed Staff N, CNA, and Staff O, CNA. The DON indicated someone wiped the hot chocolate off Resident #6's lap but could not recall who did it. The DON denied knowing that Resident #6 remained in her room for the following week and confirmed that she had not observed the wounds. Staff L assessed the burn after the incident occurred and notified Staff J. The DON denied communicating with the ARNPs since the incident. On 1/30/23 at approximately 2:45 PM, Staff H reported that on 1/20/23 a CNA informed her that Resident #6 spilled hot chocolate on herself during lunch. Staff H asked Staff L to assess the resident with the assistance of Staff N and Staff O. Staff H never observed the burns until 1/27/23, and thought the burns needed some attention. On 1/27/23 Staff H saw Resident #6's wounds along with the Wound Clinic Physician. Staff H reported that she believed that Resident #6 came out for meals. Staff H reported that as of the previous week, she would assume responsibility for skin assessments and will do the rounds with the wound doctor. The wound doctor ordered a new treatment for the wounds on January 27. On 1/30/23 at approximately 10:30 AM, Staff M reported that since the incident involving Resident #6, the staff received reeducation and were instructed to check the temperature of the water before using it to make tea or hot chocolate. The staff were to make sure the temperature is at 140 degrees or less. Staff M explained that she worked on 1/20/23 when Resident #6 spilled the hot chocolate on her lap. Staff M had her back turned to the resident. When Resident #6 spilled the hot chocolate, she yelled I spilled my hot chocolate. Staff M explained that she immediately grabbed towels, began cleaning her up, and pulled her clothing away from her skin. Staff M grabbed additional staff and the DON who addressed it. That day, another Dietary Aide served Resident #6 hot chocolate using water from the thermos. The dietary staff fill the thermos with water from the coffee maker about an hour prior to dining services. That day, the staff failed to document the water temperature prior to serving the hot chocolate. At 10:30 AM Staff M checked the thermos water temperature, and reported it at 135.4 degrees Fahrenheit. The water that came directly from the coffee maker tempted at 143 degrees Fahrenheit. Staff M indicated that the staff never serve hot water directly from the coffee maker, as they always serve it from the pre-filled thermos containers. Staff M reported that they fill the thermos at least thirty minutes prior to meal service. On 1/30/23 at approximately 1:45 PM, Staff O reported that she worked on 1/20/23 when the incident occurred. Around 11:15 AM she assisted another resident in a wheelchair towards the dining room and observed Staff M from dietary tell the DON something about Resident #6 in the hall. Staff O had to return to her resident's room and then a supply room, to fetch foot pedals for the wheelchair. Staff O returned about fifteen minutes later and heard Resident #6 crying and saying it hurts. Staff O observed a cup on the resident's lap. Staff N also entered the dining room and they removed Resident #6 from the dining room. Staff O informed Staff H and she said to let Staff L know. Staff N and Staff O transferred Resident #6 to bed, undressed her and placed cold washcloths on the burns. Staff O indicated they had the resident in bed by 11:35 AM. The resident cried in pain. The nurse instructed them to leave Resident #6 in bed, covered with a sheet and assist her with eating her meals in bed. Resident #6 expressed pain with movement and said it hurt a lot. Staff O reported that Resident #6 seemed to have less pain at the time of the interview. On 1/30/23 at approximately 1:25 PM, Staff N reported that she worked on 1/20/23 along with Staff O. Staff N heard Resident #6 crying out It's burning at lunch time, as her cup spilled onto her lap. Staff N rolled Resident #6 out of the dining room. Staff M indicated that the DON knew and the DON said the girls would take care of it. Staff N informed Staff H who told Staff N to tell Staff L to complete an incident report. On 1/30/23 at approximately 3:30 PM, Staff L reported that she worked on 1/20/23 when Resident #6 spilled her hot chocolate in the dining room. During lunch, a dietary aide came to Staff L and reported that Resident #6 attempted to feed herself with her glasses. Staff L went to Resident #6, gave her medications, and proper utensils. Next thing she knew, a CNA assisted Resident #6 to her room. Staff L never heard her cry out, but she may have been coming down the hall. The CNA told Staff L, that Staff M told the DON of the incident. The DON never came to Staff L and the DON did not assess Resident #6. The staff got Resident #6 into bed and removed her clothing. Staff L called the provider and received an order for Silvadene Cream. When she returned to Resident #6's room, the burns had already started to blister. Resident #6 said it hurt, but she had difficulty expressing herself at times. Resident #6 had an order for Tylenol as needed for pain. Staff L could not remember if the CNA's reported that Resident #6 had pain. Resident #6 transferred with a Hoyer lift so they decided to have the resident remain in bed to avoid pressure from the sling during transfers. Staff L had no follow up with the ARNPs. On 1/30/23 at approximately 8:00 PM via phone, Staff Q, Medication Aide, reported that she worked on 1/20/23. She explained that Staff N told her that they were keeping Resident #6 in bed to avoid pain or injury from the Hoyer lift. One day Staff Q assisted another aide with positioning Resident #6 in bed before her meal. When they slid Resident #6 up in bed and raised the head of the bed, Resident #6 cried out in pain so they lowered her head a bit. Staff Q explained that she assumed the abdominal burns caused pain when they raised the head up. On 1/31/23 Staff M added that she did not know how much time passed between the time she informed the staff and when they removed Resident #6 from the dining room. Staff M returned to the kitchen after she informed the staff. On 1/31/23 at approximately 10:30 AM, Staff R, Medication Aide reported that when she worked on 1/23/23, Resident #6 experienced pain. It hurt her to bend, to move, everything, and Resident #6 told her that she had pain. Staff R informed the nurse and the DON. Staff R reported that every resident has a daily pain assessment that they document on the MAR. Staff R observed the January MAR and found no daily pain assessments documented. On 1/31/23 at 11:00 AM, Staff C reported that the next time she worked following Resident #6's incident they decided to keep her in bed because of the pain she experienced. Staff C administered the Silvadene cream and instructed the Medication Aides to administer Tylenol as needed. The Hot Liquid Safety policy dated 22 directed that hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. Definitions: Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns. Scalding is a burn caused by spills, immersion, splashes, or contact with hot water, food and hot beverages, or steam. Policy Explanation and Compliance Guidelines: 1. Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure. Refer to the table attached to this policy for an illustration of the time required for a burn to occur at various temperatures. 2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature. 3. All residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices in order to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care. Interventions include, but are not limited to: a. Wide based cups b. Cups with lids and handles c. Limit Styrofoam cups to residents with no difficulties d. Aprons e. Disallow hot liquids while lying in bed 4. Staff shall respond immediately to spills or other accidents with hot liquids to minimize the risk for burns. Follow procedures regarding incidents/accidents should anyone experience exposure to hot liquids. 5. Monitor residents for at least 24 hours following exposure to hot liquids, as redness or blisters may not appear initially. 6. General safety precautions when serving hot liquids include, but are not limited to: a. Make sure resident is alert and in proper positioning to consume hot liquids. b. Use cups, mugs, or other containers that are appropriate for hot beverages. c. Dot not overfill containers. d. Regulate temperature of hot liquids to which residents have direct access. e. Place filled containers directly on the table. Do not hand them directly to residents. f. Keep hot liquids away from edges of the table. g. Do not refill containers while the resident is holding the container. The table labeled Time and Temperature Relationship to Serious Burns indicated the time required for a third degree burn to occur with the following water temperatures. Water Temperature Time Required for a 3rd Degree Burn to Occur 155 degrees 1 second 148 degrees 2 seconds 140 degrees 5 seconds 133 degrees 15 seconds 127 degrees 1 minute 124 degrees 3 minutes 120 degrees 5 minutes Note: Burns can occur even at water temperatures below those identified in the table, depending on an individual.

Based on clinical record review, facility policy review, staff, and resident interviews the facility failed to adequately supervise one of three residents (Resident #3), to prevent an elopement and a subsequent fall with injury. The facility reported a census of 52 residents. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS indicated that Resident #3 could be independent with ambulation, transfers, personal hygiene, and toilet use. The MDS included diagnoses of tobacco use, anemia, anxiety and depression. Resident #3 use an antianxiety medication for five out of the seven days in the lookback period. In addition, Resident #3 used an antidepressant for four out of the seven days in the lookback period. The Care Plan initiated on 12/22/22 included the resident having an ADL (Activities of Daily Living) self-care performance deficit related to dementia, depression, hypothyroidism, anxiety disorder, and muscle weakness. The Intervention dated 1/18/23 directed the staff to know that Resident #3 could no longer leave the facility independently due to physical limitations related to injuries from a fall causing right femur fracture. The initial Nurse Practitioner Progress Note dated 12/22/22 revealed the resident had past medical history significant for asthma, hypertension, tobacco dependence, depression, anxiety, alcohol abuse, memory loss, and recurrent falls. The Progress Note dated 1/15/23 at 1:19 PM, Staff C, Licensed Practical Nurse (LPN), documented that Resident #3 did not sign herself out of the building. The Morse Fall Scale assessment dated [DATE], post fall, identified a score of 15, indicating a low risk for falling. The Fall Incident Report dated 1/15/23 at 1:21 PM documented by Staff D, LPN, indicated that a CNA (Certified Nurse Aide) found Resident #3 lying on her right side in the parking lot. Staff D assessed and transferred the resident to the emergency room . Resident #3 appeared to be alert and oriented to three (person, place, and time). Resident #3 denied hitting her head and said that she was walking and tripped on the cement. Resident #3 complained of right shoulder, elbow, and hip pain. The Progress Note dated 1/15/23 at 1:23 PM indicated that a CNA found Resident #3 lying on her right side on the ground outside in the parking lot. Resident #3 appeared alert and Oriented to 3 (Person, place, and time). Resident #3 denied hitting her head. Resident #3 reported extreme pain in her right shoulder and elbow. Resident #3 refused to move her right upper extremity (RUE) for range of motion (ROM) with reports of extreme pain in right hip. Resident #3 could not extend her extremity without pain and refused to extend passively (nurse attempting to move it). Resident #3's left palm appeared to have abrasions. The ED Provider Notes dated 1/15/23 at 8:31 PM indicated that Resident #3 fell while walking (Patient states she tripped on a crack in the parking lot at the nursing home). Resident #3 fell while standing on the concrete. The point of impact was the right shoulder and right hip. The pain presented in her right hip, right shoulder, and right elbow. The pain is at a severity of 7/10, indicating moderate pain. The diagnostic testing determined a displaced acute right olecranon fracture (bony point of the elbow) and a nondisplaced right femur fracture, basicervical/proximal intertrochanteric (hip fracture). On 1/23/23 at 10:30 AM, Staff E, Administrator reported that the camera video footage revealed that Resident #3 exited the building at 1:18 PM at the same time visitors came and rang the doorbell. Staff F assisted the visitors inside and let Resident #3 exit. At 1:25 PM staff observed the resident on the ground in the parking lot. Staff E reported that all staff including Staff F were re-educated regarding the need for residents to sign out, and a nurse must be made aware. No current residents are care planned to leave the facility without accompaniment. Staff F made a wrong assumption. On 1/15/23 at 12:42 PM, Staff F, CNA, reported that she worked for an agency. On 1/15/23 she worked on the South unit and Resident #3 resided in the East unit. At approximately 1:15 PM, Staff F sat at the nurse's station and charted. Resident #2 walked by wearing a jacket and appeared to be leaving. Staff F said have a nice day. The front door bell rang, Staff F answered it, allowed visitors to enter and Resident #3 to exit. Five minutes later, a passerby rang the doorbell and reported that someone fell in the parking lot. Staff F observed Resident #3 on the ground, still unaware she was a resident. Staff F called inside and Staff D came out. When she arrived, she assessed the resident and called 911. Staff F said that if she knew that Resident #3 was a resident, she would not have allowed her to exit the facility. Staff F wrote a statement. Staff E, Administrator called her the next day and educated her. On 1/23/23 at 2:30 PM, Staff D reported she worked at the facility for three years, primarily on the weekends. On 1/15/23 she went out to the parking lot after someone called the facility and reported they found a resident on the ground. Staff D observer Resident #3 lying on her right side, she appeared alert and oriented. Resident #3 stated she tripped and fell . Staff D assessed Resident #3 and summoned EMS (Emergency Medical Services). Staff D did not know how Resident #3 got outside or that she could go out alone. Staff received education to be sure no other resident exits the building unattended. On 1/23/23 at 4:14 PM, Staff G, CNA reported that she worked on 1/15/23 during the day shift. Resident #3 asked Staff G to take her outside around lunch time. Staff G told Resident #3 that she would take her outside when the second shift came in at 2:00 PM. Resident #3 indicated she would wait. Staff G observed Resident #3 in bed at approximately 1:00 PM and never saw her leave the unit. Staff G observed the resident on the ground in the parking lot and appeared to be in a lot of pain. The Elopements and Wandering Residents policy revised January 2023 and implemented March 2023 defined Elopement as when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The section labeled Policy Explanation and Compliance Guidelines instructs that the facility should establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.

Based on observation, clinical record review and staff interviews the facility failed to assess and provide appropriate intervention for 1 of 3 (Resident #4) reviewed. The Registered Nurse failed to apply direct pressure or a pressure dressing to a bleeding wound. The facility reported a census of 48 residents. Findings Include: The Face Sheet for Resident #4 documented an admitted [DATE]. The Minimum Data Set (MDS) dated [DATE] for Resident #4 identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident needed extensive assistance with bed mobility, transfers, walking, dressing, toilet use and hygiene. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions on the Care Plan for resident #4 included administer anticoagulant therapy as ordered. Interventions also included observe for any signs or symptoms of bleeding, excessive bruising, and hematomas. Review of the Progress Notes for Resident #4 documented the following: a. On 7/28/22 at 11:51 AM, Staff D, Registered Nurse (RN) documented the resident received [MEDICATION(S)]/acetaminophen 5 milligrams (MG)/325 mg for bilateral lower extremity pain. b. On 7/28/22 at 12:52 PM, Staff D documented the resident had a fluid filled blister on her left shin measuring 2 centimeters (cm) x 3 cm. The blister appeared to be blood filled. The resident complained of pain to bilateral legs associated with increase in fluid to bilateral legs. The doctor was updated. c. On 7/28/22 at 3:59 PM, Staff D documented the [MEDICATION(S)]/acetaminophen provided effective pain relief. d. On 7/28/22 at 6:16 PM, Staff D documented the resident was having increased pain with the left leg along with increased swelling. The resident was yelling hysterically and unable to be redirected. The Advanced Registered Nurse Practitioner (ARNP) was notified of resident condition. The ARNP wanted to treat at the facility and [MEDICATION(S)]/acetaminophen was administered. e. On 7/28/22 at 7:30 PM, Staff E, RN documented the resident had increased swelling in her left shin, both legs had generalized swelling, left worse than right. The left leg had blisters filled with blood. While a Certified Nursing Assistant (CNA) was providing cares, she notified the nurse that the area with blisters had popped open and was oozing blood. Assessment including vital signs was completed. The Physician was notified and ordered an ace wrap for compression, a 1-time order for [MEDICATION(S)] (a fluid reducing mediation, diuretic), elevate legs, check labs in the morning and notify him of any changes. The family was made aware of the resident's condition. f. On 7/28/22 at 8:00 PM, Staff E documented the resident started crying. Vital signs were obtained with low blood pressure and low oxygen saturation. Oxygen was started. The Physician was called again notifying of blood pressure, oxygen saturation and oxygen started. New order was received to send the resident to the Emergency Department (ED) at a local hospital. The resident's family was notified. Report was called to the ED and the resident was transferred to the hospital. During an interview on 8/24/22 at 3:29 PM, Staff B, Licensed Practical Nurse (LPN) stated she received a call from Staff A, CNA around 6:40 PM in regards to Resident #4 bleeding. She stated Staff B was upset stating the RN was passing medications and not addressing the bleeding. Staff B stated she instructed Staff A to tell the RN to prioritize and take care of Resident #4 and then go back to passing mediations. She stated she communicated with Staff A again and was asked to come in to the facility. She arrived at the facility around 7:30 PM. Staff A stated when she arrived the resident was sitting in her recliner with her feet elevated and blood was running off her leg onto the floor. She stated a large amount of blood was on the floor. She stated no pressure, no dressing and no ace wrap had been applied to the leg in an attempt to stop the bleeding. Staff B stated she called 911 and the family while Staff E, RN went to the hall passing medications, and no dressing or ace wrap had been applied to the area yet. Staff B stated she was opening a dressing to apply when the medics arrived. During an interview on 8/25/22 at 10:10 AM, Staff A, CNA stated she notified Staff E, RN about the resident's leg bleeding. She stated Staff E was trying to multitask, passing medications and doing other regular tasks while Resident #4 was bleeding. Staff E stated she was going to finish passing medications, get a set of vital signs and get some oxygen for the resident. Staff A stated she was not instructed by Staff E to do anything at that time. She stated the Director of Nursing (DON) was called and asked to come in to assist. She stated the DON refused to come in stating it was the responsibility of the staff that was in the facility to take care of the situation. Staff A then called Staff B, LPN/Unit Manager to come to the facility to assist. She stated Staff B did come to the facility and took control of the situation and the resident received the care she needed. During an interview on 8/30/22 at 11:49 AM, Staff D, RN stated earlier in the day he noted a blister on the resident's left leg that appeared to be blood filled. He stated he notified the provider and requested someone come out and lance it. Staff D stated the provider didn't want to do that to introduce infection and ordered to paint with [MEDICATION(S)]. Staff D stated near the end of his shift (6 PM), while he was waiting for his replacement the CNA's came to him and stated the resident was bleeding. He stated he examined the resident and noted the top layer of skin was off. He stated not active bleeding and he poked at the blister and no blood came out. He stated he notified the provider again to request the resident be sent to the hospital for evaluation. Staff D stated the provider stated the resident was a Do Not Resuscitate (DNR) and the Plan of Care (POC) was to treat in the facility. He stated he made the provider aware of increased swelling in the leg in the last 2 hours. He was instructed to give an as needed (PRN) pain medication. He informed the CNA's he tried to get the resident sent out and then gave report to the next nurse. During an interview on 8/30/22 at 12:58 PM, Staff E RN stated she took report from Staff D. She stated Staff D told her the resident was not doing well and that the provider did not want to send the resident out at that time. She stated the resident was in pain and Staff D had given her pain medication. She stated her shift started at 6:00 PM and around 6:30 PM, a CNA came to her and stated the resident was bleeding. She stated she called the provider and he declined to send the resident out. She stated she received an order to apply ace wraps and monitor. Staff E stated she took the resident's vital signs and the resident's oxygen saturation was dropping. She stated she applied oxygen and called tor provider back stating the resident's vital signs were dropping and needed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff E stated at that time Staff B, LPN/Unit Manager came in and assisted with care of the resident. She stated Staff B called 911 for the medics to come and Staff B also notified the family. Staff E stated she did not apply pressure in an attempt to stop the bleeding and she did not apply the ace wrap that was ordered. She stated Staff B was opening the ace wrap to apply when the medics arrived. The resident was then taken to the hospital. The hospital Emergency Department provider notes documents the medics noted about a half a liter (500 ml) blood loss at the facility. The medics also provided 500 ml of normal saline in route to the hospital.

Based on observation, record review and staff interview, the facility failed to initiate a Nursing Care Plan to address a resident's pressure ulcer, implement an order to treat a pressure ulcer until 7 days after identified and failed to prevent two facility acquired pressure ulcers to develop for one of one residents reviewed in the standard sample (Resident #200). The facility reported a census of 52 residents. Findings Include: 1. Resident #200's Minimum Data Set assessment dated [DATE] identified the resident as cognitively impaired with a Brief Interview for Mental Status score of 99, and with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also identified the resident required extensive staff assistance with most activities of daily living, had an indwelling catheter and two stage 2 pressure ulcers present upon admission. A review of the Admission Record revealed the resident admitted to the facility on [DATE]. A review of the Care Plan provided revealed the Problem: I have a Stage 3 pressure ulcer to right buttock and left buttock (date initiated 12/10/21). Interventions Included: a. Assess/record/monitor wound healing weekly. b. Measure length, width and depth where possible. c. Assess and document status of wound perimeter, wound bed and healing progress. d. Report improvements and declines to the physician. During an observation of wound care on 12/9/21 at 9:24 AM, Staff G, Licensed Practical Nurse (LPN) verified the resident now has 3 pressure ulcers and initially admitted with just one. The wound beds and surrounding skin edges noted without signs of infection. In an interview on 12/8/21 at 7:00 AM, the Social Worker (SW) reported a Facsimile (Fax) report on the resident sent out to her physician on 11/30/21 to request orders to treat her pressure ulcers. On 12/8/21, the SW reviewed the new orders and saw a doctor's order dated 12/1/21 not entered into the Electronic Medical Record (EMR) yet. The SW showed the doctor's order to Staff P, Registered Nurse (RN), who later entered the order into the EMR A review of the Fax from the physician dated 12/1/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the December 2021 Treatment Administration Record (TAR) on 12/8/21 at 1:30 PM, revealed the above order not entered into the TAR. A review of the paper record for Resident #200 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The first treatment noted not signed out as completed until 12/7/21. A review of the Nurse's Notes revealed the following entries: a. On 11/24/21 at 7:12 PM revealed the following assessment of a pressure ulcer: Location: coccyx. Length: 10 centimeters (cm), Width: 11.5 cm, and Depth: 0.1 cm. The entry did not identify which side the pressure ulcer located. b. On 11/30/2021 1:46 PM: Stage III pressure ulcer to the right buttock: Length: 8 cm, Width: 5 cm, and Depth: 0.1 cm. Stage III pressure ulcer to the left buttock: Length: 8 cm, Width: 2.5 cm, and Depth: 0.1 cm. Wound assessments documented as completed weekly. c. The last assessment completed 12/21/21 at 11:21 AM: Stage III pressure ulcer to the right buttocks: Length: 4.2 cm, Width: 3 cm, and Depth: 0.2 cm. Stage III pressure ulcer to left buttock: Length: 4 cm, Width: 2.5 cm, and Depth none documented. The documentation did not include an assessment of the third pressure ulcer. In an interview on 12/16/21 at 8:47 AM, Staff P, RN reported the following: a. When residents have new orders written, the nurse who received the order is responsible for transcribing the order to the Medication Treatment Record MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] b. The order should then be reviewed by two nurses, and then the order is placed in the Director of Nursing (DON) box. c. Orders should be should be noted within the shift the order had been received or the next shift. d. Any of the nurses are responsible for follow-up on new orders written. e. When the order for the [MEDICATION(S)] had been received on 12/1/21, evidently it did not get noted, therefore did not get transcribed to the TAR. f. When this resident admitted to the facility, she had only one pressure ulcer, she now has one on each gluteal area. In an interview on 12/16/21 at 9:39 AM, the Facility Medical Director reported he would expect Physician Orders to be processed and entered on to the MARs/TARs within twenty four hours or less, especially if it is something stocked in the emergency kit. A review of the facility policy with the implementation date and last revision date of 12/13/21 and titled: Pressure Injury Prevention and Management documented the following: INTERVENTIONS FOR PREVENTION AND TO PROMOTE HEALING: a. After completing a thorough assessment/evaluation, the Interdisciplinary Team shall develop a relevant Care Plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. d. Basic or routine care interventions could include, but are not limited to: 1. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc), 2. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. 3. Provide appropriate, pressure-redistributing, support surfaces. 4. Maintain or improve nutrition and hydration status, where feasible. e. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. f. Pressure injuries will be differentiated from no-pressure injuries, such as arterial, venous, diabetic, moisture or incontinence related skin damage. g. Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue. MONITORING a. The RN Unit Manager or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing and compliance at least weekly, and document a summary of findings in the medical record. b. The attending Physician will be notified of the presence of a new pressure injury upon identification.

Based on observation, record review and staff interview, the facility failed to ensure the safe and proper storage of portable oxygen tanks, failed to document complete assessments after unwitnessed falls for two of nine residents reviewed with falls (Resident #2, #39), failed to provide a safe transfer for a resident identified with a [CONDITION(S)] for one of nine residents reviewed with falls (Resident #12), failed to report a fall with major injury to the Department of Inspections and Appeals (Resident #22), failed to document possible causes and implement timely interventions for one resident with multiple falls, with one resulting in multiple fractures (Resident #50). The facility reported a census of 52 residents. Findings Include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitively impaired with a Brief Interview for Mental Status of 11, and with the following diagnoses: diabetes mellitus, Non-Alzheimer's Dementia and depression. The MDS also identified the resident required limited staff assistance with most activities of daily living and had two falls with no injury and one fall with minor injury. A review of the Care Plan identified the resident with the problem of being at risk for falls with the following interventions documented with dates of implementation in parenthesis: a. Resident educated to use call light ([DATE]). b. Anticipate and meet the resident's needs ([DATE]). c. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to requests for assistance. ([DATE]). d. Door to room to remain open when in room ([DATE]). e. Dycem in recliner ([DATE]). f. Have commonly used articles within easy reach water, call light ,remote control for TV, telephone ([DATE]). g. I have a motion night light outside my bathroom to help me find my way due to my fall on ([DATE]). h. I have a sign on my walker to remind me to use it at all times related to (r/t) my fall on ,d+[DATE]. ([DATE]). i. Resident re-educated to use call light and wait for assistance ([DATE]). j. Staff educated not to leave the resident unattended in her wheelchair in her room related to fall on ,d+[DATE] ([DATE]). An observation on [DATE] at 11:26 AM, revealed the resident in a wheelchair with both feet on foot pedals, wearing gripper socks, properly positioned and appears comfortable. Further observations of the resident during the survey revealed the resident with no falls during the hours surveyors were in the facility. A review of the Incident Reports received revealed the resident fell on the following dates: a. Seven times on [DATE]. b. Three times on [DATE]. c. Six times on [DATE]. The resident's record failed to have documentation of neuro checks completed as per the facility policy for all the unwitnessed falls or a Root Cause Analysis (RCA) completed to determine the causes of the frequent falls. 2. Resident #12's Minimum Data Set, dated dated dated [DATE] identified the resident as cognitively impaired with a BIMS of 8, and with the following diagnose: cancer, Alzheimer's Disease and Non-Alzheimer's Dementia. The resident required limited staff assistance with all Activities of Daily Living (ADL's) and had one fall with no injury. A review of the Care Plan identified the resident with the problem of being at risk for falls (goal target date [DATE]) with the following interventions documented with dates of implementation in parenthesis: a. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to requests for assistance. ([DATE]). b. Encourage, remind, & escort to activities, as resident will allow ([DATE]). c. Encourage and assist resident to transfer and change positions slowly, as resident will comply. ([DATE]). d. Encourage and assist the resident to wear appropriate footwear when ambulating or mobilizing in w/c, ie: gripper socks at bedtime (HS) and shoes during the day while up. ([DATE]). e. Have commonly used articles within easy reach ([DATE]). f. Monitor /anticipate/ intervene for causative factors ([DATE]). g. Place walker within reach as resident allows ([DATE]). A review of the Nurse's Notes dated [DATE] at 6:54 AM, Staff Q, Registered Nurse found the resident on the floor, Assessment completed, vital signs noted as ,d+[DATE], 103, 97.5, 20, 95% RA (room air), pain of ,d+[DATE]. Resident was able to move BUEs and LLE ( both arms and legs) without problems with limitation to the right lower leg (RLE). The resident assisted back to bed with assistance of 2 staff using a gait belt. Doctor notified, order to send resident to hospital for right hip evaluation received. The resident left the facility at 6:45 AM on a stretcher accompanied by paramedics. In an interview on [DATE] 7:00 AM, Social Worker (SW) reported the resident fell out of bed Thanksgiving morning. When she came to work the following day, the SW looked at the resident's chart, saw that resident fell and went to the hospital and nothing more documented. The next day, Staff F, Agency Certified Nurse Aide (CNA) reported that the other CNA's picked the resident up off the floor before the nurse even came in the room to assess her, then they put her on the bed and tried to get her dressed before the ambulance came. The SW called the resident's family member and reported the resident fell . The family member reported the resident broke her hip and only had hours to days to live. The SW reported the resident died at Hospice. In an interview on [DATE] at 1:39 PM, Staff Q, Agency RN reported when she found the resident on the floor in her room, the resident said my hip cracked, take me to the hospital, I'm going to die. Staff Q stayed with the resident and sent the CNA (she could not recall the name of the CNA) to get the vital machine and took the resident's vitals. The resident laid on the floor on her right side and her right leg was shorter than the left. Staff Q explained, the resident should be transferred with the assist of one with a gait belt. Then Staff Q and the CNA put the gait belt on the resident, helped her stand and she stood on her left leg. They moved her from the floor to the bed. The resident's right leg appeared shorter than the left, and she kept screaming get me to the hospital, I don't feel good, I need a doctor, I need a doctor. Staff Q told the CNA to stay with the resident while she called the doctor for orders. Orders received to send the resident to the hospital and then the Emergency Medical Technicians (EMT's) arrived to take her. Staff Q stated the most important thing is not to displace the fracture. [DATE] at 8:47 AM, Staff P, RN reported if she found a resident after a fall, screaming in pain, she would not move the resident, call the doctor for an order to transfer the resident to the hospital. In an interview on [DATE] at 1:09 PM, Staff G, CNA reported if she found a resident on the floor after a fall, she would stay with the resident until the nurse assesses the resident. Staff G stated, staff should not move the resident from the floor unless the nurse gives instructions to do so. In an interview on [DATE] at 1:30 PM, Staff H, CNA reported if found a resident on the floor after a fall, she would call the nurse, if the nurse thought there might be a broken hip, the staff should not move the resident, the EMTs will move the resident. 3. Resident #22's MDS dated [DATE] failed to have a BIMS score to show the resident evaluated for cognitive status. The MDS also identified the resident with the following diagnoses: heart failure, peripheral vascular disease and other fracture and required limited assistance with bed mobility, ambulation, dressing, toileting and personal hygiene and bathing. A review of the Care Plan identified the resident with the problem of: The resident is at risk for falls related to pain and weakness (goal target date [DATE]) and with the following interventions documented with dates of implementation in parenthesis: a. Apply gripper socks at HS as I will allow. ([DATE]). b. Call light re-routed to the foot of the bed r/t fall on ([DATE]). c. Follow facility fall protocol ([DATE]). d. I have been educated not to use my tray table as an assistive device or ambulate backwards, and to use my walker to ambulate due to my fall on ([DATE]). e. I have been educated to use my call light for assistance r/t my fall on ([DATE]). f. I have been educated to wear my shoes for all transfers r/t my fall on ([DATE]). g. I have grip strips on the floor in front of my toilet r/t my fall on ([DATE]). h. Physical Therapy/Occupational Therapy (PT/OT) to eval and treat r/t to fall on ([DATE]). i. Staff and I have been educated to keep my door open as I will allow for better supervision due to my fall on ([DATE]). The Care Plan failed to address the potential problems after a cast had been applied. Observation on [DATE] 10:35 AM, noted the resident sitting up in a recliner in her room, with a cast to her left arm noting good circulation, no [CONDITION(S)], denied numbness or tingling to her left fingers. A wheeled walker placed beside her had a platform for left arm. Observations of the resident during the survey from [DATE] through [DATE] revealed the resident remained with a cast to her left arm. A review of the Nurse's Notes revealed the following: a. On [DATE] 13:40, Resident noted to be lying on her left side in front of her recliner and states she broke her fall with her left elbow and does complain of left elbow pain. b. No documentation noted that the resident sent out for evaluation and treatment A review of the Incident Report dated [DATE] at 1:40 PM, documented the following: a. Nursing Description: called to resident's room due to resident being on the floor, lying on left side, not wearing shoes and wearing regular socks. b. Resident's Description: stated she was unsure of what she was doing. c. Injury Noted to Back of Left Hand: bruise, d. Injury Noted to Left Elbow: hematoma (an area of localized swelling that is pooled blood) with no measurements documented. A review of the Incident Reports for the eleven falls the resident had between [DATE] and [DATE], revealed nine were unwitnessed falls with no documentation to refer to neuro checks completed as per the facility protocol. One post fall evaluation completed on [DATE]. In an interview on [DATE] at 10:42 AM, the former Director of Nursing (DON) reported after a fall occurs, Witness Statements should have been taken from staff involved. In an interview on [DATE] at 11:15 AM, the former DON reported unable to find any documentation of Staff Interviews or Witness Statements regarding Resident #12 and #22's falls. In an interview on [DATE] at 10:45 AM, the Administrator reported the following process should be followed after a resident fall: a. The Charge Nurse on the day of the fall should be the one to complete the Incident Report and get Witness Statements and come up with interventions. b. Typically the DON would sign the incident report afterward. c. At our Daily Morning Meetings, facility staff discuss resident falls, why did the resident fall, what new interventions did they put in place or do we need to put into place. d. During Medicare Meetings, we also discuss falls to discuss the possible need for Speech Therapy (ST), PT and/or OT. e. The Charge Nurse is responsible for filling out the Incident Report in Point Click Care (Computer Program) completely and getting the Witness Statements. The Charge Nurse also responsible for describing the whole incident and who was involved. In an interview on [DATE] at 1:03 PM, Staff I, Nurse Supervisor reported she failed to find any documentation in the resident's record of a radiology report of the resident's fracture to her left arm or documentation in the Nurse's Notes to indicate when the fracture occurred. 4. Resident #39's MDS dated [DATE] identified the resident as cognitively impaired with a BIMS of 8, identified her with the following diagnoses: heart failure, depression and nutritional deficiency. The MDS also identified the resident required limited assistance with most ADL's. A review of the Care Plan identified the resident with the problem of being at risk for falls related to weakness (in red font problem identified as being overdue for review with date initiated [DATE] and no updates since). Interventions: I have Dycem in my recliner to decrease the possibility of me slipping out of it. A review of the Nurse's Notes dated [DATE] at 11:45 PM, documentation showed: Date/Time of Fall: [DATE] 3:30 PM, Fall was not witnessed, and Fall occurred in the Resident's room. A review of the Neurological Checklist dated [DATE] at 11:30 PM revealed only one assessment for orientation, level of consciousness, pupils, responses, pain, extremities had been documented. Only four sets of vitals signs had been documented on [DATE] at 10:45 PM, 11:30 PM, and 11:43 PM. In an interview on [DATE] at 11:47 AM, Staff M, RN reported she assessed the resident at 10:20 PM after she received report. She noticed blood on the sheets, checked the Incident Report which documented the resident fell at 3:30 PM. Staff M received report from one of the Medication Aides because the nurse had already left for the day at 6:00 PM. Staff V, Medication Aide (MA) reported the resident fell at 3:30 PM, and the resident had diarrhea and fell while she tried to walk using her walker. Staff M explained, after an unwitnessed fall, the nurse should start neuros and vitals every 15 minutes four times, then every 30 minutes four times , then every hour four times, and then every 4 hours for remainder of 3 days. Staff M reported she completed the only neuro check and vitals. The nurse who took care of her when she first fell did not document anything about the fall, no neuros or vitals. In an interview at [DATE] at 10:21 AM, Staff V, CMA could not recall the details of the resident's fall on [DATE], reported that another CNA took care of the resident. Attempts made to contact that other aide, and no return the call received. In an interview on [DATE] at 10:36 AM, Staff N, RN reported if she found a resident on the floor after a fall, The nurse should do a head to toe assessment, if unwitnessed, do neuros and vitals every 15 minutes four times, then every 30 minutes four times, then hourly four times, then every 4 hours four times, and then every shift for 3 days and report it to the DON. If she suspected the resident had a fractured hip, Staff N would not move the resident until the EMTs arrived and would complete a head to toe assessment. In an interview on [DATE] at 1:09 PM, Staff G, CNA reported if she found a resident on the floor after a fall, she would stay with the resident until the nurse assesses the resident. Staff should not move the resident from the floor unless the nurse gives instructions to. In an interview on [DATE] at 1:30 PM, Staff H, CNA reported if she found a resident on the floor after a fall, she would call the nurse, if the nurse thought there might be a broken hip, the staff should not move the resident, the EMTs will move the resident. A review of the undated facility policy titled: Assessing Falls and Their Causes documented the following for after a fall: a. If a resident has just fallen, or is found on the floor without a witness to the event, Nursing Staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. b. If there is evidence of a significant injury, such as a fracture or bleeding, Nursing Staff will provide appropriate first aid. c. Once an assessment rules out significant injury, Nursing Staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. d. Nursing Staff will notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, Nursing Staff will notify the practitioner immediately by phone. A review of the undated facility policy titled: Falls and Fall Risk Managing, documented the following: IDENTIFYING CAUSES OF A FALL OR FALL RISK: a. Within 24 hours of a fall, the Nursing Staff will begin to try to identify possible or likely causes of the incident. They will refer to the resident-specific evidence including medical history, known functional impairments, etc. b. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. c. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a [CONDITION(S)] or an adverse drug reaction or if the resident continues to fall despite attempted interventions, the nursing staff will discuss the situation with the attending physician or Medical Director. d. If the causes of a fall cannot be readily identified and if the fall is accompanied by other signs and symptoms (e.g. confusion or lethargy), the staff and physician will consider a possible underlying acute medical cause. DOCUMENTATION: When a resident falls, the following information should be recorded in the resident's medical record: a. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair). b. Assessment data, including vital signs and any obvious injuries. c. Interventions, first aid, or treatment administered. d. Notification of the physician and family, as indicated. e. Completion of a falls risk assessment. f. Appropriate interventions taken to prevent future falls. g. The signature and title of the person recording the data. A review of the protocol for Unwitnessed Falls (kept in a Communication Notebook at the South Nurse's Station) POST FALL DOCUMENTATION: a. Assessment of resident, description of what the staff saw or did not see, heard, etc. b. Vital signs and any treatment performed should be documented in matrix. c. Physician notification and document in Matrix. d. Call the responsible party and document in Matrix. If shift is unable to reach party, the next shift should try to continue to contact responsible party A FALL RISK OBSERVATION and PAIN OBSERVATION Form should be filled out at time of fall and updated in the Matrix as follows: a. If fall was unwitnessed by staff, nurse needs to start and complete neurological exam/neuro observation in Matrix as per protocol. b. Assess and document for any head injuries, injuries, skin. c. If fall was witnessed and did not hit his/her head, the body assessment and vitals needs to be done d. Update fall care plan with evaluation note and approach with any new interventions to assist with preventing fall e. Neuro checks as follows: every 15 minutes x 4 times; every 30 minutes x 4 times, every hour x 4 times, every 4 hours x 4 times and then every shift for 72 hours. 5. The Significant Change Minimum Data Set (MDS) Assessment for Resident #50 dated [DATE] revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was severely cognitively impaired and also documented Resident #50 with disorganized thinking present which fluctuated. Per this assessment Resident #50 required the extensive assistance of one person for bed mobility and transfers, and was not steady and was only able to stabilize with staff assistance for moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off the toilet, and for surface to surface transfer (transfer between bed and chair or wheelchair). The assessment documented the resident without falls since admission/entry, reentry, or the prior assessment, whichever was most recent. The Face Sheet for Resident #50 revealed diagnoses which included muscle weakness and encounter for Palliative Care. The Care Plan dated [DATE] documented, The resident is at risk for falls r/t weakness and confusion. Interventions per the plan of care included the following with dates implemented in parenthesis: a. Anticipate and meet the resident's needs. (initiated date [DATE]) b. Apply gripper socks as resident will allow. ([DATE]) c. Follow facility fall protocol. ([DATE]) d. I have a motion detecting alarm at the foot of my bed to alert staff if I attempt to get up without assistance. ([DATE]) e. I have a sign on my walker to remind me to use it when ambulating. ([DATE]) f. I have a touch pad call light. ([DATE]) g. I now eat in the South dining room for increased assistance and supervision. ([DATE]) h. I was moved to a room closer to the nurse's station with direct sight. [Room Number Redacted] ([DATE]) i. I was moved to a room closer to the nurse's station. [Room Number Redacted] ([DATE]) j. Maintenance repaired the threshold going into the bathroom. ([DATE]) k. Rearranged room for ambulation safety. ([DATE]) l. Staff educated to not leave wheelchair in resident's room. ([DATE]) m. Staff has been educated on the need for frequent checking and toileting resident. ([DATE]) n. Therapy to place a tray on my FWW (front wheeled walker). ([DATE]) o. UA (urinalysis) obtained. ([DATE]). The Incident Note dated [DATE] at 10:08 AM, documented, in part, Resident had an unwitnessed fall without injury. Found lying curled around the bottom of her room mate's bed. Resident confused stating she was trying to get the weed eater. Room mate's bed was moved with the foot of the bed pointing towards the door and the lower part of bed stuck in an upward position. Room mate states her motorized wheelchair (wc) moved the bed. The Incident Note dated [DATE] at 8:25 AM, documented: This nurse called to resident's room and noted the resident lying on the floor next to the bathroom as if she were just coming out. Resident is an assist x 1 but very non compliant and had been ambulating on her own with walker. Back of head noted to be bleeding. Nurse already assisting and had resident's neck stabilized so she would not move her head. Resident awake and alert but moaning in pain with visible shaking noted to legs. Pupils reactive to light however not equal. The Incident Note dated [DATE] at 10:54 PM, documented: This nurse was notified by a Certified Nursing Assistant (CNA) that resident was found on the floor laying next to her bed. Upon arrival this nurse performed a skin assessment some redness was noted to back of the resident's head. Resident complained of (c/o) pain in that area as well and rated the pain at a ,d+[DATE] on numeric pain scale. Vital Signs (VS) completed and within normal limits (WNL) .Neuro assessment performed and WNL for this resident. She is alert and oriented to self. The Incident Report Follow Up Note dated [DATE] at 1:30 PM documented: Resident is on a fall follow up. Resident is non compliant with asking for assistance for transfer and found multiple times lying in her roommates bed. Resident complains of leg pain, and VS WNL. The Communication with Physician Note dated [DATE] at 3:36 PM documented: Resident noted to have 4 abrasions to her back, likely from falls that occurred over the weekend. There are 3 abrasions that measure 0.5 centimeters (cm) x 0.5 cm each are on resident's left upper back, and another abrasion noted to the left of resident's spine that measures 1.0 cm x 1.0 cm. The wound bed is clean at this time, no signs/symptoms (s/s) of infection noted to area. Will continue to monitor areas. Resident denies pain to areas. The Behavior Note dated [DATE] at 2:50 PM documented: Resident very restless since lunch. Repeated attempts to get out of bed, assisted to chair outside room after resident needed to go to the bathroom, and offered drink or snack. Repeated attempts to ambulate without the walker from chair, with frequent reminders to relax in chair, and newspaper provided. The Behavior Note dated [DATE] at 5:40 PM documented, Res. repeatedly trying to stand up from w/c while awaiting meal as she was ready to get up from resting in bed. Sitting 1:1 with nurse for safety as needed (PRN)provided for restlessness. The Incident Note dated [DATE] at 2:11 AM, documented: Nurse alerted by CNA that resident on the floor in her room on the floor mat, resident states she did not know why she was up, resident was offered the washroom, but did not need to go, this nurse observed multiple skin tears to the right and left arms and hands, also noted post fall very large hematoma to the left hip, resident was given prn pain medication as prescribe, Hospice Nurse in at 9:10 a.m. to evaluate resident and recommends cold therapy to hip, Primary Care Physician (PCP) notified via fax, on call notified, will pass on to Day Shift Nurse to notify Power of Attorney (POA), will continue to monitor. The Fall Risk Evaluation dated [DATE] revealed Resident #50 at risk for falls and scored 19 on the Assessment. The Assessment noted the resident had intermittent confusion, three or more falls in the past three months, was ambulatory and incontinent, with poor vision, balance problems while walking and standing, required the use of assistive devices, and had one to two predisposing diseases present. Clinical Suggestions included the following: Utilize personal/pressure sensor alarms. This assessment noted the only Fall Risk Evaluation included in the resident's Electronic Clinical Record. The Post Fall assessment dated [DATE], revealed the Assessment remained in progress, and no documentation present for the Assessment. The Incident Report dated [DATE] at 9:40 PM, documented no witnesses to the fall event. The Behavior Note dated [DATE] at 5:08 PM documented: Resident up since 1545 (3:45 PM) as she was trying to get out of bed unassisted. Assisted to bathroom. Very restless, multiple attempts to get up out of her chair, tolerated request to sit back down. Scheduled Tylenol and PRN [MEDICATION(S)] (anti-anxiety medication) provided at 1600 (4:00 PM). Assisted with walk down hall and back, given thickened drink. Continues to require 1:1 for safety. The Health Status Note dated [DATE] at 10:40 documented: CNA found Resident sitting on the floor in her room, upright and on her buttocks with both legs extended forward. Denies hitting her head. When this writer entered room, Resident was lying prone on the floor with a pillow under head. Staff stated She said her back was tired. So we helped her back. Alert, Oriented x self per usual. Denies pain at present. No injury or redness noted at this time. Res. had socks and shoes on and ambulatory w/o assist or walker. The Incident Report dated [DATE] a 10:40 AM documented the following predisposing situation factors: Ambulating without Assist. The Post Fall assessment dated [DATE] revealed information inputted for the Assessment. The Assessment revealed there were similarities between current and post falls. The Incident Report for the fall dated [DATE] at 10:40 AM documented there were no witnesses to the event. The N Advanced - Long Term Care Evaluation dated [DATE] at 1:50 PM documented: Resident #50 obeyed commands, was confused, experienced signs of short-term memory loss, and had disorientation and inattention. Noted the resident severely cognitively impaired, and disorientation was at baseline for the resident. Safety concerns documented the resident frequently attempted to ambulate without assist. The Incident Note dated [DATE] at 7:20 AM authored by Staff L, Licensed Practical Nurse (LPN) documented, CNA told this writer Resident #50 is on the floor. Resident found on the floor by her door way in the hall. Lying on left side in fetal position. Alert and Oriented x self per usual. Temperature -96.3, Pulse -57, Respiration -18, Blood Pressure - ,d+[DATE], Oxygen (O2) saturation -98% at room air. Noted she had reopened an old injury on left lateral scalp. Measured 0.2 cm x 0.2 cm with scant red drainage, also reopened area on left lateral knee. The corresponding Incident Report dated [DATE] at 7:20 AM documented: The following injuries at time of incident: a. Bruise to left elbow, laceration to left knee, and unable to determine to back of head. b. Immediate action taken documented, Physical evaluation of the resident. c. Upon return, placed a motion detector toward bed. d. The resident's pain score noted at a level of 8. e. Mental status assessed as oriented to person. f. Predisposing situational factors documented, Ambulating without Assist. g. Other info documented: sitting in her w/c in hall with foot pedals in place. The Incident Report documented no witnesses to the fall found. Information was not provided by the facility which documented who had last seen the resident prior to the fall, or what time the resident last observed by staff prior to the fall. The Emergency Department Provider Notes for the encounter date of [DATE] documented: in part, Patient currently on Hospice, arrives from facility care center, suffered a ground-level fall with her walker. Has a left parietal scalp hematoma. Complains of left shoulder and left hip discomfort. Verbal report received reported Hospice wanted the resident's injuries evaluated and then to be contacted for further treatment advice. X-Ray and a Computerized Tomography (CT) reports documented, in part,the following: a. X-Ray left shoulder left minimum 2 views: 1 Findings highly suspicious for comminuted distal clavicular fracture. This can be confirmed with dedicated clavicle radiographs as clinically warranted. b. X-Ray Right hip left minimum left 2 views: 1. Impacted subcapital left femoral neck fracture. c. CT Head without contrast: 1. Bilateral acute subdural hematomas, left greater than right with associated mass effect and left-to-right midline shift of 7 millimeters (mm). There is evidence of active bleeding within the left subdural hematoma. Neurosurgical consultation advised. On [DATE] at 2:35 PM, review of the Post Fall assessment dated [DATE] revealed the assessment remained in progress, and no documentation present on the assessment. The Health Status Note dated [DATE] at 5:21 AM documented: Resident restless at beginning of shift, removing her night gown and attempting to exit her bed to go to the Avenue. PRN medications given by Day Shift Nurse. Resident fell asleep after supper and slept most of the shift, and woke about 2:15 AM moaning and groaning. PRN Tylenol and [MEDICATION(S)] (antianxiety medication) given. Resident sleeping at this time. On [DATE] at 5:18 PM, Staff L, Licensed Practical Nurse (LPN), was queried about the resident's fall which occurred [DATE], and to the identity of the CNA who had notified them of the resident being on the floor. Staff L explained this was too long ago for them to remember. Staff L was queried if the resident walked or used a wheelchair, and responded the resident used a wheelchair but thought they could still walk. Staff L was queried if the resident attempted to self transfer, and acknowledged the resident attempted to do so. Staff L explained pretty sure the resident had a history of falls prior and this was not an isolated event. Staff L was queried about the process following a fall, explained the nurse would come into the room and complete a head to toe physical assessment, vitals, and if not a witnessed fall, then neuro checks would occur. Staff L acknowledged neuros were done in the Electronic Health Record (EHR) system. Staff L was queried about the Post Fall Assessment in the EHR, and explained she believed charting would occur once a shift as well as neuros. Staff L explained their was a system for follow up for almost 72 hours. Per Staff L the nurse would do the Incident Re [TRUNCATED]

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to protect against hazards from self and elements in the environment. Resident #6 eloped from the facility. Eight residents wore Wanderguard devices (Bracelet to alert staff when nearing an alarmed Wanderguard door). The facility reported a census of 75 residents. Findings include: 1. Resident #6 had a MDS (Minimum Data Set) assessment with a reference date of 2/15/17. The MDS indicated the resident could independently transfer, walk and use the toilet. The BIMS (Brief Interview for Mental Status) scored the resident as a 2. A score of 2 reflected the resident had severe cognitive impairments. The form titled Resident Face Sheet identified [DIAGNOSES REDACTED]. The facility performed an Elopement Risk assessment on 4/11/17, which identified the resident not at risk for an elopement. The assessment indicated the resident would look outside but did not open the doors. The resident would bang on the doors inside the facility. The Progress Note dated 4/4/17 indicated the staff noted the resident wandering and exit seeking lately that evening. The staff redirected and helped to bed. The Progress notes of 4/10/17 at 11:00 a.m. indicated the resident walked out the front door and staff redirected to his/her room. The facility performed an Elopement Risk assessment on 5/11/17. The assessment determined the resident had exit seeking behavior at times and had a wandering history. The assessment determined the resident to be at risk for elopement and unsafe. The Care Plan, last revision dated 2/27/17, identified a problem starting 4/11/16 with the potential for elopement regarding dementia, roaming throughout the facility and a new admission into the facility. The approaches directed staff to have a Wanderguard in place and check each shift for proper functioning. The goal identified the resident would not leave the building unattended before the next review (5/27/17). An Incident/Accident Report dated 5/14/17 at 3:30 PM indicated Resident #6 eloped through the east dining room door and found wandering in the east parking lot corner. The resident seemed alert, easily redirected and brought back to the resident's room. On 5/30/17 at 3:15 p.m. Staff B (housekeeper), was interviewed and stated she typically checks alarms once a day. The front door and the east doors have Wanderguard on the doors. Staff B stated she checked the alarms that Sunday and all functioned except the front and east door with the Wanderguard system. The Wanderguard checking devices were not functioning on Friday (5/12/17) and reported this to the Housekeeping Supervisor. On Sunday (5/14/17) the Wanderguard system did not sound at the front and east doors and the pod doors did not alarm. The east dining room door did not alarm. Staff did inform the housekeeping supervisor the Wanderguard checking device did not function. Staff B stated she did document the doors were checked but not functioning on the daily security door check sheet. On 5/31/17 at 1:40 PM with Staff C, Certified Nursing Assistant (CNA) stated alarms are not always able to be heard related to oxygen, television and location of room. On 5/31/17 at 2:10 PM the exit door at the end of the east hall was opened and entered room E 20. The sound of the door alarm could not be heard inside the room. The buzzer alarm sound for the door is located over one hundred feet away from the door at the nurse's station. On 5/31/17 at 2:15 PM Staff D, CNA was interviewed and stated the door alarms had a faint beeping and she could not always hear them when other things are going on in the building. On 5/31/17 at 2:50 PM Staff E (Housekeeping Supervisor) was interviewed and stated Staff B did report on 5/12/17 that the alarms did not function. Staff E stated he went to the central supply and found only one Wanderguard checking device left so he did not want to use the remaining one. Staff E stated on 5/17/17, the new devices arrived and he replaced the old devices with new devices and documented on the daily security door check sheet. Staff E stated he generally replaces the devices when not working or every 90 days. On 5/31/17 at 3:15 PM, Staff A, Licensed practical nurse (LPN), was interviewed and stated on 5/1/4/17 around 3:00 p.m. another resident informed him Resident #6 was outside. Staff A stated he exited through the east dining room door and the door did not alarm. Staff A stated he redirected the resident back into the facility and observed the Wanderguard did alarm but the other alarm on the door did not alarm. Staff A stated he checked the main control panel and noted the alarm shut off. Staff A stated he reported the incident to the supervisor on 5/14/17. On 5/31/17 at 4:00 PM the Director of Nursing (DON), was interviewed and stated she learned of the resident's elopement on 5/16/17, when she read it in the Progress Notes. The DON stated the facility started the investigation and did not know the Wanderguard checking device was not functioning to check the doors until 5/17/17. The device was replaced on 5/17/17. The DON stated she suggested the doors should be alarmed at the door instead of at the nurse's station control panel. The DON stated when completing door alarm checks, this should be done with two people so someone is always at the door. The DON stated this was implemented after the elopement on 5/14/17. On 5/31/17 at 4:15 PM the Administrator was interviewed and stated he learned during the investigation on 5/15/17, the push button on the outside was sticking and by passed the alarm. The Administrator stated the staff should not have waited until 5/17/17 to replace the Wanderguard checking device. The Administrator stated he was unaware someone had shut off the alarm system on the day of the incident. The Administrator stated new alarms were installed on every exit door in the facility. Alarms are loud enough to be heard when in the resident rooms now. A form titled Elopement Management Program (not dated), provided by the facility identified an elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. A resident who leaves a safe area may be at risk of (or have the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning or being struck be a motor vehicle. On 6/1/17 at 9:55 AM the Administrator stated the facility did not have a policy/procedure for checking the door alarms but it is understood to check daily. Inservice records identified on 5/17/17, the DON and the Housekeeping Supervisor, instructed the staff about elopement instructions. The summary topic and key points were: secure residents safety, notify supervisor, facility wide resident head count, incident/accident report, notify the physician, notify the resident's family and direct staff to write statements. The inservices included direction to do 2 person door checks. One person is to be at the alarm panel and the other person is to be opening and closing the doors. On 6/1/17 at 2:45 p.m., the Wanderguard door and other alarmed doors were checked with the housekeeping supervisor and the Administrator. All of the doors were alarmed and sounded when opened or when checked with a Wanderguard checking device.

Based on clinical record review, observation, and staff interviews, the facility failed to follow the resident's care plan and provide supervision to ensure each resident's individual safety for one of four residents reviewed (Resident #1). The facility reported a census of 74 residents. Findings include: 1. According to the MDS (Minimum Data Set) dated 10/13/2016, Resident #1 had intact cognition, transferred and ambulated with the assistance of one staff and had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident had moderately impaired cognition and [DIAGNOSES REDACTED]. The Care Plan, Date Range 2/15/2016 - 11/21/2016 identified Resident #1 had a potential for injury from falls related to a history of falls, impaired cognition and limited mobility. On 10/23/2015 the Care Plan added approaches including tamper resistance pressure alarms on bed and chair; ensure proper function each shift, keep frequently used items within easy reach, floors clean and dry, and encourage resident to wear well fitted shoes and nonskid socks. On 10/31/2015 the Care Plan added: Uses alarms, stay with resident when you take to the toilet. On 2/16/2016 the Care Plan added: Do not allow resident to be in his/her room unless supervised or in bed. The Fall Risk assessment dated [DATE] revealed Resident #1 had an incomplete assessment. Resident #1 displayed balance problems while standing. The Incident/Accident Report dated 11/17/2016 revealed Resident #1 fell at 5:30 p.m. in his/her room. Staff assessed the resident, notified physician and family and transferred the resident to the emergency room via ambulance services. The form documented Pressure alarm with code to turn off and/or tamper proof alarm as the intervention to prevent recurrence. Incident Reports revealed the resident also fell on [DATE], 12/2/2015, and 2/8/2016. The Progress Note included: On 11/17/2016 at 5:30 p.m., Staff A, LPN (Licensed Practical Nurse) documented: Nurse summoned and observed Resident #1 lying on the floor in front of roommate's bed, face up with feet closest to bathroom, no indication of bowel or bladder incontinence, and slacks half way up with no underwear. Wheelchair to the right and tipped on its back. Resident stated he/she came out of the bathroom and tipped his/her cart. The resident complained of left hip pain and staff noted external rotation. Staff transferred the resident to the wheel chair and bed without resident bearing weight on the left leg. On 11/25/2017 the Social Services staff documented the resident admitted to the hospital after being found on the floor in his/her room. No mood concerns. Resident noncompliant with alarms and transfers. Resident had short term memory deficits. Hospital records revealed dated 11/17/16- 11/25/2016 revealed Resident #1 had closed fracture of the neck of the left femur, fracture left pubic ramus, Alzheimer's Dementia, and Chronic Kidney Disease. The resident had been unable to provide any meaningful history due to confusion and his/her mental condition. The resident had been admitted on [DATE] due to left hip pain after a fall. The nursing home resident fell backwards when his/her wheelchair tipped over. The workup (at hospital) showed a hip fracture and the resident underwent [REDACTED]. Observation on 2/24/2017 at 9:50 a.m. revealed Resident #1 seated in a wheelchair with a pressure alarm in place with the alarm box attached to the rear of the wheelchair. The resident sat at the dining room table and ate breakfast with set up assistance. The resident appeared alert, clean and neat and verbal with staff. The resident reported he/she fell and injured his/her shoulder about two months ago, had surgery and it healed. The resident denied hip pain and said he/she tripped over the cart and fell . Observation on 2/24/2017 at 12:30 p.m. with the DON (Director of Nursing)/RN (Registered Nurse), present, revealed Resident #1 had an alarm box with a button in the back used to silence it. The box had no code to reset the alarm. At 12:45 p.m., observation with the DON present, revealed the resident sat in the wheelchair inside his/her room with the door partially closed. Staff E, CNA (certified Nurse's Aide) arrived and indicated the resident self-propelled from the dining room to his/her bed room. Staff E applied the gait belt and assisted the resident to the recliner. The recliner had an alarm box with a code that sounded when checked. The Fall Risk assessment dated [DATE] revealed the resident had a high fall risk. During an interview on 2/24/2017 at 12:15 p.m., the DON revealed on 11/17/2016, Resident #1 told staff he/she transferred to the toilet and attempted to return to the wheelchair when it rolled, tipped over, and he/she fell on to it. The resident had a pressure alarm in the wheelchair at the time. The facility had two types of alarm boxes, some have a button in the back that you push to silence it; and the others had a code that staff had to enter to reset it. The DON thought Resident #1 had a box with a code presently, and knew of no instances where the resident turned off the alarm. Staff checked the alarm after the resident fell and it functioned properly. The fall happened before supper and the resident had been in his/her room. After the fall on 11/17/2016, staff added the Care Plan intervention, directing staff not to leave the resident alone in the room unless in bed. The resident had no further attempts to self-transfer since returning from the hospital. On 2/24/2017 at 1:15 p.m., the DON reported they added a tamper resistant alarm to the resident's wheelchair. The alarm from the recliner is also used in the resident's bed. The DON verified the tamper resistant alarm required staff to enter a code to silence and reset it. During an interview on 2/28/2017 at 12:00 p.m., the DON reported the resident had no major injuries from prior falls and the falls occurred when the resident attempted to self-transfer. When the resident returned from the hospital, staff updated the Care Plan to reflect the resident could be in the room unsupervised since the resident made no further attempts to self-transfer. The resident self-propels the wheelchair and showed improvement. During an interview on 2/28/2017 at 1:20 p.m., Staff A, LPN (Licensed Practical Nurse), reported working on November 17, 2016 when Resident #1 had a fall and sustained a hip fracture. Staff A found the resident on the floor with his/her pants half way up with no underwear or brief on. Staff A observed the resident's wheelchair tipped over. Staff A checked the resident's alarm after the incident and it functioned appropriately. Staff A reported the resident had a history of [REDACTED]. Staff A felt the resident had the ability to turn off the alarm by pressing the button. After the fall, Staff A added the intervention to place a tamper resistant alarm; one that required a code to be entered. Staff A checked resident alarms at the beginning of the shift and documented it on the TAR (Treatment Administration Record). During an interview on 2/28/2017 at 2:10 p.m., Staff J, LPN reported on November 17, 2016 when Resident #1 fell , Staff J had just returned from break. Staff K, CNA informed Staff J that Resident #1 fell . Staff J found the resident on the floor and he/she failed to recall where the resident sat prior to leaving on break. The resident never used the call light, often attempted to self-transfer, and Staff J never witnessed the resident turn off the alarm. Since the fall, the resident changed rooms closer to the nurse's station. Staff gets the resident ready for bed immediately after supper. After meals the resident will go to his/her room and attempt to transfer to the recliner, therefore staff cannot leave the resident alone in the room in the wheelchair. The resident can only be left alone in the room if he/she is in bed or the recliner. During an interview on 2/28/2017 at 10:50 a.m., Staff D, LPN (Licensed Practical Nurse) reported Resident #1 had pressure alarms in the chair and bed and nurses checked the alarms every shift to ensure they functioned. Staff D reported the resident had no attempts to turn off the alarm and probably would not be able to. The resident now resided closer to the nurse's station. Prior to the fall and fracture, the resident often made attempts to self-transfer, but had decreased since the fall. During an interview on 2/28/2017 at 1:55 p.m., Staff I, CNA reported prior to Resident #1's fall in November, 2016, the resident made attempts to self-transfer, had safety concerns and required an alarm at all times. Prior to that fall, staff ambulated the resident to and from meals, now the resident walked to the bathroom only with staff assistance. Staff I indicated the resident, though unpredictable, had no further attempts to self-transfer since the fall. Prior to the fall, the resident gained confidence and had progressed nicely. Staff I observed the resident fumble with the alarm box. Staff I never saw the resident turn the alarm off. After the fall on November 17 (2016), staff placed a tamper resistant alarm in the recliner. Staff I stated staff never leave the resident unsupervised in the room in the wheelchair. The resident self-propels the wheelchair to the room after meals. During an interview on 2/24/2017 at 12:04 p.m., Staff H, CNA reported Resident #1 had a low bed with an alarm and a chair alarm. Since the resident fell , he/she made no attempts to get up unassisted. Staff H had no knowledge of the resident using the call light or tampering with the alarm boxes. During an interview on 2/28/2017 at 10:30 a.m., Staff C, CNA reported Resident #1 needed supervision in his/her room if not in bed or recliner with an alarm. The resident self-propelled the wheelchair and made attempts to self-transfer. Staff C failed to recently work with the resident, but had no knowledge of the resident using the call light or turning off the alarms. During a phone interview on 2/28/2017 at 11:50 a.m., Staff K, CNA had no recall of the incident. The facility investigation completed when Resident #1 fell on [DATE] reported Staff K, CNA observed the resident on the floor on his/her back with pants half way down the legs, and the wheelchair tipped backwards lying on the resident's right side. Staff K last saw the resident at approximately 4:30 p.m. in the room with a call light within reach and denied needing to use the bathroom. Staff J, CNA last saw the resident between 4:00 - 4:30 p.m. in the room in the wheel chair. Staff A, LPN, Staff J, CNA and Staff K, CNA checked the alarm after the resident fell and it functioned. Staff asserted the resident turned off the alarm, though they never witnessed the resident doing so. The facility Fall Prevention Program included: When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again.

Based on clinical record review, policy review, staff and State Climatologists interviews the facility failed to provide appropriate supervision for 1 of 13 residents reviewed (Resident #1). The facility reported a census of 75 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE] Resident #1 ' s Brief Interview for Mental Status BIMS score of 6, disorganized thinking and inattention identified severe cognitive impairment. According to the MDS Resident #1 was independent with all activities of daily living but required supervision for personal hygiene and extensive assistance in bathing. Resident #1 ambulated about the facility utilizing a cane or walker. The MDS identified Resident #1 ' s [DIAGNOSES REDACTED]. The MDS revealed a lack of any mood altering medications. Review of the Care Plan dated 11/18/15 indicated Resident #1 ' s behavioral symptoms included pocketing his/her medications and agitation with aggression. The plan directed the staff to discuss potential negative consequences of not taking his/her pills as prescribed and monitor or remove Resident #1 from stressful situations. The Care Plan indicated Resident #1 ambulates about his/her room with the use of a cane or wheeled walker. Review of Resident #1's Nurses Notes indicated Resident #1 experienced the following behaviors: a. On 11/17/15 at 12:14 p.m. medications found in the Resident #1's private room by the housekeeping staff, the documenting nurse reported they appeared to be the Resident #1's evening medications. b. On 11/25/15 at 3:08 p.m. Tim in maintenance spoke to Resident #1 about leaving his/her water running all the time in the bathroom. Resident #1 became angry and agitated. According to staff Resident# ' 1 ' s bathroom faucet was running full blast and when the staff member turned the hot water off Resident #1 began yelling at the staff member to get out of his/her room and yelled obscenities as the staff. c. On 11/25/15 at 4:00 p.m. Resident #1 placed a phone call to emergency 911 and reported something about his/her water in Apartment 900. The Officer called the facility to inquire about the issue with the facility. d. On 11/27/15 at 10:17 a.m. Resident #1 placed a phone call to emergency 911, complaining of his/her room being cold and planned to sue the facility. e. On 11/28/15 at 9:33 a.m., Resident #1 began to throw his/her belongings around the room, slamming doors and cursing. Resident #1 stated he/she would sue the facility because the room was cold. f. On 11/28/15 at 11:26 a.m., Resident #1 again yelling in his/her room. Staff approached Resident #1 in his/her room and identified Resident #1 had no pants on and his/her shirt unbuttoned. Resident #1 calmed down and got dressed, preparing to go to lunch. g. On 11/28/15 at 1:10 p.m. the receptionist received a phone call from a local business reporting that Resident #1 was out front of the business and a passerby picked up Resident #1 and brought him/her to the business. h. On 11/28/15 at 2:15 p.m. the facility contacted Resident #1 ' s attending physician and received orders to transport to the hospital for altered mental status with elopement and for a psychiatric evaluation and treatment if needed. i. On 11/28/15 at 2:25 p.m. Resident #1 transported to the hospital via ambulance. j. On 11/28/15 at 9:55 p.m. The hospital emergency room physician called the facility to discuss the elopement and details of the potential cause of the behaviors exhibited by Resident #1. During an interview with Staff A-Receptionist on 12/17/15 at 8:15 a.m. and 12/30/15 at 9:30 a.m., Staff A stated on 11/28/15 she was assigned as the front door receptionist. At approximately 12:45 p.m. Resident #1 walked to the front desk area and sat in a chair by the front door. Resident #1 informed Staff A that his/her daughter would be coming to pick Resident #1 up and take them to lunch. Resident #1 made several complaints about not having hot water in his/her room which Staff A reported as normal behavior for Resident #1. Staff A indicated at approximately 1:05 p.m. she went to a restroom about 10 feet from the front door and reported being in the bathroom about 2 minutes. Staff A returned to the reception desk and noted Resident #1 no longer sitting in the chair by the desk. Staff A stated she looked into an adjacent sitting area and failed to observe Resident #1.Staff A then went to a sun porch about 3 feet from the desk, looked out the glass window not seeing Resident #1. Staff A stated they returned to the reception desk assuming Resident #1's daughter picked up Resident #1 for lunch and did not check the sign out log. Staff A stated she failed to complete further investigation into Resident #1's whereabouts. Approximately 10 minutes later they received a phone call from a local business reporting that Resident #1 was at the business to visit his/her son. Staff A ran down the hall to tell the charge nurse. Staff A reported Resident #1 did not have a wander-guard bracelet on so it would not activate the front door alarm. Staff A stated on 11/28/15 the front door did not have an activated alarm system when the receptionist sat at the desk or left the desk for a brief time, now when the receptionist leaves the desk for any length of time or any reason the alarm is activated, placed into night mode. During an interview with Staff B-Administrator on 12/30/15 at 10:15 a.m., Staff B stated he completed the investigation regarding the elopement of Resident #1. Staff B spoke with the passerby that picked up Resident #1 during the course of the investigation, the passerby stated he observed Resident #1outside a local business next door to the facility. The stranger stopped and asked if Resident #1 needed help, Resident #1 indicated he/she needed to go to a local business to see his/her son. The stranger assisted Resident #1 into his truck and drove Resident #1 to the requested destination approximately 1 mile from the facility. Upon arriving to the business the stranger entered the business asking for Resident #1's son. Resident #1's son came out of the business and an argument began. The stranger called the police because of the argument between Resident #1 and his/her son. Staff B reported Resident #1 refused to return to the facility until his/her granddaughter arrived and agreed to return with her. Staff B stated Staff A received a verbal re-education regarding the lack of follow thru when she discovered Resident #1 was no longer in the lobby area by the receptionist desk. Staff B stated Staff A failed to follow up on Resident #1's whereabouts and should have checked the sign out log and clarified with the nursing department to assure Resident #1 left with his/her family not to assume Resident #1 left with family. During an interview with Staff C-Director of Nursing on 12/30/15 at 8:30 a.m., Staff C stated Staff A should have checked further into Resident #1's whereabouts on 11/28/15 instead of assuming his/her daughter picked Resident #1 up for lunch. During an interview with Staff D-11/28/15 Charge Nurse on 12/15/15 at 3:50 p.m., Staff D stated she last observed Resident #1 in his/her room on 11/28/15 at 11:20 a.m. According to Staff D Resident #1 ' s Son and Grandson visited for a brief time at the facility. Resident #1 ' s son left as Resident #1 began yelling at them. Staff D entered Resident #1's room and observed Resident #1 sitting in the room in his/her underwear. Resident #1 received a room tray eating about half of the meal at approximately 1:00 p.m. Staff D stated she stepped outside for a quick break when Staff A approached her visibly upset. Staff A reported she just received a phone call from a local business that reported Resident #1 was at the business. Staff D immediately went to the local business and upon arriving found Resident #1 in a stranger ' s truck. Resident #1 told the stranger Oh that's the nurse get them away from me. Staff D stated she could not redirect Resident #1 as he/she was upset. The stranger informed Staff D he picked up Resident#1 by the facility asking to go see his/her son. The local police department arrived to the scene but Resident #1 refused to return to the facility with them but did return with his/her granddaughter. Staff D stated the facility call Resident #1's physician and obtained an order to transfer to a local hospital for an evaluation related to the elopement. During an interview with Staff B-Administrator on 12/17/15 at 2:10 p.m., Staff B stated they have a new alarm policy in place post Resident #1 elopement on 11/28/15. Staff B stated prior to the elopement, when the receptionist is on duty and leave the front desk briefly the expectation was not to place the front door alarm into night mode. Prior to 11/28/15 when the front door alarm is not in night mode the front door would not sound when opened unless a resident with a Wander-guard bracelet is near. Resident #1 did not wear a Wander-guard bracelet, thus the front door alarm did not sound when Resident #1 opened the door and exited the building. During an interview with State of Iowa Climatologist on 12/30/15 at 9:44 a.m., the Climatologist indicated a temperature of 32 degrees with a wind chill of 26 degrees on 11/28/15 at 1:00 p.m. in Cedar Rapids. Review of the Release of Responsibility for Leave of Absences form revealed Resident #1 last left the building with his/her son on 9/14/15. Staff C stated this form is kept at each nurse ' s station and not at the receptionist desk. The facility reported 13 resident ' s exhibit wandering behaviors and utilize a Wander-guard Bracelet System. Review of the Minimum Data Set-Cognitive Scores revealed 12 of 13 residents had severe cognitive ability. Review of a list of Independent ambulating residents revealed the facility identified 16 residents walk about the facility independently, 10 of 16 did not utilize a Wander-guard Bracelet System. Review of an undated Elopement Management Program, page 1, described an elopement when a resident leaves the premises or a safe area with authorization. A Resident who leaves a safe area may be at risk of heat or cold exposure, dehydration, drowning, or being struck by a motor vehicle. Review of an undated Missing Resident Recommendation form, page 2, indicated it is the responsibility of any employee to report a resident attempting to leave the premises, or suspected of being missing to the charge nurse as soon as possible. The form indicted should an employee who discovers a resident missing from the facility he/she should determine if the resident is out of the facility on an authorized leave or pass. Note: At the time of the onsite investigation the facility had implemented corrective action to abate the immediate jeopardy on 11/28/15 by training staff to turn on alarms when leaving the reception desk are and to monitor residents at risk for elopement.

Based on record review and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 2 residents reviewed (Resident #2). The facility identified Resident #2 as a fall risk. The resident was left unattended in the bathroom and fell , fracturing ribs and having a small to moderate pneumothorax (collapse of lung) which required admission into the hospital. The facility identified a census of 71 residents. Findings include: 1. Resident's #2 had a Minimum Data Set (MDS) assessment with a reference date of 10/16/14, which identified the resident had [DIAGNOSES REDACTED]. The assessment reflected the resident had moderate impairment with cognitive skills of daily decision making. The resident required limited assistance of 1 staff person when moving from one surface to another, transfers, ambulation, and with use of the toilet. The resident had an unsteady balance during transitions, walking and required staff assistance to stabilize. The MDS reflected the resident used a walker for mobility purposes. The MDS identified the resident had not had any falls since admission and had limited range of motion of a lower extremity. The Care Plan dated 11/4/14 identified Resident #2 had behavior problems manifested by resisting cares at times, does not always remember to use the call light or wait for assistance. An intervention for this problem directed staff to allow the resident to make as many decisions as it is practical related to care. The Care Plan dated 11/4/14 identified the resident unable to complete active daily living care needs independently related to weakness. The Care Plan failed to identify the number of staff to assist with transfers and ambulation. The Care Plan failed to identify the resident had a bed and chair alarm. The Care Plan identified the resident at a potential for injury from falls related to a recent femur fracture with an intervention which included fall risk assessment as needed. A Physical Therapy Plan of Care dated 11/7/14 showed precautions for the resident as a fall risk, full code and a recent history of right hip fracture in 8/2014. The report noted the current function of the resident with a Tinetti (assessment tool) balance and gait score of 3/12 for a total balance and gait score of 4/28, which relates to the high risk (under 19/28) fall risk category. The report also identified the resident as able to safely complete all functional transfers requiring minimal assistance (routinely requires 25 percent assistance to transfer). Treatments Flow sheet dated for 11/1/14 through 11/30/14 for the resident showed the following: - Pressure alarm (initiated on 8/7/14) when in bed to alert staff to unassisted transfers. Check placement and function every shift. -pressure alarm (initiated 8/7/14) when up in chair to alert staff to unassisted transfers. Check placement and function every shift. An Incident /Accident Report dated 11/10/14 at 11:20 p.m. reflected the staff assisted the resident to the toilet and the resident wanted some privacy. The CNA (Certified Nursing Aide-Staff M) stood by the bathroom door and reminded the resident to push the call light when finished. The resident attempted to get up independently and fell . The staff opened the door and found the resident. Staff T, Licensed Practical Nurse-LPN, completed the assessment and sent the resident to the emergency room . Additional comments written on the report and or steps taken to prevent a recurrence was to encourage the resident to leave the toilet door open. The Resident's Progress Notes dated 11/10/14 identified the following: At 11:44 p.m., the CNA (certified nursing assistant) called the nurse to assess the resident. The CNA had provided privacy for the resident and encouraged the resident to use the call light when finished using the toilet. The CNA stood by the door and waited for the resident. While standing at the door, the CNA heard the resident scream. The CNA opened the toilet room door and found the resident on the floor. The resident denied hitting head. The resident complained of back pain and the nurse noted an excoriation on the back. The resident could move all extremities and assisted to the chair and then the bed. The nurse cleansed the excoriated area and patted dry. The neurological assessments were initiated. The Resident ' s Progress Notes dated 11/11/14 identified the following: At 1:00 a.m. the nurse assessed the resident who complained of back pain, at the wound site. The resident received Tylenol (analgesic). At 2:00 a.m., the resident was sleeping and voiced no complaints. The Tylenol had been effective. At 3:45 a.m. the resident complained of left side pain. The nurse attempted to roll the resident over to assess the back area. The resident voiced pain and could not move. At 4:05 a.m. the physician was notified and staff received orders to send the resident to the emergency room for an x-ray to rule out any fractures. At 4:20 a.m. the ambulance took the resident to the hospital. At 6:09 a.m. the nurse contacted the hospital and learned the resident had rib fractures and a small pneumothorax. At 6:30 a.m. the hospital called to inform the facility that the resident was admitted for the fracture of ribs 6, 7 and 8 and a small pneumothorax. The impression on the hospital x-ray report dated 11/11/14 identified minimally displaced left 6th, 7th, and 8th rib fractures with a small to moderate left apical pneumothorax. On 12/9/14 at 4:15 a.m., Staff T, Licensed Practical Nurse (LPN), was interviewed and reported the resident would frequently get up and self-transfer a lot during the night. The resident had a bed alarm. The alarm went off on 11/10/14 and Staff M took the resident to the bathroom. The resident asked for privacy so the CNA closed the bathroom door. Staff T identified the resident as not good about using the call light. Staff T stated he heard Staff M call out for help and he went to the bathroom right away, as the Nursing Station is across the resident's room. Staff M sat on the floor holding the resident. Staff T assessed the resident and with the help of the CNA, they assisted the resident back to bed and did another re-assessment. Staff T started the neurological assessments per policy. The resident denied hitting head and denied any pain. Later in the night the resident complained of pain on the left truck area/side of the body and administered Tylenol. Later, the resident complained of the same left side pain, so the physician was called and ordered to send to the hospital. On 12/10/14 at 8:25 a.m., Staff M (CNA) was interviewed and stated the resident asked to go to the bathroom on rounds the night of the fall. The resident would go to the bathroom 5 to 6 times during the night. The resident wore gripper socks and was alert. The resident had alarms for the chair and bed and used 1 staff assistance for transfers. Staff M stated she assisted the resident to the bathroom, where the resident requested privacy. The resident always asked to be left alone and Staff M noted she complied with the request. Staff M showed the resident the call light and repeated instructions 3 times to use it when finished. The resident always used the call light in the past, when she had left the resident alone in the bathroom. Staff M noted this as the first time the resident did not use the call light. Staff M closed the bathroom door and did not have a visual on the resident. After a few minutes, she heard movement, opened the door as the resident fell , and couldn't catch the resident in time. The resident fell toward the sink, on the left side. The toilet has arm rests/handles (bolted under the seat) that stick out approximately a foot from each side. Staff M called out for the nurse, who quickly came to assist. Staff M demonstrated how and where the resident sat on the bathroom floor and how she held the resident, calling out for the nurse. Staff M reported her hired on instructions to honor requests for privacy, even if a resident has alarms. She commented it is the resident's choice and their privacy. Staff M remarked she tried to talk the resident into letting her stay in the bathroom, but the resident refused. On 12/8/14 at 3:00 p.m., Staff C, CNA, was interviewed and reported the standard procedure is not to leave an alarmed resident alone. If a resident is alarmed it means they are a fall risk. If a resident would request to be left alone, she would apologize and say she has to stay with them (the resident). On 12/8/14 at 3:45 p.m., Staff O, CNA, was interviewed and stated residents that required/used alarms should not be left alone in the bathroom. The resident use of an alarm identifies the resident to be a fall risk and so the staff must stay with the resident. On 12/9/14 at 4:05 p.m., Staff U, CNA, was interviewed and stated if a resident asks for the staff to leave, then she would close the door half way and standing by the door to keep an eye on the resident. On 12/10/14 at 2:45 p.m., Staff A, CNA was interviewed and reported if a resident had alarms, staff should stay with the resident while in the bathroom. If a resident requested privacy, she would stand by the door, but keep a visual on the resident. Staff A stated she noted using alarms mean the resident is a fall risk. On 12/10/14 at 2:20 p.m., Staff B, CNA, was interviewed and stated she knew if a resident had alarms, then staff must stay with the resident. Staff B noted she would try to give them as much privacy, standing by the door, but keeping an eye on them. Staff B noted any resident with alarms mean they are a fall risk. On 12/15/14 at 12:00 p.m., the DON (Director of Nursing) was interviewed and reported it is standard procedure to stay with an alarmed resident in the bathroom. Anyone with alarms means they are a fall risk. Staff M should have stayed with the resident, at least stand by the door, keeping a visual on the resident, so the minute the resident moves, one would be right there. The DON retrieved the resident's Care Plan from the computer and noted the Care Plan failed to identify the resident had alarms, or address the bathroom privacy concern. The DON stated the MDS Coordinator is responsible to update resident's Care Plans and the alarms should have been identified on the Care Plan. An interview on 12/15/14 at 3:20 p.m., the Administrator stated there was no facility policy for the use of alarms. He noted it is standard procedure to stay with an alarmed resident in the bathroom.

Based on clinical record review, staff and family interviews, the facility failed to plan for and direct nursing services to ensure Resident #7 received adequate supervision against hazards in the environment. Concerns were identified for one (1) of eleven (11) residents. The facility reported a census of 69 residents. Findings include: 1. The MDS (Minimum Data Set) dated 08/20/2013 revealed Resident #7 had moderately impaired cognitive skills for daily decision making skills. The resident required extensive assistance of one staff to transfer from one surface to another, use the toilet and ambulate in the room. The MDS reported the resident's balance as not steady and only able to stabilized with staff assistance during transition and walking including moving from seated to standing, walking, turning around, moving on and off toilet, and during surface to surface transfer. The MDS indicated the resident had [DIAGNOSES REDACTED]. The resident's Care Plan with last care conference dated 08/20/2013 included: 1. Problem: Resident unable to complete ADL care needs independently, related to weakness from UTI (urinary tract infection), arthritis, macular degeneration, contraction of fingers with a start date of 06/11/2013. 2. Problem: Potential for injury from falls related to weakness, macular degeneration, arthritis with a start date of 06/11/2013. 3. Altered visual function related to macular degeneration. 4. Potential for injury related to [DIAGNOSES REDACTED]. On 07/18/2013 the care plan added knee sleeve on to right knee during transfers or when ambulating. Not needed when resident was resting as resident will comply." On 06/11/2013 the care plan added fall risk assessment as needed, keep floors clean, dry, free of clutter, encourage and assist resident to wear well fitted shoes or nonskid socks when out of bed, keep frequently used items within easy reach, call light within reach, answer requests for assistance promptly, PT (Physical Therapy) consult as needed. On 06/22/2013 the care plan added, explain all care/procedures, maintain safe environment, avoid twisting motions when moving/positioning to avoid pathological fractures, provide assistive devices for safety, provide needed assistance with bed mobility, transfers, and ambulation. On 08/22/2013 the Care Plan added Resident #7 had bed and chair alarms. The August physician's orders [REDACTED]. The September Treatment flow sheet identified Resident #7 had a pressure alarm in the bed and chair on 08/26/2013, open ended. The Incident/Accident Report dated 08/22/2013 at 10:00 a.m. reported Resident #7 stood up from toilet and fell , alerted by resident's roommate, found lying on back with head against wall, without bumps, bleeding, lacerations noted. Staff re-educated. The Nurse's Notes dated 08/22/2013 at 10:15 a.m. revealed Resident #7 sustained a fall in the bathroom. Staff K found the resident on the floor with his/her head up against the wall. The resident denied pain until he/she attempted to straighten the legs, and then complained of right hip pain. Staff assessed the resident, notified physician and family and transferred the resident to the emergency room . The Nurse's Notes at 1:15 p.m. documented the resident admitted to the hospital with [REDACTED]. The Nurse's Notes on 08/26/2013 at 9:45 a.m. revealed the resident returned to the facility, and admitted to a skilled level of care with history of fall, weakness, alert and oriented to self and place. The resident stated "ouch" when extremities touched. According to the Nurse's Notes on 08/27/2013 the facility received faxes from physician with several new orders including knee sleeve to right knee to be used during transfers and ambulation. The Physician Discharge Summary signed 08/26/2013 included: Discharge Diagnoses: [REDACTED]. Hospital Course: Closed head injury after a fall, CT head showed two small foci of hemorrhage within the left lateral ventricle, repeat head CT was done in 24 hours to assess for stability, showed slightly expansion of hematoma, but no active bleeding, neuro stable. The Encounter notes, Progress Notes dated 08/22/2013 revealed Resident #7 admitted to inpatient and discharged to the facility on [DATE]. During an interview on 09/04/2013 Resident #7's family member reported on 08/22/2013 the resident fell from the toilet. The resident had a brain bleed and spent the weekend in the hospital. Normally staff stayed with the resident while on the toilet. The resident had a GI (gastrointestinal) bleed in August and had been getting stronger. During an interview on 09/04/2013 at 4:00 p.m. the DON reported Resident #7 had a bed alarm at the time of the fall on 08/22/2013. The facility gave Staff I, CNA a verbal warning for leaving the resident alone on the toilet. The facility policy is that any resident with an alarm needs staff to remain at the toilet. During an interview on 09/09/2013 at 11:30 a.m., the Administrator reported Resident #7 had a bed alarm, the standard of care required staff to remain with the resident while on the toilet if they have any alarm, including a bed alarm. Staff I received a verbal warning for leaving the resident on the toilet. During an interview on 09/04/2013 at 5:00 p.m., Staff K, RN reported on 08/22/2013 Resident #7 fell from the toilet onto the bathroom floor. The resident's CNA, Staff I failed to remain in the resident's room after assisting to the toilet. The facility re-educated Staff I. According to the facility policy, when a resident has an alarm, staff are required to remain with them while on the toilet. The resident admitted to the hospital for 3-4 days with a minor brain bleed. On 09/09/2013 at 3:00 p.m. the surveyor called Staff I, who declined the interview at that time, but requested it later in the week. On 09/13/201 at 12:14 p.m. during an interview by phone, Staff I reported on 08/22/2013 he/she worked Resident #7's hall, and it was her first day off training. Staff I revealed he/she never worked on that hall alone and never assisted the resident to the toilet until that day. Staff I reported he/she assisted the resident to the toilet and instructed the resident to use the call light near the toilet when finished. The resident agreed. The resident at that time had a bed alarm only. Though Staff I received no instructions regarding resident alarms upon hire; from past experience he/she knew if a resident had a chair alarm they required supervision and were at risk for falls. After the resident fell on [DATE], staff added a chair alarm. Staff I received re-training, and had been told that residents with bed alarms should also have chair alarms. Staff I had no knowledge of who checked alarms, and if he/she had questions regarding resident cares, he/she asked the nurse. The facility Fall Policy indicated the facility used alarms as a means of fall prevention, but failed to indicate that staff were to remain with residents with alarms while on the toilet.

Based on clinical record review, and staff and physician interviews, the facility failed to appropriately assess and provide intervention, and notify one resident's physician in a timely manner for a significant change in condition for one of eleven residents reviewed (Resident #2). The facility reported a census of 69 residents. Findings include: 1. According to the MDS (Minimum Data Set) dated [DATE], Resident #2 had moderately impaired cognitive skills for daily decision making, usually had the ability to make self understood and understand others. The resident required extensive assistance of one staff to transfer from one surface to another, used a wheel chair and walker for locomotion. Resident #2 had [DIAGNOSES REDACTED]. The MDS also indicated the resident had no shortness of breath (dyspnea). The Care Plan indicated the facility addressed Resident #2's problems including: a. Infection related to respiratory infection with a start date of [DATE] and directed staff to encourage fluids, provide medications and treatments as ordered and monitor condition and notify doctor of worsening symptoms. b. Ineffective airway clearance related to accumulated lung secretions secondary to pneumonia, and directed staff to administer medications and monitor efficacy, auscultate breath sounds as needed, provide treatments including nebulizers/inhalers/oxygen as ordered and monitory efficacy, notify MD of resident illness and any changes in condition, and vital signs as ordered and pulse oximetry as ordered and as needed. c. Other problems identified included required restorative nursing, potential for complications related to Barret's esophagus/GERD, bladder incontinence, [MEDICAL CONDITION], antipsychotic medication use, potential for signs and symptoms of dehydration, impaired skin integrity, behavioral symptoms manifested by resisting cares at times, activities, at risk for fluid volume deficit, pain, need for assistance with activities of daily living, and short term memory loss. Resident #2's physician's orders [REDACTED]. a. [DATE] - [MEDICATION NAME] capsule; 200 mg (milligrams), one oral three times a day at 8:00 a.m., 5:00 p.m., and 8:00 p.m. for cough. And, one capsule three times a day as needed for cough. b. [DATE] - [MEDICATION NAME] DM liquid 5 ml (milliliters); two teaspoons as needed for cough four times a day. c. [DATE] - Chest x-ray d. [DATE] - [MEDICATION NAME] 500 mg daily for ten days (antibiotic). Repeat chest x-ray in two weeks. e. [DATE] - No new orders following the repeat chest x-ray results on [DATE]. Chest X-ray results included: a. [DATE]: Impression: Mild hazy right basilar density. In clinical context of cough, fever, elevated white blood count, or other signs of lung infection, findings would be compatible with pneumonia; otherwise atelectasis should be considered. Findings are new in comparison to prior study. Follow up chest x-ray suggested as clinically warranted. Mild Cardiomegaly, [MEDICAL CONDITION] ([MEDICAL CONDITION] changes), mild [MEDICAL CONDITION], mild degree of [MEDICAL CONDITION]. b. [DATE]: Impression: No radiographic evidence of acute cardiopulmonary disease, interval resolution of right basilar hazy opacity. Right apical pleural thickening, unchanged, mild prominence of heart size, [MEDICAL CONDITION], mild [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. On [DATE], Staff A, LPN (Licensed Practical Nurse) administered prn (as needed) [MEDICATION NAME] capsule and [MEDICATION NAME] DM syrup. The record failed to identify time administered. b. On [DATE], Staff A administered scheduled medications including [MEDICATION NAME] capsule at 5 o'clock p.m. and 8 o'clock p.m. c. The July Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Psychiatric Physician's Progress Note dated [DATE] reported Resident #2 had a hospitalization a couple of months prior related to dehydration. Resident #2's Progress Notes on [DATE] included: a. 10:46 a.m. - Physician returned chest x-ray results, no new orders. b. 8:08 p.m. - Staff A noted resident coughing, resident had dry croupy cough without phlegm. Lung sounds clear throughout bilaterally, oxygen saturation (O 2 SAT) on room air at 91%. Repeatedly asked resident if he/she had pain. Resident would not or could not communicate needs to nurse. Resident alert and sitting on bed side. BP (blood pressure) ,[DATE], P (pulse) 80, R (Respiration) 22. Resident given [MEDICATION NAME] DM 10 ml for cough at this time. c. 8:42 p.m. - Staff A noted resident continues to cough, sounding like a bark. No phlegm brought up, lung sounds clear throughout. Resident does not communicate needs, waving arms through air stating "this is it" over and over. Trying to lay resident down and calm, head of bed up at 45 degrees. Apparent [MEDICATION NAME] DM had no effective results. Given [MEDICATION NAME] capsule 200 mg. O 2 SAT 91% on room air. BP ,[DATE], P 80, R 22, Temp 97.7 degrees. d. 9:48 p.m. - Staff A noted no effective results from [MEDICATION NAME] capsule. Resident continues bark like cough, though less frequent. Lying in bed with HOP up at 45 degrees and O 2 SAT on room air at 88%, respirations increasing to 24, no lung congestion and no phlegm. Temp 98.0 degrees. e. 10:00 p.m. - Staff A documented resident had small emesis of pink liquid which may be [MEDICATION NAME] DM. Resident barking cough continues, resident alert but not making sense with verbalization to staff. P 90, R 24, BP ,[DATE], O 2 SAT on room air at 81%. f. 10:16 p.m. - Staff A documented resident experiencing extreme respiratory distress, shaking severely. BP ,[DATE], R 16, O 2 SAT on room air 60%. Resident unable to communicate needs. Nursing intervention to place resident on oxygen at 2 liters via nasal cannula, and call to the physician. g. 10:30 p.m. - Staff A documented the on call physician called and ordered the resident transfer to the hospital. h. 10:35 p.m.- Staff A documented a call to the ambulance for transport and notification of the DON (Director of Nursing). i. 10:40 p.m.- Staff A documented a call to the hospital to provide information regarding transport of resident with extreme respiratory distress with O 2 SAT at 70% on room air with nursing intervention of O 2 at 2 liters bringing SAT up to 88%. Resident continues croupy/hoarse cough and hyperventilation. Staff faxed the resident's IPOST to the hospital (Iowa physician's orders [REDACTED]. On [DATE] the resident requested CPR (Cardiopulmonary Resuscitation attempt) with limited additional interventions including: Do Not use Intubation or mechanical ventilation. Transfer to hospital if indicated, may include critical care. j. [DATE] at 5:10 a.m., the facility received notice the resident passed away. Hospital records revealed Resident #2 passed away at the hospital on [DATE] at 4:07 a.m. The Discharge Summary dated [DATE] included: Discharge [DIAGNOSES REDACTED]. The History and Physical dated [DATE] reported the facility notified the physician that Resident #2 had respiratory distress with a request to transfer to the emergency room for further evaluation. The emergency room staff intubated the resident due to respiratory distress and hypoxemia. The cause of death had been listed as [MEDICAL CONDITION] and acute, chronic [MEDICAL CONDITION] with hypoxemia and failure to thrive. Emergency Department notes included: At 10:00 p.m. patient vomited, possible aspiration. Blood glucose 223, patient became slowly unresponsive in ambulance, began bagging, patient has weak respiratory effort. Shortness of breath with gradual onset, duration of two hours, severe and constant, and worsening. Chronicity: New. Clinical impression: primary encounter [DIAGNOSES REDACTED]. Chest X-ray [DATE] at 1:37 a.m. - New dense consolidation is present in the left lung base, increased patchy airspace disease in the perihilar regions and upper lobes, possible small left pleural effusion, [MEDICAL CONDITION] vascular markings are poorly visualized, cardiac silhouette is poorly visualized. Impression: New dense pleural-parenchymal changes in the left lung base, increased patchy, bilateral perihilar and upper lobe airspace disease. The facility Physician's Discharge Summary dated [DATE] revealed Resident #2's final diagnosis "as above". The form revealed the admitting [DIAGNOSES REDACTED]. Expired at hospital on [DATE]. During a phone interview on [DATE] at 3:20 p.m., Resident #2's primary physician reported he/she would have expected notification from facility staff when the resident's O 2 saturation level fell below 90%, especially after what the resident experienced a couple of months prior including hospitalization related to dehydration and [MEDICAL CONDITION]. The physician felt the facility should have reacted, and stated "I would have thought they would have been all over that". The physician indicated when a resident starts saying things like "this is it" and "help me", they usually know, and usually know when they are dying. The resident really didn't have much of an underlying respiratory disease, they should have called. During an interview on [DATE] at 2:20 p.m., Staff A reported Resident #2 had an acute respiratory episode with a bark like cough that began around 8 o'clock p.m. Staff A administered two prn (as needed) medications, raised the head of bed, but the coughing continued. When the night shift nurse arrived Staff A and Staff B, RN (Registered Nurse) checked on the resident again and started oxygen. When a resident's O 2 SAT fall below 90% they usually notify the physician since most doctors want it maintained at 90%. Staff C, RN came into the resident's room as well. The resident denied pain but stated "This is it". As soon as Staff B arrived, the resident declined and they decided to start oxygen and notify the physician. The resident's symptoms began around 8 o'clock p.m. On [DATE] at 2:20 p.m. Staff A told the surveyor he/she should have notified the physician when the resident's O 2 SAT were at 88% at 9:48 p.m. according to the nurse's notes. Staff A indicated the two entries for prn (as needed) cough medicine entered on [DATE] were actually given on [DATE] with no times on the medication record. During an interview on [DATE] at 3:49 p.m., the DON revealed if Staff D did the resident assessment, he/she should have documented the assessment. Staff should have provided interventions for Resident #2 including cough and deep breathing with O 2 SAT at 88%, and if that fails to work, notify the physician. If O 2 SAT fall below 90%, staff need to provide interventions depending on the resident. The DON and Administrator interviewed staff regarding the resident's change in condition and death because some staff voiced concerns. When Staff A reported interventions provided and not documented. The administrator asked Staff A to enter the information in the nurse's notes identified with * (asterisk) as a late entry. The nurse's notes revealed Staff B made late entries including 10:16 p.m. and 10:35 p.m. documentation on [DATE] in the computerized notes. The computerized charting fails to document the time nurse's actually enter the information. During interviews on [DATE] and [DATE] the Administrator reported during the investigation he determined staff assisted the resident to bed around 7:00 p.m., and Staff A attended the resident's cough around 8:00 p.m. After that Staff D went into the resident's room to do a treatment on the resident's roommate and Staff E, CNA put the roommate to bed. Around shift change, Resident #2's coughing increased, had an emesis, and three nurses; Staff A, Staff B, and Staff D attended to the resident's needs, and Staff A notified the physician. With the chain of events that occurred, the assessment and interventions appeared appropriate. The DON heard from staff they had concerns, that's why they did the investigation. During an interview on [DATE] at 2:33 p.m., Staff D, RN reported orienting at the facility [DATE] on second shift with Staff A, LPN. At approximately 7:30 p.m. Staff D performed Resident #2's treatment and failed to note any unusual signs or symptoms. At approximately 8:00 - 8:30 p.m., an aide reported the resident experienced loud coughing. Staff D stayed busy providing resident treatments. A little before shift change, at approximately 9:50 p.m., Staff D heard the cough from near the nurse's station. Staff F and Staff G, CNA's (Certified Nurse's Aides) asked Staff D to assess Resident #2. The resident appeared red and Staff D told Staff A the resident didn't appear "right". Staff D assessed the resident and found he/she had O 2 SAT in the low 70's. Staff D asked the night shift nurse, Staff B, to get oxygen and they administered O 2 via nasal cannula and raised the head of bed up. They asked the night shift supervisor to assist. Staff D assessed the resident's vital signs three times and monitored his/he oxygen saturation levels. The resident communicated "help me". The cough changed to a bark like sound near shift change. Staff A reported he/she administered something for the cough and there was nothing more they could do for him/her. Staff D instructed Staff A to call the physician with O 2 SAT in the 70's, and dropped further into the 60's. With the oxygen the saturation levels increased to 80. Staff D reported he/she did not administer any cough syrup, and did not see Staff A administer any cough medicine. Staff D indicated he/she checked the resident's vitals and O 2 SATS three times, documented on paper and handed to Staff A to document in the nurse's Progress Notes. During an interview by phone, Staff G, CNA reported working second shift on [DATE]. Resident #2 began coughing at the end of second shift. Staff G and Staff F heard the resident say "Please help me, can't breathe". That wasn't normal for the resident. Staff F asked Staff A to please send the resident to the hospital. Staff G observed Staff A administer cough syrup around 10 o'clock p.m. Staff G reported staff were very upset over the incident, and he/she quit working at the facility. During an interview on [DATE] at 9:45 a.m., Staff B, RN reported working from 6:00 p.m. on [DATE] until 6:00 a.m. on [DATE]. Staff B went to Staff A at approximately 10 minutes after 10:00 p.m. to get report for the remainder of the night shift. Staff D was in Resident #2's room. Staff A told Staff B "I'll let you take over". Staff B told Staff A, "No, let's see what's going on". Resident #2 had Oxygen Saturation levels in the 60's. Staff B ran to get oxygen and told Staff A to call the physician. The aides working reported they told Staff A for a couple of hours the resident needed something. The resident appeared clammy and had distressed breath sounds. During an interview on [DATE] at 10:00 a.m., Staff C, RN reported working the night shift on [DATE]. At 10:00 p.m. Staff C went to Resident #2's unit, heard about the low oxygen levels, and observed the resident with shortness of breath, awake, but not responsive and not talking. Staff A said the resident "was fine" and "just coughing". During an interview on [DATE] at 6:00 p.m., Staff F, CNA reported working the night shift on [DATE]. When Staff F arrived on the unit, he/she heard Resident #2 coughing. Staff F and Staff G did rounds at the change of shift. Staff G became upset and reported Resident #2 stated "help me", and continued to cough. Staff F told Staff A, he/she needed to assess the resident, that was not normal for the resident. Staff A stood in the hall and said the resident was " fine", had a normal x-ray yesterday, and that he/she had coughed for two hours. Staff F observed Staff D and asked him/her to assess the resident. Staff D assessed the resident and found the oxygen saturation level in the 60's. Staff B and Staff D put oxygen on the resident and it (O 2 level) did increase somewhat. Staff F observed Staff A administer cough syrup at approximately 10:00 p.m. Staff F reported being very upset over the incident. During an interview on [DATE] at 2:00 p.m. Staff H, CNA reported working second shift on [DATE]. Around 8 o'clock p.m. Resident #2 reported not feeling well, had coughing and wanted to speak to the nurse. Staff H reported it to Staff A.

Based on record review and staff and physician interviews, the facility failed to assess Resident #2 for dehydration when the resident did not have sufficient fluid intake to maintain proper hydration and failed to notify the physician of the resident's significant change in condition. The facility also failed to plan and develop approaches when adequate fluid intake was difficult to maintain in order that the resident ' s needs were met (Resident #2). The facility identified a census of 77 residents. Findings include: 1. Resident #2 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 3/13/2013 which identified [DIAGNOSES REDACTED]. The MDS documented the resident with disorganized thinking, little interest or pleasure in doing things, feeling tired or having little energy, and feeling bad about self or that he/she a failure or have let themselves or his/her family down. The resident scored a 10 on the BIMS (Brief Interview for Mental Status) evaluation. A score of 10 reflected moderate impairment for cognitive status. The MDS documented the resident required supervision with eating. The MDS documented the resident weighed 108 pounds (64 inches tall) and experienced a loss of 5% or more in the last month or loss of 10% or more in the last 6 months and required a mechanically altered diet (One that requires change in texture of food or liquids). A nutrition assessment dated [DATE] indicated Resident #2 with meal intakes of 25 - 50% at times in the main dining room and in his/her room and received enhanced cereal and ice cream daily. The notation documented a wound to the left ankle and the recommendation for house supplement three times daily between meals due to weight loss and for healing with the physician notified of recommendation. Review of a Willow Gardens Care Center facsimile transmittal to the physician on 3/19/13 documented the resident as refusing to come to meals, poor appetite and refusing alternates or snacks. The vital signs reflected to be: temperature-97 degrees, pulse 78, respirations 18 and blood pressure 112/60. The fax identified the skin as pale, warm, and dry. The correspondence indicated that Resident #2 had stated," I just don't feel like going anywhere." The facsimile indicated the resident denying nausea or vomiting and pain. The physician responded on 3/20/13 and gave orders for a urinalysis test and [MEDICATION NAME] (antidepressant) 15 milligrams (mg) every hs (hour of sleep-bedtime). On 4/16/2013 at 3:40 p.m. the Director of Nursing (DON) was interviewed and stated it was not known if the [MEDICATION NAME] (antidepressant) was used for depression or for an appetite stimulant. Review of the dietary flow sheet for March 2013 revealed the enhanced cereal documented as consumed only 6 times for the month of March on 3/14, 15, 16, 17, 20, and 22nd at breakfast. Review of the dietary flow sheet for March 2013 revealed no documentation of offering or consumption of ice cream at the designated snack time on a daily basis. The March 2013 Medication Administration Flow sheet (MAR) directed staff to give a house supplement three times each day starting on 3/17/13. The MAR indicated [REDACTED]. The resident had consumed 100% of the morning supplement. The remaining times of 3:00 p.m. and bedtime revealed the resident only consumed the supplement twice. The nurse's note dated 3/20/13 at 7:34 p.m. revealed the facility as receiving the signed facsimile from the physician with the order for [MEDICATION NAME] 15 milligrams at bedtime but review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the meal documentation on the dietary flow sheet from breakfast 3/21/13 through supper 3/31/13 for the 33 meals since the physician became aware of the residents refusal to go to meals, poor appetite, and refusal of alternates and snacks on 3/19/13 and with physician response on 3/20/13 revealed the following: 1. 3 breakfast meals consumed (50, 50, and 25%) 2. 2 lunch meals consumed (25 and 100%) 3. 6 supper meals consumed (50, 50, 50, 25, 25, and 25%) Total documented fluid intake consisted of the following at meals for a total of 2,500 cc's. (2 1/2 liters) in a seven day period. 3/21/13 supper - 240 cc's 3/22/13 breakfast - 240 cc's lunch - 240 cc's 3/23/13 supper - 240 cc's 3/24/13 supper - 240 cc's 3/25/13 breakfast - 120 cc's lunch - 240 cc's supper - 240cc's 3/26/13 supper - 240 cc's 3/27/13 lunch - 460 cc's The staff Progress Notes dated 3/20/13 through 4/1/13, related to the resident's fluid and food intake since the physician became aware of the residents poor appetite on 3/19/13 consisted of the following: ? On 3/20/13 at 9:56 a.m. still does not want to come out to meals. Has no real reason why. Ate 50% of breakfast and drank 240 cc's of juice. ? On 3/20/13 at 8:58 p.m. Resident remains in his/her room all this shift. Refused supper tray and wanted only a glass of cranberry juice. States, " I want everyone to please leave me alone so I can sleep." ? On 3/21/13 at 8:21 p.m. Resident refused to come out to supper. Did not eat any food on his/her tray. Resident did drink 120 cc cranberry juice. Stated he/she does not want anyone to bother him/her. ? On 3/22/13 in part: Continues to not feel well. Wants to stay in room for breakfast. ? On 3/22/13 at 9:33 a.m. the resident ate breakfast in room. Ate 50% and drank 240 cc. ? On 3/22/13 at 9:50 p.m. the resident refused to come out for supper. Stated he/she only wants cranberry juice. Asked him/her to please eat or he/she will begin to get very weak. States he/she as not hungry. ? On 3/23/13 at 9:48 p.m. the resident refused to come out for meals this shift. Poor appetite. ? On 3/25/13 at 10:25 a.m. the resident refused to come out to breakfast. ? On 3/26/13 at 8:30 a.m. the resident refused to eat breakfast this a.m. even when brought to room. ? On 3/27/13 at 12:12 p.m. the resident out of bed for lunch. ? On 3/28/13 at 2:10 p.m. (Notation by Social Services) Went into resident's room. Advised him/her that they needed to get up and take a shower and eat and drink something. Also advised resident that it may be a good idea for him/her to have a haircut. Resident continued stating he/she not wanting to get out of bed. ? On 3/28/13 at 11:36 p.m. Resident refused supper and refused oral cares. Drank 120 cc cranberry juice. ? On 3/29/13 10:37 a.m. Refused to eat breakfast. ? On 3/29/13 at 9:01 p.m. Resident refused supper. ? On 3/31/13 at 9:46 p.m. Resident refused to get out of bed and refused breakfast tray. Fluids encouraged. ? On 3/30/13 at 9:06 p.m. the resident stayed in room all shift. Refused supper tray. ? On 3/31/13 at 9 a.m. encouraged (resident) to go to dining room for breakfast, Resident requested breakfast then decided he/she did not want to eat. Stated "The orange juice made me sick." ? On 3/31/13 at 1:02 p.m. Resident refused lunch. ? On 3/31/13 at 9:08 p.m. Resident refused to come out for supper. Ate a few bites from tray and 120 cc cranberry juice. Tried to convince resident to come out to supper and to eat better as his/her body needs nourishment. Resident refused to come out of room and wants to be left alone. ? On 4/1/13 at 1:24 p.m. Refused meals. ? On 4/1/13 at 1:50 p.m. (Notation by social services) Director of Nursing and Social Services spoke with resident after nurse advised that resident without eating or drinking much of anything that day. Advised resident that he/she will need to go to the hospital if he/she will not get up and eat or drink anything. Resident continued to state,"I want to sleep." Advised resident that he/she as in bed for several days. Director of Nursing advised nurse to contact physician to transport to hospital. ? On 4/1/13 at 2:04 p.m. order received from the physician to send the resident to ER (emergency room ) for eval (evaluation) and treat by ambulance as resident continues to refuse to eat. ? On 4/1/13 at 4:28 p.m. the ambulance crew at the facility and report given. Resident notified that he/she was going to the hospital for refusing meals. The facility transfer sheet dated 4/1/13 to the hospital revealed the reason for the transfer as: refused to eat for several days. A facility Progress Note dated 4/1/13 at 7:00 p.m. revealed the facility received a telephone call from the receiving physician asking if the resident's (attending) physician aware of the resident's current status, asking for the next of kin and indicating the resident as severely dehydrated. The Director of Nursing (DON) stated the physician had not been made aware of the resident ' s declining condition of not taking fluids from 3/19/13 forward (3/19/2013 to present). The DON stated on 3/26/2013, she gave instruction for staff to give an update to the physician and the staff did not carry this out. The DON stated the nutritional note of 3/15/13 was the only thing in the clinical record to address the resident's nutritional status. The DON stated staff did not update the resident's plan of care related to the physician's orders [REDACTED]. Review of the plan of care dated 3/27/13 revealed no additional approaches developed to attempt to increase the resident's fluid intake with non - liquid foods such as popsicles, gelatin, or other similar foods to assure adequate fluid intake for Resident #2 for whom adequate fluid intake revealed difficulty to maintain. The physician history and physical report dated 4/1/2013 identified the assessment as dehydration, acute [MEDICAL CONDITION], elevated serum troponin, [MEDICAL CONDITION]. The laboratory tests revealed the following: Serum sodium-152 (normal 136-145), potassium 4.2 (normal), glucose 92 (normal), [MEDICATION NAME] 4.0 (normal). The history of the present illness reflected for the past 2 weeks, staff indicated that the resident has been " refusing to eat " and is " refusing all cares " ; in fact during the same time period the resident has not been out of bed. The resident normally walks around the nursing home without difficulty. The 4/1/2013 History and Physical report indicated the physician admitted Resident #2 into the Intensive Care Unit. On 4/15/2013 at 11:10 a.m. the resident's attending physician was interviewed. The physician stated Resident #2 was not eating or drinking well for a 2 week period while the resident was at the facility. The physician stated he reviewed the nurse's notes and the resident was clearly not eating or drinking. The physician stated the facility staff did not notify him of this and the resident was admitted into the hospital with a critical level of dehydration and in acute [MEDICAL CONDITION]. The resident was admitted into the intensive care unit. The physician voiced concern that the resident was not eating or drinking and the facility did not call him.