Every finding on record at State Center Specialty Care

Based on observation, staff interview, menus and policy review, the facility failed to follow the menu approved by the facility Dietician for the pureed meal. The staff failed to provide bread as listed on the menu. In addition, the staff didn't post the menu correctly after substitution changes. The facility reported a census of 36 residents. Findings include: A facility document titled, Diet Type Report, dated 1/20/26 revealed 3 residents required pureed diets. A facility document titled, Diet Spreadsheet, signed by the Dietitian on 10/13/25 outlined the cycling pureed menu for the lunch meal included, an eight-ounce servicing of king ranch chicken, a half cup serving of pinto beans, a half cup serving of corn, and a wheat roll. Those on regular diet included an ice cream sundae. A document titled, Fall/Winter 2025/26 dated 10/15/25 documented the lunch menu for regular/no added salt (NAS) posted in the main dining room for the residents to view, listed the noon meal as king ranch chicken, pinto beans, buttered corn, wheat roll, and an ice cream sundae. A document hung in the kitchen titled Puree Process, undated directed steps for puree meal preparation included step 4 to measure the total volume of food after it is pureed and step five directed to divide the total volume of the pureed food by the original number of portions on pureed diets also documented to reference the pureed scoop chart. During a continuous observation on 1/21/26 of the lunch meal service beginning at 11:38 AM to 12:35 PM began with the pureed meal process for 3 residents on a therapeutic pureed diets. Staff B, Dietary, added four, eight-ounce servings of ranch chicken to the Robot-coupe (brand name mixer to puree food). Staff B reported the serving size is an 8-ounce serving. Staff B measured 4 cups of the pureed chicken and added the mixture to the aluminum container in the steam table. During continuous observation beginning at 11:38 AM Staff C, Dietary, added 4 half cup servings of green beans to the Robot-coupe pureed. The measured 1-1/2 cup of green bean puree mix was placed in the aluminum pan in the steam table. During continuous observation on 1/21/26 beginning at 11:38 AM observed Staff C added the 4 half cup servings of pinto beans to the Robot-coupe pureed the mixture and measured 2 cups. Staff C placed the pinto beans in the aluminum pan and into the steam table . Observation of Meals served to residents began at 12:01 PM included Staff C, prepared 3 plates of pureed foods. Each plate included 8 ounce serving of the chicken mixture, a quarter cup of green bean pureed mixture and a quarter cup of pinto bean mixture. On 12/21/26 at 12:35 PM, Staff C and Staff E, Certified Dietary Manager (CDM), acknowledged they didn't add bread to the pureed diets and they should have. Staff C reported they substituted green beans instead of corn. Staff C acknowledged they used the same measurements directed by the menu that did not reflect the change of the food consistency to puree. Staff C acknowledged they had a pureed graph posted to use if needed, but no observation of them using the graph. Staff C reported they didn't have ice cream for the ice cream sundaes. They felt because the staff often served the residents ice cream for a snack, it caused them to run out. Staff C acknowledged the menu in the dining room informed the staff they had ice cream sundaes for dessert and they should have updated the menu with the substitutions. On 12/21/26 at 1:30 PM, Staff E reviewed the posted meal board in the dining room. They acknowledged they didn't have an accurate menu board and agreed some residents would have looked forward to the posted, but not offered, ice cream sundae. Staff E added they should post the diet changes. On 12/22/26 2:10 PM, the Administrator acknowledged the facility didn't post the food substitutions. They explained they needed improvements in the kitchen, would initiate a performance improvement plan to address food and processes in the kitchen. The undated policy provided by the facility, titled, Pureed Food Preparation Policy and Procedure instructed a resident on a pureed diet would receive the same items as the regular diet. All residents on a pureed diet shall receive the correct portions of pureed, meat, fruit, starch, fat, vegetables and dessert. The policy directed to review the menu for food items that need pureed. Bread and butter as planned on the menu may be added to the mixture, half of the bread and butter in the meat and half in the vegetable is suggested if the bread is not pureed separately.

Based on observation, record review, staff interview, and policy review the facility failed to revise a resident's Care Plan to indicate current transfer status for 1 of 12 residents reviewed (Resident #11). The facility reported a census of 36 residents. Findings include: On 1/20/25 at 10:57 AM, observed Resident #11 get transferred to restroom with the use of a standing mechanical lift and 2 staff. On 1/20/25 at 11:07 AM, watched a staff member transfer Resident #11 with a standing mechanical lift from the toilet to the wheelchair. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #11 required substantial/maximal assistance with ambulating and transfers. The used a walker or wheelchair for mobility. The MDS included diagnoses of kidney failure, history of femur fracture, schizophrenia, muscle weakness, unsteadiness on feet, and lymphedema (a build-up of fluid in the tissue of the body usually in the arms and legs). Resident #11's Care Plan Conference Progress notes dated 2/26/25, 5/20/25, 8/20/25, and 12/3/25, indicated they used a standing mechanical lift for transfers with activities of daily living (ADLs). Resident #11's Care Plan Focus related to ADLS included an Intervention that directed to transfer with an assist of one with a front wheeled walker. On 1/21/26 at 2:14 PM, the Director of Nursing (DON) reported Resident #11 used the standing mechanical lift for security due to increased anxiety and fear with transfers. The DON acknowledged Resident #11's Care Plan should include the use of the standing mechanical lift. Review of facility provided Care Plans, Comprehensive Person-Centered Policy, revised December 2016, directed assessments of residents are ongoing and Care Plans are revised as information about the residents and the residents' conditions change.

Based on clinical record review, policy review, resident, and staff interviews, the facility failed to assess and follow-up on a rash for 1 of 1 resident reviewed for skin concerns (Resident #16). The facility reported a census of 36 residents.Findings:Resident #16's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #16 required substantial to maximal assistance with toileting hygiene. The MDS included diagnoses of Parkinson's disease(a disorder which affected movement and caused tremors and stiffness), seizure disorder, and anxiety disorder.The facility policy Skin Tears-Abrasions and Minor Breaks, Care of, revised 2013, directed staff to assess the wound and surrounding skin for swelling, redness, drainage, and tissue healing progress. The SPN-Admit-Re-Admit note dated 1/5/26 at 3:33 PM indicated Resident #16 had a rash to the groin. The note lacked additional information related to the rash including the size, color, or any signs and symptoms of pain, itching, discomfort, or infection. Resident #16's January 2026 Medication Administration Record (MAR) listed an order dated 1/5/26 for nystatin (an antifungal medication) powder to the groin three times daily for candidal intertrigo (an inflammatory skin infection caused by candida yeast). Resident #16's Care Plan lacked information related to their groin rash. On 1/20/26 at 10:01 AM, Resident #16 explained he had an itchy groin since before admission to the facility. He added the itching hasn't got better. On 1/21/26 at 9:56 AM, Resident #16 stated his groin still burned. The facility lacked additional assessments of the area from 1/5/26 until 1/21/26, after the State Agency inquired about the rash.On 1/21/26 at 10:46 AM, Staff A, Registered Nurse (RN), reported she assessed the Resident #16's sacrum the day before but didn't observe his groin. She explained Resident #16 came in with a pretty bad excoriation in his groin and they put powder on him. She said they didn't take pictures of the area but they should have.On 1/21/26 at 1:39 PM, the Director of Nursing (DON) stated upon admission, the staff carried out a skin assessment and initiated a treatment. She said the staff monitored the skin concerns weekly. She added that is how they tracked the wound.

Based on clinical record review, observation, staff interview and policy review the facility failed to maintain head of bed elevated to avoid complications during tube feeding for 1 of 1 resident reviewed with a gastrostomy tube (G-tube), Resident #40. The facility reported a census of 36 residents. Findings include: Resident #40's Minimum Data Set (MDS) assessment dated [DATE] listed an entry date of 1/15/26. The Physician Order dated 1/16/26 directed to elevate the head of bed 30 degrees during feedings every shift.Resident #40's January 2026 Medication Administration Record (MAR) included an order with a start date 1/15/26 of give enteral feed with a formula flow rate at 65 milliliters per hour.The Care Plan Focus initiated 1/16/26 indicated Resident #40 had a tube feeding. The Goal documented she would remain free of side effects or complications related to the tube feeding. The Interventions directed to have the head of bed elevated thirty degrees during and thirty minutes after a tube feeding. On 1/21/26 at 9:12 AM observed Resident #40 in bed, with her head of bed slightly elevated. Resident #40 laid flat on her backside, under the slightly elevated part of the bed. At the time, she had her feeding tube running at 65 milliliters per hour. On 1/21/26 at 9:18 AM Staff C, Certified Nursing Assistant (C.N.A.), summoned to the room. When queried about Resident #40 positioning, Staff C responded they reposition her at least every two 2 hours and sometimes they would reposition her more frequently. Staff C exited the room, didn't address the head of bed elevation being lower than 30 degrees, and/or she laid with the feeding tube running at 65 milliliters per hour. On 1/21/26 at 9:20 AM Staff D, CNA, entered Resident #40's room. Staff D reported Resident #40 should sit up with her head of the bed elevated. Staff D explained Resident #40 should be up higher and would need help to get her higher in bed. Staff D reported they didn't know how to determine if they had the head of the bed at thirty degrees. On 1/21/26 at 9:24 AM Staff A, Registered Nurse (RN), came to Resident #40's room and said they would need to pause the feed while they reposition Resident #40 to have her head elevated. Staff A confirmed Resident #40's head of the bed should be at 30 degrees, but didn't know how to measure that degree. Staff A would check to see if the bed gave indication of degrees of elevation and ensure to notify the CNA staff.On 1/22/26 at 10:30 AM the Director of Nurses (DON) explained they added tape to the wall so that staff knew where to adjust her head of the bed elvation for the tube feeding. Facility policy titled Enteral Nutrition, revised November 2018 directed the provider would consider the need for supplemental orders included, head of bed elevation.

Based on clinical record review, resident interview, staff interview and policy review, the facility failed to contact a resident's representative after she had voiced, she had suicidal thoughts and a plan in place for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status score of 15 indicating intact cognition. The MDS further revealed the resident had diagnoses including anxiety disorder and encephalopathy (viral infection of the brain).The Care Plan initiated 3/20/25 revealed Resident #1 had a history of making comments about being dead with a goal to resolve thoughts of being better off dead or harming herself. Review of the Progress Notes dated 3/20/25 at 4:01 PM revealed Resident #1 had voiced comments of having suicidal thoughts and a plan. The resident stated she would put Visine on her food because she had seen that if ingested a person would have a heart attack within 15 minutes and it could not be traced. One-to-one (1:1) was initiated. The Progress Notes lacked documentation that the resident's representative was notified. During an interview on 10/9/25 at 9:20 AM, the Director of Nursing (DON) revealed the resident representative would be contacted if there was a change in a resident's condition and that generally they offer to reach out to others. The DON further acknowledged the Progress Notes for Resident #1 lacked documentation that she had offered to contact the resident's representative. During an interview on 10/9/25 at 10:00 AM, Resident #1 revealed that staff did not ask her if she wanted her representative contacted when she had suicidal thoughts and a plan when the 1:1 was initiated but preferred they would have done so. Facility policy titled, Change in a Resident's Condition or Status, revised February 2021 directed the facility to promptly notify the resident representative of changes in the resident's medical/mental condition and/or status. The policy further documented that unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status.

Based on observations, clinical record review, staff interview, resident interview and policy review the facility failed to ensure resident call light within in reach for 2 of 16 residents reviewed (Resident #13, #28). The facility reported the census is 35. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #28 documented a Brief Interview of Mental Status (BIMS) of 15 indicated intact cognitive impairment. The MDS documented diagnoses included cerebral infarction, cancer, diabetes, pain and anxiety disorder. The Care Plan initiated 12/16/23 documented Resident was at risk for falls, interventions included encourage to use call light for assistance. An observation on 11/18/24 at 11:46 AM, Resident #28 in room recliner in residents private room. A call light hung on the wall behind resident's television in front of the recliner, not reachable, television in front of the call light. In an interview on 11/18/24 at 11:47 AM, Resident #28 in room recliner did not have a call light within reach, relayed does not like to bother staff, and would get what she wanted. Resident #28 agreed in the event of a fall or emergency the call light was not within reach. In an observation on 11/19/24 resident viewed in room recliner throughout the day, no call light was within reach. In an observation on 11/20/24 at 1:46 PM with Resident #28 who sat in her recliner without a reachable call light, resident relayed there is one behind me at the head of the bed, acknowledged in the event of a fall or emergency may not be able to get to the call light. In an interview on 11/20/24 at 2:00 PM with the Director of Nursing (DON) agreed call lights should be accessible to residents. Facility policy titled Answering the Call Light, not dated, documented upon admission and periodically as needed, explain and demonstrate use of the call light to the resident, ask for return demonstration, be sure the call light is plugged in and functioning at all times, when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 44972 2. The MDS assessment dated [DATE] revealed Resident #13 had a BIMS of 15 which indicated intact cognition and had diagnoses that included atrial fibrillation, heart failure, diabetes, anxiety disorder, depression, respiratory failure, muscle weakness and shortness of breath. The resident used a wheelchair or walker for mobility and needed moderate assistance with toileting and personal hygiene and supervision with transfers. The Care Plan dated 10/10/24 revealed the resident was at risk for falls and had an activities of daily living (ADL) deficit. The Care Plan indicated the resident needed standby assistance with a walker for mobility and was independent in bed mobility, personal hygiene and toileting. In an observation on 11/18/24 at 3:04 PM, Resident #13 was seated in her recliner near the foot of her bed facing the wall watching TV. The call light was attached to the wall located at the head of the bed and not in the residents reach. The resident reported she sometimes attached the call light to the bottom of her bed so it was more easily accessible but stated she thought she could get up and get to it if needed. In an observation on 11/20/24 at 1:09 PM, Resident #13 was seated in her recliner eating her lunch. The recliner was located near the foot of the bed facing the wall. The call light was attached to the wall located at the head of the bed and not in the residents reach. The resident stated she was able to independently walk to the call light using her cane if she should need it. The resident acknowledged she was at times weak and at risk for falls and stated maybe she should ensure the call light was within her reach in the recliner. The resident stated the staff did not put the call light in her reach when she was seated in her recliner. In an observation on 11/21/24 at 9:26 AM, Resident #13 was seated in her recliner watching TV. The call light was attached to the wall at the head of the bed and not within the residents reach.

Based on facility document review, staff interview and policy review, the facility failed to comply with all applicable Federal Regulations regarding Medicare requirements governing billing practices by failing to serve a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) form 48 hours before the resident ended skilled services for 1 of 3 residents reviewed for liability and appeal notices (Resident #90). The facility identified a census of 35 residents. Findings include: Review of facility documentation for Resident #90 revealed the resident received Medicare benefits for skilled services 6/6/24 through 6/26/24. The facility failed to provide the required SNF ABN (Centers for Medicare and Medicaid Services (CMS) form 10055), to inform the resident of the potential liability if skilled serves continued, 48 hours prior to skilled services ending. In an interview on 11/20/24 at 9:47 AM, the Administrator stated it was the expectation the ABN's be completed timely and accurately. He reported there had been a change in staff and 1 of the 3 residents reviewed was not completed timely or accurately. He reported training had been initiated to ensure the ABN's were completed appropriately moving forward. In a facility provided policy titled Medicare Advanced Beneficiary Notice dated 4/21, it stated the following: If the admissions coordinator or business office manager believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee-for-Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). a. The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered not medically reasonable and necessary, or custodial. b. The resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility.

Based on record review, resident interview, staff interview and policy, the facility failed to ensure quarterly interdisciplinary team meeting with inclusion of the resident to discuss resident changing goals and revisions to the care plan for 1 of 2 residents reviewed, (#28). The facility reported a census of 35 residents. Findings included: The Minimum Data Set (MDS) dated [DATE] for Resident #28 documented a Brief Interview of Mental Status (BIMS) of 15 indicated intact cognitive impairment. The MDS documented diagnoses included cerebral infarction, cancer, diabetes, pain and anxiety disorder. The Care Plan included initiated 12/15/23 documented intervention to review resident choices quarterly and as needed. In an interview on 11/18/24 at 11:48 AM, Resident #28 relayed recalled going to only one care conference meeting. Stated, wanted to attend and inquired about how to know when the meetings occurred. On 11/20/24 at 10:15 AM, Social Services, Staff D relayed she is now responsible for ensuring care conference meetings for quarterly review and MDS updates. Relayed started the process about three months ago. Staff D stated had a new process and not sure how process was handled in the past, could not locate a meeting book or sign in sheets to verify the care conference meetings were done. On 11/21/24 at 9:00 AM, the Administrator revealed two documents to support resident involvement in a care conference on 12/15/23 and on 8/29/24. Administrator relayed could not locate any other documents to indicate Resident #28 was invited or took part in any other quarterly care conferences. The Administrator stated the expectation is the resident should have been included in quarterly reviews. Policy titled, Resident Participating, Assessment/Care Plans, revised February 2021 documented: The social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices to include a. Date, time and location of the conference. b. Name of each person contacted and the date was contacted. c. Method of contact. d. Input from the resident/representative if not able to attend. e. Refusal of participation if applicable. f. The date and signature of the individual making the contact.

Based on resident interview, staff interview, record review and policy the facility failed to follow professional standards of medication administration leaving medication at bedside for 1 of 1 resident's (Resident #6). The facility reported a census of 35. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented the diagnoses for Resident #6 included diabetes, seizure disorder or epilepsy, psychotic disorder, schizophrenia, pain, respiratory disease, and depression. The resident's Brief Interview for Mental Status (BIMS) score was 14, indicated is cognitively intact. A Care Plan initiated 5/28/21 for Resident #6 documented resident had a mood problem related to schizophrenia, delusional disorders, and major depressive disorder requires medications included antidepressants, anticoagulant a term for blood thinners, antianxiety, antipsychotic, hypoglycemic and antihypertension medications. Staff to administer the medications as ordered observe for adverse side effects, document and report to the physician. During an observation on 11/19/24 at 8:45 AM two clear medication cups with various pills of different color and sizes sat on Resident #6 bedside. Resident #6 was lying in bed appeared to be sleeping with eyes closed. On 11/19/24 at 8:46 AM Resident #6 quired about the pills observed in two separate cups on the bedside table. Resident #6 relayed they are mine and am not ready to get up yet, nursing staff summoned. On 11/19/24 at 8:47 AM Certified Medication Aide, (CMA) Staff A came to the room, resident took all pills. Staff A relayed did set up resident medications this morning in two separate medication cups because there are so many. Stated gave resident the nasal spray, inhaler, eye drops and left. Stated resident is usually good to get up and take them right away, did not see her take the pills, had assumed resident would take them. On 11/19/24 PM at 4:00 PM Administrator and Director of Nursing (DON) notified, feedback relayed that medications should not be left unattended, staff to wait and observe to ensure medications are taken. Resident #6 is not approved to self administer own medications. Facility policy titled Administering Medications, not dated revealed residents may self administer their own medications only if the attending physician in conjunction with the team has determined resident have the decision making capacity to do so safely.

Based on observations, clinical record review, staff interview and resident interview. The facility failed to ensure resident treatment per the physician order for 1 of 3 residents reviewed (Resident #28,). The facility reported the census is 35. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #28 documented a Brief Interview of Mental Status (BIMS) of 15 indicated intact cognitive impairment. The MDS documented diagnoses included cerebral infarction, cancer, diabetes, pain and anxiety disorder. The Care Plan included initiated 12/16/23 documented focus had potential for impairment to my skin related to fragile skin and at risk for potential skin and soft tissue infection, interventions included to assess for signs and symptoms of infection. The Medication Administration Records (MAR) documented an order to start on 10/24/24 for salicylic acid external liquid, apply to toes topically one time a day for wart, soak wart in warm water for 5 min, dry area and apply one drop, let dry. The treatment was not done as ordered daily from 10/24/24 to 11/21/24. The Progress Notes documented revealed drug was unavailable. On 11/18/24 at 11:57 AM, Resident #28 stated has pain in her toe, scaled at 2 or 3 on a scale of 10. Resident #28 stated staff looked at it, not sure if it was a podiatrist, did recall was said, would get something for it, no one ever did, relayed it is going on two months. In an interview on 11/19/21 at 2:30 PM, the Director of Nursing (DON) queried about process's when a medication is not available from the pharmacy. The DON relayed had another provider if that provider could not ensure delivery the provider would be notified to get another alternative order or to hold. In a follow up interview on 11/21/24 at 12:45 PM the DON acknowledged resident had not had the treatment ordered on 10/24/24 and called the pharmacy yesterday and was told by the pharmacy needed additional approval and thought they would be sending it out today. Also relayed, thought had called the pharmacy about this prior, could not provide documentation of any alerts to the provider or the pharmacy that the medication was not available.

Based on clinical record review, observation, staff interview and facility policy review, the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents when providing medications and treatments. The facility reported a census of 35 residents. Findings include: 1. In an observation on 11/19/24 at 7:23 AM, Staff A, Certified Medication Aide (CMA) failed to perform hand hygiene prior to donning gloves to administer Timolol medicated eye drops to Resident #4. She was further observed to touch several items with gloved hand prior to administering the eye drops to the resident. Upon completion of administration per facility protocol, Staff A, removed her gloves but failed to perform hand hygiene. 2. In an observation on 11/19/24 at 7:25 AM, Staff A, CMA was observed to drop Resident #24's Amlodipine tablet on the top of the medication cart. Staff A picked the tablet up with her ungloved hand and placed it into the medication cup with the resident's other medications and administered them to the resident. She failed to discard the tablet and obtain a new one for the resident. 3. In an observation on 11/19/24 at 7:25 AM, Staff A, CMA failed to perform hand hygiene prior to setting up and after administering Resident #24's morning medications. She further failed to perform hand hygiene prior to donning gloves to assist resident with Fluticasone nasal spray. She was observed to touch several items with donned gloves prior to administering the nasal spray. Upon completion of administration per facility protocol, Staff A removed her gloves but failed to perform hand hygiene. 4. In an observation on 11/19/24 at 7:37 AM, Staff A, CMA failed to perform hand hygiene prior to setting up and after administering Resident #35's morning medications. She further failed to perform hand hygiene prior to donning gloves to assist resident with Stiolto Respimat inhaler. She was observed to touch several items with donned gloves prior to assisting the resident with the inhaler. Upon completion of administration per facility protocol, Staff A removed her gloves but failed to perform hand hygiene. 5. In an observation on 11/19/24 at 7:48 AM, Staff A, CMA failed to perform hand hygiene prior to setting up and after administering Resident #31's morning medications. She further failed to perform hand hygiene prior to donning gloves to assist resident with Refresh eye drops. She was observed to touch several items with donned gloves prior to administering the eye drops. Upon completion of administration per facility protocol, Staff A removed her gloves but failed to perform hand hygiene. In an interview on 11/21/24 at 10:30 AM, the Director of Nursing (DON) stated it was the expectation all medication staff perform hand hygiene prior to and after each medication pass. The DON stated staff were to perform hand hygiene before and after donning gloves as well. If a medication was dropped during a medication pass, staff were to don a glove and dispose of it per policy and obtain a new medication to administer to the resident. Review of a facility provided policy titled Administering Medications revised April 2019 stated staff were to follow established infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observations, staff interview, resident interview and policy review the facility failed to ensure a clean, sanitary environment in a kitchen storage room and failed to ensure a clean comfortable environment for 1 of 14 resident rooms (Resident #28). The facility reported the census is 35. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #28 documented a Brief Interview of Mental Status (BIMS) of 15 indicated intact cognition. The MDS documented diagnoses included cerebral infarction, cancer, diabetes, pain and anxiety disorder. The Care Plan included initiated 12/16/23 documented Resident is at risk for falls, interventions included needed a safe environment without clutter. An observation on 11/18/24 at 11:46 AM Resident #28 in room recliner, next to the recliner on the floor was a pile of paper, books, clothing items, open candy, open box of snack food and additional clutter. On the sink counter was more candy, open food, clothing and papers piled. A small square counter refrigerator observed on the floor. In an interview on 11/18/24 at 11:48 AM Resident #28 reported wished staff would sweep or mop once in a while, had not done cleaning since arrived, relayed takes own trash to the larger receptacle, hated to bother staff. On 11/19/20 at 3:20 PM Resident #28 sat in room recliner observed again the counter top, both sides of the sink were piled with food, open caramel popcorn, various kinds of candy boxes and open packages, decor, papers and other personal items piled. Resident relayed staff have never ever come to help me clean my room, would love if could get help sorting some of that, pointing to the counter. In addition relayed maintenance staff is very busy, does not want to bother anyone. On 11/20/24 at 4:00 PM resident in room recliner, acknowledged again, no housekeeping had been done in the room and could not recall ever having help with cleaning. In an interview on 11/21/24 at 10:23 AM with Maintenance Supervisor, Staff B relayed was responsible for housekeeping schedule, all rooms were clean alternating schedule with two housekeepers that collaborated so no rooms were missed. Staff B expected a resident to have staff assistance with organization as the wanted. Relayed all rooms are deep cleaned on a rotating schedule. Staff B entered Resident #28 room and acknowledged work was needed with the clutter. Resident #28 present and expressed her desire to have housekeeping and assistance with organization. 2. In an observation on 11/18/24 at 10:00 AM during a tour of the kitchens dry storage room viewed a steel rolling rack against the wall, visible crumbs, powder, plastic cup lids, spoon and an open torn package of rodent poison on floor. A desk next to rack had a paper debris underneath. Also observed appearance of mice droppings along the baseboard. In an interview on 11/18/24 at 11:00 AM with the Kitchen manager, Staff C who relayed has not had any issues with mice in months, issue corrected with replacement of door strips on bottom of doors that were missing, acknowledged concern of debris and mouse droppings in the food storage room and responded the storage room should have been clean. In an interview on 11/18/24 at 4:00 PM with the Administrator relayed pest control was called and resolved mice issue quickly months ago, would be forwarding pest control report and invoices, would have expected the floor to have been clean. Facility policy titled, Cleaning and Disinfecting Residents room, Revised August 2013 included housekeeping of floors, tabletops will be cleaned on a regular basis, included disinfected. Personnel should remain alert for evidence of rodent activity (droppings) and report such findings.

Based on clinical record review, policy review, resident, and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 4 residents reviewed (Resident #3). The facility identified a census of 33 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of anemia (low blood iron), anxiety and depression. The MDS listed Resident #3 as independent with activities of daily living (ADLs). The Care Plan Focus revised 1/29/24, reflected Resident #3 used antidepressant medication, related to her depression. The Interventions directed the following: *Monitor behaviors such as anxiety, agitation, and restlessness. *Nonpharmacological interventions: watching tv and talking with son. An Incident Report dated 7/19/24 at 9:30 AM listed an Allegation of Abuse. Resident #3 informed the nurse the overnight Certified Nursing Assistant (CNA) told her to sit her ass down and the situation happening was none of her business. The nurse assessed Resident #3 who reported it didn't affect her and it didn't hurt her feelings because she knew she was in the right. The facility suspended the staff member pending investigation and reported to the Department of Inspections Appeals and Licensing (DIAL). The Incident, Accident, and Unusual Occurrence Note dated 7/19/24 at 11:39 AM reflected Resident #3 informed the nurse the overnight staff told her, sit her ass down and the situation happening was none of her business. Resident #3 denied any hurt feelings or being affected by what they said. Resident #3 stated she knew she was in the right. The facility reported as needed, made the resident and physician aware. Interview on 10/15/24 at 4:00 PM, Resident #3 confirmed the staff member made those comments back in July. She hasn't seen the staff member since and the staff at the facility treat her with dignity and respect. Interview on 10/16/24 at 4:30 PM, the facility Administrator verified they expected the staff to treat residents with dignity and respect at all times. The Dignity Policy Statement dated February 2021, directed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The section labeled Policy Interpretation and Implementation instructed residents are treated with dignity and respect at all times. The staff must speak respectfully to residents at all times.

Based on resident and staff interviews, and facility policy review the facility failed to assure one (1) staff member remained awake and in full work status while working and failed to assure staff not use an e-cigarette ([NAME] pen) while in the facility and/or during provision of direct cares. The facility reported a census of 39 residents. Findings Include: During an interview 12/12/23 at 2:28 p.m., Resident #1 (identified by the facility as cognizant) indicated one (1) night Staff A, Certified Nursing Assistant (CNA), entered her room and slept in her recliner. The resident indicated there had been another night the same staff member used a [NAME] pen and smoked it in her room. The resident asked the staff member to not [NAME] in her room and the staff member stated, you can not smell it. During an interview 12/15/23 at 11:18 a.m., Staff C, Licensed Practical Nurse (LPN) confirmed she witnessed Staff A as she slept on the couch in the lounge area while in work status. Staff C reported the incident to the Director of Nursing (DON) During an interview 12/20/23 at 8:37 a.m., Staff A, confirmed she slept in the facility while in work status but denied using a [NAME] pen at any time but confirmed she smoked cigarettes. The staff member indicated she witnessed other unknown staff members as they vaped in the facility. During an interview 12/20/23 at 11:10 a.m., Staff B, CNA confirmed she witnessed Staff A as she slept on the couch in the lounge area while in work status. Staff B indicated she knew Staff A used a [NAME] pen but she had been unaware if Staff A smoked the pen in the facility. According to an email 12/21/23 at 11:40 a.m. the Administrator indicated the facility's undated Smoking, Vaping and Tobacco Use Policy and the facility's undated Rest and Meal Breaks Policy included the following: a. The smoking, vaping and tobacco use policy directed the facility staff that smoking of any product, including e-cigarettes ([NAME] pens) had been prohibited by Iowa law inside every Care Initiatives buildings. b. The rest and meal breaks policy directed the facility staff that no sleeping had been allowed during paid breaks.

Based on clinical record review, staff, resident, and police officer interviews and review of the facility's Resident Rights the facility failed to treat 1 of 3 residents with dignity and respect while requesting cares (Resident #1). The facility reported a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment form dated 6/11/23 identified Resident #1 with diagnosis that included a cerebrovascular accident (CVA) and prediabetes. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), required extensive assistance of two (2) staff with bed mobility, transfers, ambulation, toilet use and frequently incontinent of urine. An Incident Report form dated 8/31/23 at 3:14 p.m. included the following documentation: a. At 9:30 p.m., staff assisted the resident to bed. At 11:30 p.m. the resident pulled her call light for assistance to the bathroom. Staff A, Certified Nursing Assistant (CNA) responded and told the resident there had been no way she had to go to the bathroom again but assisted her to the bathroom. Approximately an hour or an hour and 1/2 later the resident pulled her call light again. Staff A responded and again stated there had been no way she had to go to the bathroom again and walked out of the resident's room. The resident then laid in bed and peed herself which made her not feel like a person. A Follow Up Question Report dated 8/27/23 through 9/2/23 included the following documentation: a. On 8/30/23 at 9:28 p.m., and 10:36 p.m., the same staff member assisted the resident to the bathroom. There had been no further documentation indicating the staff toileted the resident the remainder of the night. During an interview 12/12/23 at 2:28 p.m., Resident #1 indicated on the date of the incident, staff assisted her to the bathroom around midnight. At around 2 a.m. she used her call light for assistance to the bathroom again. Staff A responded and stated, there had been no way she had to go to the bathroom again, turned off the resident's call light and left the room. The event caused incontinency and made the resident mad. During an interview 12/20/23 at 11:02 a.m., Staff B, CNA indicated the night in question she observed Staff A as she entered the resident's room the first time and noted she had been in the room long enough to have assisted the resident to the bathroom. Staff B reported, also noted the resident's call light on the 2nd time and observed Staff A as she responded however the staff member had not been in the room long enough to have toileted the resident and then her call light had been shut off. Review of the facility's Resident's [NAME] of Rights form included the following: a. A facility treated each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life and recognized each resident's individuality.

Based on observation, resident interview, family interview, and staff interview, the facility failed to maintain a homelike environment related to urine odors in the hallways and resident rooms, stains and debris on the hallway carpet, scratches on and holes in the walls of resident rooms. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #13 revealed the resident had a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. The MDS documented the resident had a diagnosis including Fragile X syndrome and was independent with activities of daily living (ADLs). The Care Plan revised 11/3/22 for Resident #13 revealed the resident had impaired cognitive function related to diagnosis of Fragile X syndrome and directed staff to communicate with the resident, his family, and caregivers regarding his needs. The clinical record documented Resident #13 resided in room C26-A. During an interview 8/28/23 at 1:33 PM Resident #13's emergency contact #1 stated he was at the facility last Friday and reported a concern that his brother's room smelled like urine due to his roommate. 2. The MDS dated [DATE] for Resident #17 revealed the resident had a BIMS of 10 indicating moderately impaired cognition. The MDS documented the resident had a diagnosis of cerebrovascular accident (CVA) and required assistance with all ADLs. The Care Plan revised 12/6/22 for Resident #17 revealed the resident had impaired thought process related to CVA and directed staff to communicate with the resident, his family, and caregivers regarding his capabilities and needs. The clinical record documented Resident #17 resided in room A6-B. During an interview 8/28/23 at 1:31 PM, Resident #17 reported the urine smell in his room was from his roommate. During the interview observed multiple linear scratches on the wall behind Resident #17's recliner. 3. The MDS dated [DATE] revealed Resident #24 had a BIMS of 5 indicating severely impaired cognition. The MDS documented the resident had a diagnosis of non-Alzheimer's dementia and required extensive assistance with toilet use, personal hygiene, and dressing. The MDS further documented the resident was not on a toileting program. The Care Plan initiated 7/26/23 documented Resident #24 had a mood problem related to dementia and record mood to determine if related to external causes such as medication, treatments, or concern over diagnosis. The clinical record documented Resident #24 resided in room A6-A. During an observation at 8/28/23 at 1:31 PM observed Resident #24 enter his room, begin to pull down his pants and enter the bathroom independently. During an interview 8/30/23 at 7:10 AM, Staff D, Registered Nurse (RN) acknowledged the A hallway smelled like urine and stated Resident # 24 used a urinal and sometimes he would spill it resulting in the urine smell. 40907 4. An MDS dated [DATE], revealed that Resident #22's diagnoses included cerebral infarction (stroke). This resident's BIMS score was 0 out of 15, which revealed severely impaired cognition. Resident #22 required extensive assist of 2 for toilet use and personal hygiene. On 8/27/23 at 11:37 AM, Resident #22 was lying in bed. There were disposable pads on the floor that were partially wet. A strong smell of urine was in the room. Staff B, CNA stated that Resident #22 peed everywhere. She stated that Resident #22 would not urinate in his attends. She added he just pees where ever. When Staff B was asked about how Resident #22's roommate (Resident #13) felt about this, Staff B stated that Resident #13 was oblivious to the smell of urine. Staff B acknowledged the odor. On 8/28/23 10:18 AM, the Director of Nursing (DON), acknowledged the concern with 2 rooms smelling of urine, and of the roommates having to live in these rooms. On 8/28/23 at 9:48 AM, the smell of urine was strong in Resident #22's room. A picture taken of flooring in Resident #22's room, revealed discolored and dirty flooring and floor board. 5. An MDS dated [DATE], revealed that Resident #9 had a BIMS score of 15 out of 15, which revealed his cognition was intact. On 8/27/23 at 3:06 PM, Resident #9 stated that they clean his room when they can keep the staff to clean it. The room, the walls, and the floors were dirty. During an observation 8/27/23 at 10:20 AM, observed multiple stains, a variety of debris including dirt, shredded toilet paper, and dead crickets on the carpet in the resident hallways and resident hallways A and C smelled like urine. On 8/28/23 at 3:15 PM, concerns were reviewed regarding strong urine odor in rooms and down hallways, holes in walls, no housekeeping on the weekend, carpet stains, large stain by breakroom on the hall carpet, and dead crickets, with Maintenance Supervisor and the Administrator. They acknowledged the strong urine odors down Halls A and C. They stated they are trying different things but had not found anything that would mask the odor coming from Resident #22's and Resident #24's room. The Maintenance Supervisor stated he just saw a cricket that morning, and it was the first time he had seen one. He contacted Eco Lab and they were coming out. The Administrator stated that the facility is backed up to a [NAME]. He stated that Eco Lab comes in regularly for maintenance and also comes in when needed as noted by today's phone call to them. They stated that they just had the carpets deep cleaned last Monday (8/21/23). They acknowledged the holes in the dry wall. The Administrator stated they are trying to hire more staff. He stated that administration staff try to assist on the weekend with keeping the building clean. He stated that the DON worked overnight Saturday into Sunday and did surveillance. He stated that the large carpet stain outside of the breakroom was related to the roof leaking. He stated they had repaired the roof recently. He stated the facility had 2 bids out at the time for someone to come in and redo the breakroom as it was damaged as well. He stated that they have requested hallway carpeting to be replaced from their corporation, but it had been denied at this point. On 8/30/23 at 2:52 PM the Administrator documented via email that the facility did not have environmental policies related to odors, holes in the walls, and carpet stains.

Based on observations, interviews, and record review, the facility failed to correctly document resident assessments in the Minimum Data Set (MDS) for 1 out of 16 residents reviewed (Resident #1). Resident #1's most current MDS revealed she required an assist of 1 for ADLs, when she was independent with most of her ADLs. The facility reported a census of 35 residents. Findings include: An MDS dated [DATE], documented that this resident's diagnoses included schizophrenia and morbid obesity. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognition. The MDS documented that this resident required staff assistance of 1 for bed mobility, transfer, dressing, and toilet use. An MDS dated [DATE], documented that this resident was independent in bed mobility, transfer, and toilet use. According to the MDS's above, this resident had a decrease in bed mobility, transfer, and toilet use from independent to supervision of 1. On 8/27/23 at 2:53 PM, Resident #1 stated that she does everything for herself and she gets herself ready. On 8/28/23 03:45 PM, Staff A, Registered Nurse (RN), stated that this resident likes her privacy. Staff A stated that Resident #1 toilets herself but will call staff if she does have an accident. She is very clean per staff and uses many wipes after toileting. On 8/29/23 at 1:10 PM, the MDS Nurse stated that she wasn't sure when this resident was an assist of 1 but really this resident was safe to be independent. On 8/29/23 at 1:30 PM, the Director of Nursing (DON), acknowledged the concern with the MDS documentation not reflecting the needs of this resident. A Certifying Accuracy of Resident Assessment policy dated as reviewed on 11/2019, directed the following: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and Implementation 1. Any health care professional who participates in the assessment process is qualified to assess the medical, functional, and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. 4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse. 5. Inquiries concerning the signing of the MDS should be referred to the Assessment Coordinator, Director of Nursing Services, or to the Administrator. 6. Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action.

Based on observations, interviews, and record review, the facility failed to correctly document/revise resident needs and interventions in the Care Plan for 2 out of 16 residents reviewed (Resident #1 and Resident #20). Resident #1's Care Plan directed that she required an assist of 1 for ADLs, when she was independent with most of her ADLs. Resident #20's Care Plan directed staff that he required assist of 1 for showers, when he required set up help only. The facility reported a census of 35 residents. Findings include: 1. A Minimum Data Set (MDS) for Resident #1 dated 7/20/23, documented that this resident's diagnoses included schizophrenia and morbid obesity. A Brief Interview for Mental Status documented a score of 15 out of 15, which indicated intact cognition. The MDS documented that this resident required staff assistance of 1 for bed mobility, transfer, dressing, and toilet use. A Care Plan with interventions dated 12/23/22, directed staff that Resident #1 needed assistance of 1 staff for transfers, ambulation, toilet use, bathing, dressing, and personal hygiene. On 8/29/23 at 8:16 AM, in all observations thus far during this survey, Resident #1 had been ambulating independently with a walker. No assistance from staff had been provided. On 8/29/23 at 1:10 PM, the MDS Nurse stated that she updated Resident #1's Care Plan to independent. She stated she wasn't sure when Resident #1 was an assist of 1, but really this resident is safe to be independent. When the MDS Nurse was asked about this earlier on this day (approximately 9:00 AM), the MDS nurse had said she would need to educate the staff about assisting this resident with cares, ambulation, transfers, and so on. The MDS nurse stated that this resident won't wait for staff. She stated that she would look into this more. 2. An MDS for Resident #20 dated 8/17/23, documented that this resident's diagnoses included Parkinson's and syncope and collapse. A BIMS documented a score of 12 out of 15, which indicated this resident's cognition was moderately impaired. This resident was independent for bathing with set up help only. A Care Plan with an intervention dated 12/26/22, directed staff that Resident #20 required assistance of 1 staff person. On 8/29/23 at 1:10 PM, the MDS nurse stated that she updated his Care Plan to be independent with set up help for bathing. When the MDS nurse was asked earlier about this today (approximately 9:00 AM), the MDS nurse had said she would have to look into this more. On 8/29/23 at 1:30 PM, the Director of Nursing (DON), acknowledged the concern with MDS and Care Plan not matching, and the Care Plan not being updated. A Care Plans/Comprehensive and Person-Centered policy dated as revised in December 2016, directed staff that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interviews and record review, the facility failed to provide a shower twice a week for 1 of 3 residents reviewed (Resident #20). The facility reported a census of 35 residents. Findings include: An MDS dated [DATE], documented that this resident's diagnoses included Parkinson's and syncope and collapse. A BIMS documented a score of 12 out of 15, which indicated this resident's cognition was moderately impaired. This resident was independent for bathing with set up help only. A Care Plan with an intervention dated 12/26/22, directed staff that Resident #20 required assistance of 1. A POC Response History (Certified Nurse Aide documentation of residents' activities of daily living) with a 30 day look back was printed on 8/30/23 at 11:19 AM. It documented that this resident was to receive a shower on Tuesdays and Fridays. It documented that Resident #20 did not receive a shower and was not offered a shower from 8/15/23 to 8/22/23. It documented that on 8/25/23 a shower was 'not applicable' by Staff B, CNA. It documented that he had not been offered another shower nor received another shower up to the date and time it was printed. On 8/29/23 at 10:27 AM, a call was made and a text was sent to Staff B requesting a call back. She did not return the call. On 8/29/23 at 4:00 PM, the MDS Nurse, acknowledged that this resident was not given his twice weekly showers. She stated he should have had another shower between 8/15/23 and 8/22/23. When asked about the documentation of 'not applicable' on 8/25/23, the MDS Nurse stated it meant that Staff B did not provide nor offer Resident #20 a shower. When asked if Resident #20 has had a shower since 8/22/23, the MDS Nurse stated he had not. The MDS Nurse acknowledged that he should have had a shower on Tuesdays and Fridays (8/18/23 and 8/25/23) and was due for one on this day 8/29/23. On 8/30/23 at 2:00 PM, the MDS Nurse verified that this resident did receive a shower earlier on this day (8/30/23) but had not documented it yet. A Care Plans/Comprehensive and Person-Centered policy dated as revised in December 2016, directed staff that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was to be developed and implemented for each resident.

Based on observations, interviews, and record review, the facility failed to provide wound care while following infection control guidelines, for 1 of 1 resident reviewed (Resident #33). Staff C, Certified Medication Aide (CMA), failed to remove her gloves, sanitize her hands, and apply new gloves after removing a soiled dressing. Staff C failed to properly dispose of a dressing that had discharge from a wound on it. The facility reported a census of 35 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that Resident #33's diagnoses included non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 3 out of 15, which indicated this resident's cognition was severely impaired. It documented that this resident required extensive assist of 2 for bed mobility, transfers, and personal hygiene. A Treatment Administration Record for the month of August 2023, directed staff to apply Iodine every day to the right heel until healed for deterioration. A Care Plan for Resident #33 included: -a Focus Area revised on 8/25/23, that directed this resident had skin impairment which included a right heel pressure ulcer. -a Goal dated 8/14/23, directed that Resident #33's pressure injury would show signs of healing and would remain infection free. -an Intervention dated 8/25/23, directed staff that this resident was to have heel protectors on to bilateral lower extremities. On 8/29/23 at 8:42 AM, Staff C, CMA, walked into room with gloves on and a medicine cup with iodine and a cotton ball in it. She removed Resident #33's left heel protector and looked at the heel, there was a dressing on it. She then removed the right heel protector and looked at the right heel saw there was a dressing on it. She then stated that she didn't realize there was a dressing on wound and she'd have to go and get another dressing. Staff C then left the room. On 8/29/23 at 8:50 AM, Staff C returned to Resident #33's room with a dated dressing. Staff C did not know what the dressing was called. She washed her hands then applied gloves. She looked at the resident's right heel and removed the dressing. The wound was approximately 2 inches in diameter. When the dressing was removed macerated skin(softening and breaking down of skin resulting from prolonged exposure to moisture) tissue and drainage stuck to the dressing that had covered about 1/2 of the wound. The dressing was thrown in the garbage. It was not folded on to itself or placed in a biohazard bag. The CMA then touched several items around the room, then grabbed a paper towel turned on the sink, wetted down part of the paper towel and dabbed around the edges of the wound with the moistened edge of the paper towel. She then took the cotton ball and dabbed the wound along the edges with iodine. She threw the paper towel in the garbage along with the cotton ball and medicine cup that the cotton ball with iodine was in. Staff C then removed her gloves and threw them in the garbage. She then washed her hands. When asked if she should have done anything after removing the dressing, she said she should have removed her gloves, when asked if there was anything else she should have done, she said she should have washed her hands. This CMA acknowledged that there was a good amount of macerated skin and blood/drainage on the dressing. When asked if there was a bag she should have disposed of the dirty dressing in, she stated no, there wasn't. Staff C stated that they are just to dispose of dressings in the trash. This CMA did not carry the trash out with her. On 8/29/23 at 1:53 PM, the Director of Nursing (DON), acknowledged that this resident had developed a pressure ulcer and the other 2 pressure ulcers have worsened. When told about the above observation, she stated that the wound needs to be cleaned between removal of a dressing and application of a new dressing. She acknowledged not removing gloves and sanitizing her hands between clean and dirty was an issue. She acknowledged that throwing the dressing with wound discharge into the trash and then not removing the trash bag out of the room was also an issue. A Wound Care Policy dated as revised on 10/2010, directed the following: Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have PRN orders for pain medication to be administered prior to would care. 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc., with alcohol pledget before opening, as necessary. (Note: This may be performed at the treatment cart.) Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 1. Dressing material, as indicated (i.e., gauze, tape, scissors, etc.); 2. Disposable cloths, as indicated; 3. Antiseptic (as ordered); and 4. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 8. Apply treatments as indicated. 9. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on clean field. 10. Remove the disposable cloth next to the resident and discard into the designated container. continues on next page 11. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed. 13. Place the call light within easy reach of the resident. 14. Use cleansing wipe to wipe overbed table. 15. Return the overbed table to its proper position. 16. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. 17. Wash and dry your hands thoroughly. 18. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on clinical record review, resident and staff interviews, the facility failed to provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the Nursing Staff did not complete a thorough assessment and provide treatment according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #23). Resident #23 noted with multiple bruises which had not been assessed, documented nor were additional interventions put in to place by/at the time of the Survey. Resident #23 had bruises in different stages of healing. The facility reported a census of 38. Finding Include: 1. Resident #7's Minimum Data Set (MDS) Assessment, dated 4/14/22, revealed Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident's cognition intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Care Plan dated 4/20/22 revealed directive for staff to give anti-hypertensive medication as ordered. There was no directive for treating of chest pain with [MEDICATION(S)], and no direction for staff to follow for when to monitor blood pressure or when to call physician. During an interview on 7/5/22 at 2:30 PM, resident #7 stated they facility ran out of the evening blood pressure medication and he experienced chest pain and a headache at the base of his skull. Resident #7 stated it felt like when he had his stroke and described the feeling as the blood pressure was frightening, my head was throbbing and I could hear the whooshing sound. Resident #7 stated the nurse brought the evening medication and the resident noticed the blood pressure pill was not there. Resident #7 stated when he inquired about the medication, the nurse stated they ran out and you're not the only one this happens to. Resident #7 stated his blood pressure was over 200 and he called 911. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress Notes revealed on 6/9/22, resident #7 experienced stabbing chest pain, Tylenol given, physician not notified. Resident #7 experienced chest pain again on 6/13/22 and 6/15/22 when the physician was sent a fax. The fax was answered on 6/16/22 with the new order for Nitro for chest pain. Resident was monitored on 6/17/22 through 6/20/22 with no reoccurring chest pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress Notes dated 6/24/22 revealed at 6:58 PM, the medication [MEDICATION(S)] for high blood pressure was not available. At 11:00 PM, staff was called to resident #7's room, resident was agitated, reported a headache, feels exactly like when I had my stroke, blood pressure 220/143, heart rate 87. Resident #7 calling police. At 11:10 PM nurse called the Physician Assistant (PA) and received an order to send resident #7 to the hospital. At 11:15 PM the nurse called the Emergency Medical Service (EMS) and they were on the way already. At 11:35 PM EMS arrived to the facility. Progress Notes dated 6/25/22 at 4:05 AM, revealed resident #7 returned to the facility, blood pressure 164/111, resident #7 complained of headache. There are no further cardiac assessments nor follow up completed. On 6/30/22 at 2:27 PM the physician seen resident #7. Review of a document from the local hospital - Ambulance Service Transport Record dated 6/24/22, contained a paragraph titled History of Present Event revealed that resident #7 developed chest pain and headache after 7:30 PM described chest pain as stabbing and reported the facility had trouble adjusting resident's blood pressure medications over the last two months, resident had not received his blood pressure medication that evening resulting in a blood pressure of 230/120. The document listed resident #7's past history of two heart attacks and stroke. The document revealed an electrocardiograph (EKG) results of sinus rhythm and blood pressure at 11:36 PM at 186/96, at 11:42 PM 181/100 and at 11:50 PM 167/102. Resident taken to a local hospital A document from the local hospital's Emergency Department dated 6/24/22 revealed resident #7 was seen for elevated blood pressure. Resident #7 reported his chest pain stopped and was given a pain medication for headache in the Emergency Department (ED). An EKG, Chest X-ray and labs were performed and reviewed. The elevated blood pressure was stabilized and resident #7 was returned to the facility. During phone interview on 7/8/22 at 12:45 PM, Staff B, Licensed Practical Nurse (LPN) stated they have been having problems receiving medications from the pharmacy, not arriving. Staff B stated she worked on 6/25/22 and remembered the situation with resident #7's medication, it was labeled wrong. She stated she found it with that mornings medication, relabeled it and put it with the evening medications. During an interview on 7/9/22 at 2:00 PM, the Director of Nursing (DON) stated the Evening Staff Nurse, Staff C, LPN, called and notified her of Resident #7 transfer and return to the facility. The DON revealed she knew about the missing medication and that it was found in the morning, incorrectly labeled. She stated her expectations of her nurses for chest pain, I would expect them to do a cardiac assessment for symptoms and take blood pressure and pulse then call the doctor to report, probably get a onetime order for blood pressure medication or transfer him to the hospital. 2. A MDS assessment dated [DATE], documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status revealed a score of 6 out of 15, indicating severely impaired cognition. The resident required assist of 1 with transfers and ambulation. A Care Plan with a focus area initiated on 7/2/22, directed staff that Resident #23 was at risk for falls. Her goal was that she would not experience any injuries related to falls. The Care Plan directed staff on the following: a. To encourage this resident to use her call light for assistance. b. This resident needed a safe environment without clutter. c. To make sure she was wearing appropriate footwear. d. To monitor her for unsteady gait. Nursing Skin Observation forms documented the following weekly assessments: a. On 6/23/22 this resident had no new skin issues b. On 6/29/22 this resident refused a skin assessment. c. On 7/6/22 this resident had no new skin issues. d. On 7/13/22 this resident had no new skin issues. A Hospital Emergency Department Provider Notes document dated 7/6/22, documented that there was a number of bruises mainly on extremities. Pictures revealed that there was more than 20 bruises on this resident's lower extremities and left wrist. Progress Notes included documentation of the following: a. On 6/24/22 at 4:50 AM, Certified Nurse Assistant (CNA) called this nurse that the resident is on the floor. Upon arriving in resident's room, the resident was on the floor and laying on her right side. Resident was in front of the door, behind her wheelchair and next to foot of her bed. Resident laid on her back and head supported with a pillow. Resident was assessed and vitals were taken. No injuries noted, res denied having pain or discomfort. Resident was wearing gripper socks at the time of fall, resident did not utilize call light. b. On 6/24/22 at 11:10 PM, Resident denies pain or injury from recent fall. c. On 6/25/2022 at 9:45 AM, Resident has no injuries noted related to fall. d. On 6/25/2022 at 8:35 PM, Resident denies pain or injury from recent fall. Full Range of Motion (ROM) to all extremities. Resident is alert but forgetful. e. On 6/26/2022 at 9:15 AM, Resident has no injuries noted related to the fall. Resident is alert and oriented x 3 (person, place and time) with noted forgetfulness at times. f. On 6/26/22 at 8:25 PM, Resident forgetful at times but alert. Denies changes pain or injury related to recent fall. g. On 6/27/22 at 12:50 PM, Follow up related to unwitnessed fall. Resident is alert, resting in bed with no complaints of pain or discomfort. No new skin issues or injuries observed. h. On 6/29/2022 at 1:45 AM, fall follow up, denies injury. i. On 7/1/2022 at 4:10 PM, Resident being monitored for unwitnessed fall on 6/30. No injuries noted. Resident Alert and Oriented x 3 with noted forgetfulness. j. On 7/7/2022 at 1:26 AM, CNA reports to his nurse that resident was on the floor. Found resident sitting on the floor by bed side, no injuries noted, vitals and neuros stable. k. On 7/9/2022 at 1:50, Resident complained of chest pain. At 2:30 AM, resident was transported to the hospital. l. On 7/12/2022 at 5:35 PM, Resident noted to have scattered bruising in multiple healing stages. A fax (was sent) to the doctor related this resident was on [MEDICATION(S)] and aspirin and will have various bruises. m. On 7/13/22 from 3:17 to 3:21 PM, 6 entries were documented each entry had an identified bruise. n. On 7/13/2022 at 3:56 PM, Nurse notified of resident having multiple bruises to extremities. Resident assessed head to toe and bruises noted in various stages to all extremities. Skin evaluations completed. Resident states she bumps them (arms and legs) a lot. Medications reviewed and resident taking [MEDICATION(S)] and aspirin. Resident has fragile skin and bruises easily. Doctor notified. Call placed to brother and made aware. Thanked nurse for the update. On 7/12/22 at 12:56 PM, Skin Assessments and Evaluations were requested regarding bruises on this resident. The Director of Nursing (DON) was not aware of bruises and stated she would look into it. On 7/14/22 at 10:59 AM, the Director of Nursing (DON) stated she had went down and did a head to toe on Resident #23. She stated this resident did have extremity bruises in various stages and some were faded out yellow. There were one or two that were a darker purple. The DON stated this resident had a couple of falls lately and is also on [MEDICATION(S)] and aspirin. The DON stated this resident said she bumped into things. The DON stated this resident is hit or miss on reliability. The DON felt like when she talked to the resident about stuff the resident is reliable. She was not sure why none of the bruises were charted. She stated they should have been charted on the weekly skin checks. When told the weekly skin checks on the 7th and the 13th stated there were no new skin issues, she stated it should have been charted there. When asked if the CNAs report bruises, she said the bruises should have been reported and documented on. She stated that directly after the 3 falls the bruises may not have shown up yet. She stated she called the Nurse Consultant about the bruises after being asked about documentation on them on 7/12/22. The DON stated that she was directed to call the physician, do assessments on the bruises and document it all in the chart. The DON stated she did not start any type of investigation into this. She stated she will need to ask some questions of her staff as to why this was not documented. She repeated it should have been documented on the weekly skin assessments. On 7/14/22 at 12:25 PM, Staff A, CNA, stated Resident #23 is technically an assist of 1, but she is non-compliant and transfers all the time by herself. She stated this resident takes herself to the bathroom and is incontinent and doesn't' always change her brief when it is wet. Staff A stated they check and change this resident. Staff A stated this resident puts her knees on the bed instead of sitting then crawls on to the bed and gets the bruises on her shins a lot. Staff A, reported that she didn't see the bruising so much when working as a Medication Aide, as this resident would have pants on but Staff A saw it a lot more as a CNA. Bruises are pretty typical for this resident. Staff A stated this resident uses her call light when she needs something as well, but has had a couple of falls lately. On 7/14/22 12:36 PM, Staff E, CNA, stated that sometimes Resident #23 has bruises on her legs. Staff E stated that when she first started, she reported the bruising, but she was told it happens and they knew about the bruising. She repeated that they just tell me they know about it. On 7/14/22 at 12:57 PM, Staff F, Licensed Practical Nurse (LPN), stated she just started working again in the last 2 weeks as she was in Nursing School. She stated she had done the weekly skin assessment on 7/13/22 for Resident #23. She stated that none of those bruises were new and that is why she marked no, to the question if there are any new skin areas. When asked if records were kept of bruises, she stated she would assume they would keep those on a record until they were healed or gone. She stated there is an I-Pad thing that they use to take a picture of the new skin areas and measure them. She did not know the paper work piece of it yet. She hadn't heard anything about the bruises through report so she guessed those bruises were from Resident #23 transferring herself and recent falls. Staff F stated that she was still in orientation so not sure how the records are kept. An Accidents and Incidents-Investigating and Reporting Policy revised on 7/2017, directed that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor shall promptly initiate and document an investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 4. This facility will adhere to the definitions in the Medical Device Reporting Act when filing the Food and Drug Administration MED-WATCH Forms (3500). 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/ Accident form for each occurrence. 7. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

Based on clinical record review, physician and staff interviews, the facility failed to provide ongoing assessment and interventions for 1 of 4 residents who needed respiratory intervention due to shortness of breath and difficulty breathing (Resident # 1). The facility reported a census of 33 residents. Findings include: A Minimum Data Set ((MDS) dated [DATE] documented Resident #1 with [DIAGNOSES REDACTED]. The MDS indicated the resident needed extensive assistance of 1 staff to physically assist the resident with bed mobility, transfer and ambulation. A Staff Assessment for Mental Status documented a score of 2. A score of 2 indicated severe cognitive impairment. A speech therapy evaluation dated 1/5/13 revealed the resident had a medical [DIAGNOSES REDACTED]. A care plan with a problem onset dated 6/12/16 indicated impaired communication due to a [DIAGNOSES REDACTED]. A 60 day Nursing Home Evaluation dated 12/8/16 at 1:45 p.m. by the resident's primary PA documented no respiratory concerns. Auscultation revealed no wheezing, rales, crackles or rhonchi. Breath sounds are normal with good air movement. Interdisciplinary progress notes dated 11/28/16 documented the resident is aware of self when spoken to but did not speak often. Nurse's notes dated 12/12/16 at 4:00 p.m. documented the resident had vomited. Vital signs (VS) taken revealed a Temperature T) of 96.7 degrees Fahrenheit (F), Respirations (R) at 16 breaths per minute (bpm), blood pressure (BP) 149/56 and oxygen(O2) levels in the blood ) at 93% on room air. Notes indicated the facility notified the resident's primary physician of the vomiting by fax at 6:08 p.m. A facility flow sheet dated 12/12/16 with Resident #1's first name and without a time revealed VS - T-98.4, P-76, R-18, BP-1/29/72 and O2-92%. On the back of the flow sheet a record of Resident #1's VS for 7:25 (p.m.) without date listed - VS - T-96.3, P-82, R-18, BP-109.77 and O2-94%. A Physician Assistant's (PA) telephone order dated 12/12/16 at 8:30 p.m. indicated the resident may be suctioned as needed and to send to the resident to a local hospital emergency room . Please note Staff B reported the PA's order she had written dated 12/12/16 at 8:30 p.m. indicated the resident may be suctioned as needed and to send to the resident to a local hospital emergency room had been written in error. She had combined both orders (given at different times on 12/12/16). Nurse's notes dated 12/12/16 (without a time listed) documented by Staff B, a licensed practical nurse (LPN); the resident had vomited this evening (time not specified). Lung sounds were coarse and congested. VS taken revealed T-98.4 F, P-76, R-18, BP-129/72 and O2-92% room air. Notes indicated family present. The facility called the on-call PA due to the resident attempting to cough congestion without success. An order to suction had been given. The resident's family requested the resident be sent to a local hospital emergency room for evaluation and treatment. Staff placed a call to emergency medical services; an ambulance arrived at 9:00 p.m. and transported the resident. (During an interview dated 1/25/17 at 1:10 p.m. Staff B reported the nurse's notes written on 12/12/16 without a time listed had been written after the events the evening of 12/12/16.) She reported the nurse's notes did not contain accurate documentation of the events the evening of 12/12/16.) Nurse's notes dated 12/13/16 at 1:00 a.m. documented facility staff called the hospital and told resident had been admitted to the intensive care unit with pneumonia [MEDICAL CONDITION]. Prehospital care report dated 12/12/16, section Scene Management from emergency medical services (EMS) documented being dispatched at 8:52 p.m., arriving at the facility at 9:13 p.m., departing the facility at 9:28 p.m. and arriving at the hospital at 9:56 p.m. Upon arrival the Emergency Medical Service (EMS) staff completed an assessment which included the following: resident was assisted to stand and pivot to the cart. The resident's SpO2 (measurement of oxygen in the blood) read 86% on room air, however the resident's lips did not appear dusky or cyanotic. The resident had a heavy coat of nail polish (on his/her fingers.) The physical examination identified the resident's skin looked normal in color, warm and dry. The resident's chest equally rise and fell ; and his/her respirations slightly rapid and labored. The upper airway noted gurgling and his/her lungs course throughout with crackles noted. In route to the hospital EMS staff administered a nebulizer treatment resulting in the resident breathing better and the audible gurgling had been greatly reduced. Hospital records dated 12/12/16 at 10:11 p.m. revealed the resident arrived at the hospital with SpO2 at 92% without a fever. At 11:16 p.m. the resident had wheezing, crackles and gurgling in all lung fields and tachypneic (abnormal rapid breathing) and in severe respiratory distress. An assessment revealed the resident had [MEDICAL CONDITION] due to aspiration pneumonitis - at risk for aspiration pneumonia, acute [MEDICAL CONDITION] due to dehydration with an elevated BNP (brain natriuretic peptide) greater than 5000 - likely due to [MEDICAL CONDITION] and acute [MEDICAL CONDITION] and appears dehydrated. Laboratory results revealed a white blood count of 19.8 with normal reference range of 4.9-10.0/ul., P-112 and R- 28. The Hospital X-ray impression of [MEDICAL CONDITION] ([MEDICAL CONDITION]/ constricted airway) with bibasilar atelectasis (complete or partial collapse of a lung) or pneumonia and pleural effusion (a buildup of fluid between the tissues that line the lungs and chest). The diagnostic imaging dated 12/12/16 at 10:18 p.m., revealed one view completed for x-ray with the following findings: a). There is an elevation of the medial aspect of the right hemidiaphragm (likely a hiatal hernia or other hernia). b). There is hyperexpansion of the lungs which could be seen with [MEDICAL CONDITION]. (Hyperexpanded lungs, is a condition in which the lungs have overinflated, causing them to grow beyond their usual size. This condition can cause respiratory problems, especially when exhaling. A person with hyperexpanded lungs cannot fully exhale, which leaves air trapped inside the lungs.) c). There are moderate bilateral pleural effusions and bibasilar atelectasis which is all worst on the left than right. d). Pneumonia was not excluded. e). There was no pneumothorax (presence of air or gas in the cavity between the lungs and chest wall causing collapse of lungs. Hospital records dated 12/13/16 at 1:30 a.m. revealed the resident passed away. The resident had been placed on [MEDICAL CONDITION] for respirator support and became bradycardic and unresponsive. The cause of death listed as [MEDICAL CONDITION], acute [MEDICAL CONDITION] and aspiration and aspiration pneumonitis. During an interview dated 1/25/17 at 7:50 p.m. the emergency physician reported the resident presented multiple issues at the time h/she arrived at the emergency room . It was unlikely that suctioning the resident would have benefited the resident prior to arrival. EMS had administered a nebulizer treatment during transport to the hospital and this procedure increased her blood oxygen saturation levels. In a written statement; as part of the facility's investigation dated 12/15/16, Staff A, reported a certified nursing assistant (CNA) reported the resident had vomited. She went to the resident's room and noted the vomit had been red/white in color and smelled like spaghetti. She completed a set of vital signs which were normal. She faxed the primary physician and told the on-coming nurse, Staff B, a licensed practical nurse (LPN) of the resident ' s vomit episode and the fax she had sent to the primary physician. She told Staff B she had not called the family about the resident vomiting earlier that day. During an interview dated 1/9/17 at 1:05 p.m., Staff D, a paid nutritional assistant reported the resident had a pureed prepared meal for lunch at 12:00 p.m. and finished at 12:40 p.m. The resident had no difficulty with eating. During an interview dated 1/19/17 at 11:00 a.m. Staff A reported Staff C CNA reported the resident had vomited. She confirmed she had faxed the primary physician at 6:08 p.m. of the vomiting episode at 4:15 p.m. Staff A reported she hadn't expected the physician to respond to her fax until the next day. She reported the resident didn't look distressed. In a written statement: as part of the facility's investigation dated 12/18/16, Staff C reported the resident had vomited on 12/12/16 at 4:15 p.m. She gave the resident water and the resident drank without any problem. She cleaned the resident and assisted the resident to bed. Sometime between 6:30 p.m. - 7:00 p.m. she and Staff F CNA went to the resident's room and noted the resident pale white, having gray discoloration in h/her lips and eyelids and had a gurgle sound when breathing. The resident's eyes were rolling back and the resident was ice cold to the touch. She reported to Staff B of the resident's status. Staff B replied, stating she had been in the resident's room [ROOM NUMBER] times and the resident was fine. Staff C asked Staff B if she had asked for an order to suction the resident. Staff B reportedly replied that she had been working on it. Staff C asked if family had been notified and Staff B said she had notified the family. During an interview dated 1/23/16 at 2:11 p.m. Staff C reported she went on her lunch break from 6:15 p.m. to 6:45 p.m. At 7:00 p.m. she went into the resident's room and saw the resident trying to push out - coughing out something from h/her throat but the resident couldn't. Staff C reported the family arrived sometime after 8:00 p.m. In a written statement: as part of the facility's investigation dated 12/15/16, Staff E CNA and Staff F CNA reported at 6:30 p.m. both went into the resident's room and found the resident had vomited. The resident had been lying on h/her side with vomit coming out of h/her mouth. The resident had a bad color and made a gurgling noise. Staff E left and reported to Staff B the resident had vomited and had difficulty breathing. Staff E asked if the resident could be moved to a recliner in case the resident threw up again. Staff B reportedly said that was fine and she would be down to look at the resident. Staff E reported once they placed the resident into a recliner the resident's color improved and smiled at one of the CNA's. Both Staff E and Staff F left the resident's room as Staff B entered the resident's room and started to take vital signs. Staff E reported she returned later, after helping other residents and noted the resident cold, clammy and had difficulty breathing. She left and reported her findings to Staff B who told her she had been in the resident's room [ROOM NUMBER] times and the resident was fine. Staff F reported she returned to the resident's room after she assisted other residents. She reported the resident continued making gurgling sounds and cold/clammy to the touch. Staff F stated she left the room saw Staff B and yelled are we going to do something. Staff F reported she couldn't hear what Staff B had said. As she walked back up the hall Staff F heard Staff B tell two other CNA's she had been to the resident's room [ROOM NUMBER] times. During an interview dated 1/23/17 at 3:20 p.m. Staff E reported she went to the Administrator and voiced her concern of the resident's health status. In a written statement; as part of the facility's investigation dated 12/12/16 at 7:00 p.m., the Administrator reported on Staff E came to her office reporting the resident was passing away, as the resident had difficulty breathing, had been cold and clammy to touch. The Administrator asked Staff E if the nurse (Staff B) knew about the resident's status. Staff E reported Staff B had been aware. At 7:05 p.m. the Administrator went to the resident's room and saw Staff B standing in the resident's doorway. Staff B asked her if the aides had come to her, accusing her of not doing her job. Staff B reassured her she had everything under control and family had been notified and were on their way to the facility. During an interview dated 1/19/17 at 9:30 a.m., the Administrator reported the evening of 12/12/16 a 7:25 p.m. Staff B asked her where the facility stored the suction machine. Both she and Staff B looked throughout the facility but could not find the device. The Administrator reported the family wanted the resident to go the hospital. During an interview dated 1/25/17 at 3:30 p.m., the Administrator reported she directed Staff B to call the director of nursing (DON) the evening of 12/12/16, but Staff B called another nurse. The Administrator reported she called the DON. In a typed written statement dated 1/23/17, the DON documented she had checked her phone log and she received the first call at 8:43 p.m. and the second call at 8:56 p.m. In a written statement; as part of the facility's investigation dated 12/15/16, Staff B reported a CNA (not identified), came to her at 6:30 p.m., reporting the resident had vomited again and could staff get the resident up out of bed. Staff B reported this was the only time a CNA approached her the entire night. Staff B reported she went down to the resident's room with the CNA's and assessed the resident. Staff B reported the vomit was yellow/white in color and looked like phlegm. She completed VS, which were normal. She reported the resident seemed to have congestion and sounded like the resident just needed to cough it up. The resident showed no signs of distress and noted the resident sitting up in a recliner and smiling. Staff B reported she called the on-call PA to update him on the resident's condition but he did not answer so left a message to call back. Staff B reported family arrived and she completed a second set of VS at 7:25 p.m. and noted no abnormal findings. Family requested the resident be suctioned. She called and spoke to the on-call PA, gave an update on the resident's status and asked for and was given an order to suction the resident. She asked the Administrator if she knew where the suction machine had been stored and both she and the Administrator looked for but couldn't find the device. She told family she could not find the suction machine and family requested the resident be sent to a local hospital emergency room for evaluation and treatment. Staff B reported the resident had been sent out per family request. Staff B stated she had not called family. Staff A had told her during report she had called the family and they were on their way in. Staff B reported suctioning the resident was an appropriate intervention and if she had suctioned the resident the congestion would have been resolved. During an interview dated 1/19/17 at 1:10 p.m. Staff B stated she arrived at 6:00 p.m., received report from Staff A the resident had thrown up at lunch and the resident's physician had been notified by fax. At 6:30 p.m. a CNA reported the resident vomited again. At 6:35 p.m. she completed VS which were normal, listened to the resident's lungs which were clear. She placed a call to the on-call PA, no one answered so she left a message the resident had vomited again and the color of the vomit. While waiting for the PA to call back she started her medication pass. At 7:30 p.m. the resident's family members arrived. She told the family the resident had vomited and h/her VS were normal and the lungs were clear with no signs of distress. She completed another set of VS, left and administered medications to residents. During her medication administration, a family member asked if the resident could be suctioned to remove something in h/her throat. Staff B reported she listened to the resident's lungs and noted the lungs were clear in the bases and congestion in the upper throat. She told family she would call the on-call PA again and see what could be done. She called the on-call PA and reported the resident's lungs were clear but asked for an order to suction the resident as needed (prn). She notified the resident's family member she received an order to suction. She looked in the medication and supply room, asked the Administrator if she knew where the machine had been stored but neither one could find the device. Staff B told family the suction machine could not be found and the resident's family requested the resident be taken to a local hospital emergency room . She called the on-call PA and obtained an order to send the resident to the hospital. During a phone interview dated 1/19/17 at 3:39 p.m. the resident's family member reported h/she and another family member had been shopping in a nearby town and stopped at the facility at 8:05 p.m. When they arrived he resident appeared to have difficulty breathing. Family voiced concerns to the nurse and asked if the resident could be suctioned. The nurse reported she would have to get an order from the physician. The nurse returned 20 minutes later and told family an order had been given to suction the resident and then the nurse left. The nurse returned 30 minutes later and told family the suction machine couldn't be located. Family requested the resident be sent to a local hospital emergency room . An ambulance arrived at 9:00 p.m. and transported the resident to the hospital. During a second interview dated 1/25/17 at 1:10 p.m. Staff B reported she had called to on-call PA at 8:00 p.m. when family arrived at the facility. Family requested the resident be suctioned. She reported the PA had never called her back from her first phone call. She called the PA and reported the suction machine could not be located and asked to transfer the resident to a local hospital emergency room for evaluation and treatment. During an interview dated 1/19/17 at 10:40 a.m., the director of nursing (DON) stated LPN's and RN's are within their scope of practice to use a suction machine and she expected staff to know where the device is located and to use the device when a provider has ordered its use. During an interview dated 1/19/17 at 1:35 p.m., the resident's primary physician confirmed he had received a fax from the facility regarding the resident's vomiting episode, but the fax had been sent after work hours and he didn't see the fax until the following morning. He stated the resident didn't have a history of vomiting and he had not been notified of any change of condition prior to 12/12/16. He stated if the resident needed to be suctioned then the resident needed to be sent to a hospital for evaluation and treatment. During an interview dated 1/19/17 at 2:00 p.m., and 1/25/17 at 3:30 p.m. the on-call PA reported he received a call at 8:37 p.m. from a nurse asking for an order to suction, as the resident had difficulty breathing and the resident had previously benefited from suctioning in the past. He received another call at 8:47 p.m. from a nurse who reported the suctioning had not improved the resident's respiratory status. The nurse asked for and received an order to send the resident by ambulance to a local hospital emergency room for evaluation and treatment. He reported he didn't receive a phone message from the facility earlier in the evening.