Every finding on record at The Creston Health & Rehabilitation

Based on interview and record review it was determined the facility failed to ensure physician orders were implemented in a timely manner for 2 of 3 sampled residents (#s 5 and 6), reviewed for medications. This placed residents at risk for a delay in treatment and recovery. Findings include:1. Resident 5 admitted to the facility on [DATE] with diagnoses including an opened wound to his/her left foot and decreased white blood cell count.Resident 5's Progress Notes documented:-On 6/5/26 at 5:59 AM, Resident 5 complained of pain and burning upon urination.-On 6/8/26, a urinalysis was collected from Resident 5.-On 6/10/25, Resident 5 continued to complain of pain and burning with urination, had an active UTI and results of a culture and sensitivity were pending.On 6/15/26 at 12:15 PM, Resident 5 stated she/he first notified the facility of their UTI symptoms about two weeks prior. Resident 5 explained the facility completed a UA about one week prior which was positive and thought she/he would have an antibiotic prescribed but had not yet received one. Resident 5 also complained of ongoing pain with urination.On 6/17/26 at 10:22 AM, Resident 5 stated she/he received the first dose of antibiotics the previous night. She/he explained the results of her culture and sensitivity were sent to an assisted living and not the nursing facility, which caused their treatment to be delayed.On 6/17/26 at 12:01 PM, Staff 1 (Administrator) provided the results of Resident 5's culture and sensitivity test dated 6/12/26 at 2:02 PM because the results were not available in Resident 5's electronic health record. The results included a handwritten note by Staff 13 (RN) indicating an antibiotic was prescribed by the on-call provider on 6/16/26.On 6/17/26 at 3:37 PM, Staff 9 (Nurse Practitioner) stated normally a provider was alerted by phone by the facility for a positive UA and culture and sensitivity test and results are viewable in the electronic health record. Staff 9 stated the UA results and culture and sensitivity were not available in the electronic health record at time of interview, but Staff 13 had called the on-call provider on 6/16/26.On 6/17/26 at 3:49 PM and 6/18/26 at 8:40 AM, attempts to contact Staff 13 were unsuccessful.On 6/18/26 at 9:38 AM, Staff 11 (LPN) stated the lab results are typically posted in residents' electronic health record by the lab for viewing, and stated the lab typically calls the facility for critical labs or culture and sensitivity reports. She stated if she was expecting a result that was not available in the electronic health record, she would call the lab for clarification.On 6/18/26 at 9:43 AM, Staff 12 (RN/Assistant DNS) stated Resident 5's culture and sensitivity results should have been available for viewing in the electronic health record on 6/12/26 but were sent to Resident 5's assisted living facility. Staff 12 stated on 6/16/26 she called Resident 5's assisted living and found the results. She stated Staff 13 then called the on-call provider and got the order for the appropriate antibiotic. On 6/18/26 at 10:01 AM, Staff 2 (DNS) stated normally results are uploaded to residents' electronic health record by the lab when available and the lab also calls to notify staff of the culture and sensitivity results. Staff 2 explained he would have expected the nurses to call the lab for results if they were not available in the electronic health record and to notify the provider of issues so a determination could be made on whether the resident should be sent to the ER for evaluation, which was not done.2. Resident 6 admitted to the facility in 2024 with diagnoses including chronic multifocal osteomyelitis of right ankle and foot, Type II diabetes with diabetic polyneuropathy and pressure injuries on both lower extremities. Resident 6 discharged from the facility in 3/2026.Resident 6's Physician Orders documented a 2/11/26 order for doxycycline (an antibiotic medication) 100 mg tablet BID for 10 days for a skin and soft tissue infection.Resident 6's 2/2026 MAR documented the medication was started on 2/17/26 (6 days after the orders).On 6/17/26 at 2:13 PM, Staff 7 (LPN) stated the facility received orders from Resident 6's provider through a fax number accessible only to certain staff, which caused the orders to be received late.On 6/18/26 at 9:43 AM, Staff 12 (RN/Assistant DNS) stated Resident 6's provider faxed orders to a fax number that was only accessible to admission staff, likely resulting in orders to be received late.On 6/18/26 at 10:01 AM, Staff 12 (DNS) stated normally Resident 6's providers faxed orders and called to ensure the order was received. Staff 12 explained that on 2/17/26 Staff 13 (RN) found an order for Resident 6 and brought it to him as Staff 12 was the charge nurse that day. Staff 12 called the provider to verify the order and the provider stated to start the order and give as directed because Resident 6 had an abscess. Staff 12 stated he should have documented this in a progress note, but could not find the documentation.

Based on observation, interview and record review it was determined the facility failed to follow care plan interventions to ensure safe transfers and prevent falls for 3 of 4 sampled residents (#'s 2, 48 and 74) reviewed for accidents. This failure resulted in resident 74 having a fall and sustaining an ankle fracture requiring emergency medical services. Findings include: The facility's undated Fall Prevention Program Policy revealed the following: -Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.-Interventions will be monitored for effectiveness, and the plan of care will be revised and needed. -When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions and obtain witness statements in the case of injury. 1. Resident 74 was admitted to the facility in 10/2024 with diagnoses including left collarbone fracture with routine healing and unspecified fall. Resident 74's 10/16/24 care plan indicated the resident was a moderate fall risk requiring two-staff participation to use toilet and two-staff participation for transfers. Resident 74's 10/22/24 admission MDS indicated the resident was cognitively intact and dependent on staff for toilet transfers. Review of Resident 74's medical record following the 11/14/24 fall and hospital transfer indicated the resident did not return to the facility. The facility's 11/26/24 Discharge Summary for Resident 74 indicated the resident had a left ankle fracture as her/his final diagnosis. The 11/14/24 10:41 AM Fall Incident Report for Resident 74 indicated Staff 18 (Former Staff CNA) assisted the resident in transferring from the wheelchair to the toilet without assistance from another staff member. Staff 18 reported they attempted to transfer the resident to the toilet; however, the resident's legs gave out and she/he was unable to stand. Staff 18 held the resident from behind and lowered her/him fully onto the floor and turned on the bathroom call light for help. At the time of the incident Resident 74 reported to Staff 18 her/his leg hurt. Staff 19 (Former Staff LPN) responded to Staff 18's call for assistance, assessed Resident 74, and found no injuries at the time of the incident. At approximately 1:00 PM Staff 27 (Nurse Practitioner) assessed Resident 74 at the facility and notified Staff 19 the resident's left ankle was swollen and bruised. The 11/14/24 1:53 PM Nurse Progress Note indicated Staff 27 instructed Staff 19 to send Resident 74 to the Emergency Department. The resident left via medical transportation and Staff 20 (Former DNS) and Witness 2 (Family Member) were notified. Multiple attempts were made to reach Witness 1 (Complainant) for interview but were unsuccessful. On 2/24/26 at 5:16 PM Witness 2 (Family Member) stated Resident 74 was sent to the facility for care and rehabilitation following a fall at home. Witness 2 stated Resident 74 fell in the bathroom at the facility while being transferred to the toilet. Witness 2 stated Resident 74 was unable to bear her/his own weight at the time of the fall and indicated the resident was a two-person transfer. Witness 2 stated Resident 74 was transferred to the hospital following the fall and was found to have fractured her/his left ankle. Witness 2 stated Resident 74 told them the CNA who assisted with her/his toilet transfer had her/him stand without providing support and collapsed because no one was holding onto her/him. Witness 2 expressed they were frustrated Resident 74 had a fall at the facility. Multiple attempts were made to reach Staff 18 for interview but were unsuccessful. On 2/25/26 at 6:08 PM Staff 19 stated they did not remember Resident 74 or the fall and did not recall writing the incident report. No further information was provided by Staff 19. On 2/26/26 at 11:57 AM Staff 20 stated they investigated Resident 74's fall and determined Staff 18 improperly transferred the resident to the toilet, resulting in a fall during which the resident sustained an ankle fracture. The fracture was concluded to be strongly correlated to the fall. Staff 20 stated Resident 74's care plan indicated the resident required a two-person transfer assist for toileting. Staff 20 stated Staff 18 acknowledged they did not review Resident 74's care plan, they were not aware the resident was a two-person transfer and performed a one-person transfer with the resident at the time of the incident. Staff 20 stated Staff 18 was placed on administrative leave following the incident. On 2/26/26 at 4:28 PM Staff 21 (Former Staffing Coordinator) stated they were witness to Staff 18's interview. Staff 21 stated the investigation revealed Resident 74 was improperly transferred for toileting by Staff 18 resulting in a fall and the resident sustained an ankle injury. Staff 21 stated Staff 18 admitted they did not review Resident 74's care plan, they did not know the resident was a two-person transfer for toileting, and they performed a one-person transfer with the resident at the time of the incident. On 2/27/26 at 9:28 AM Staff 2 (DNS) and Staff 16 (Infection Preventionist) stated they expected CNAs to review and follow residents' care plans. Staff 2 and Staff 16 reviewed Resident 74's care plan and Fall Incident Report and acknowledged the care plan was not followed at the time of the fall. 2. Resident 48 was admitted to the facility in 10/2023 with diagnoses including repeated falls. Resident 48's 9/10/25 Fall Risk Care Plan revealed the following interventions:-An orange leaf was to be placed on the resident's name plate outside her/his room to alert staff the resident was at high risk to fall. -The bed was to be kept in the lowest position with the exception of providing care. -Fall mats were to be placed on both sides of the bed at all times with the exception of providing care. -A sign was to be used to remind the resident to use her/his call light and to wear non-skid socks. Resident 48's 1/21/26 Fall Risk Assessment revealed the resident was at moderate risk to fall. Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making and dependent on assistance from staff for all ADL care. Random observations of Resident 48 from 2/23/26 to 2/26/26 between 5:47 AM and 3:17 PM revealed the resident to be in her/his room in bed. No orange leaf was observed on the resident's name plate outside of her/his room, no fall mats were in place on either side of the resident's bed and no sign was observed in the resident's room to remind her/him to use her/his call light and to wear non-skid socks. The door to the resident's room was either completely shut or slightly cracked open. The privacy curtain that separated Resident 48 from her/his roommate was always pulled as far as it could extend, so the resident was not visible from the hall even when the door was cracked open. On 2/26/26 at 5:13 AM, Staff 23 (CNA) stated Resident 48 was at risk to fall, so the resident's bed was to be in a low position with fall mats placed on both sides once care was complete. On 2/26/26 at 5:40 AM, Staff 32 (Agency LPN) stated Resident 48 was alert but experienced moments of confusion. Staff 32 stated he did not know if the resident was considered at risk to fall. On 2/26/26 at 5:56 AM, Staff 33 (CNA) stated Resident 48 was at risk to fall, and a sticker should be placed outside of the door to the resident's room to indicate she/he was at risk to fall. Staff 33 stated the resident was supposed to have fall mats in place at all times outside of care, the resident's door was to be open at all times and staff were to peak in every time they walked by the resident's room. On 2/26/26 at 10:30 AM, Staff 14 (RN) stated Resident 48's cognition varied, and at times, the resident would kick her/his legs out of bed as she/he believed she/he could get up and walk. Staff 14 stated the resident kicked her/his legs out of bed on 2/26/26 and told the CNAs she/he was going to walk out of the room. Staff 14 stated she had not seen fall mats used for Resident 48 since 6/2025, but she thought the resident was still at risk to fall. Staff 14 reviewed Resident 48's care plan and stated the resident should have an orange leaf placed outside of her/his room to indicate she/he was at risk to fall and confirmed the resident did not have an orange leaf in place. Staff 14 further stated residents who had an orange leaf placed outside of their room should have their door open at all times outside of providing care, and even with Resident 48's door open, the resident was unable to be visualized by staff as the privacy curtain was always fully extended between Resident 48 and her/his roommate. On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated she found fall prevention interventions in resident care plans. Staff 15 stated an orange leaf outside of a resident's door indicated the resident was at risk to fall, and staff were to perform frequent checks on these residents. Staff 15 stated Resident 48 was to have fall mats on both sides of her/his bed in place, her/his door was to be propped open and the resident required frequent safety checks. On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated an orange leaf outside of a resident room indicated the resident was at risk to fall, and as a result, the door to the resident's room was to be open outside of care, the resident's bed was to be at a low level and staff were to complete frequent safety rounds on the resident. Staff 1, Staff 2 and Staff 24 stated Resident 48 was at risk to fall and confirmed her/his care plan was accurate. Staff 24 stated Resident 48 should have an orange leaf placed outside of the door to her/his room, fall mats should be in place on both sides of the bed outside of care and a sign should be available in the resident's room reminding her/him to use her/his call light. Staff 24 further stated the privacy curtain in Resident 48's room was always pulled, so staff would not be able to visualize the resident during safety rounds without going all the way into the resident's room. 3. Resident 2 was admitted to the facility in 5/2024 with diagnoses including diabetes and history of falling. The 1/7/26 Significant Change MDS indicated Resident 2 was unable to complete the BIMS interview and was dependent on staff for mobility, transfers and was unable to ambulate. The 1/7/26 Fall Risk Assessment indicated Resident 2 was a moderate fall risk. The 5/30/24 Fall Care Plan indicated Resident 2 had a goal to be free from avoidable falls. A revision to the Fall Care Plan on 1/7/26 directed staff to ensure Resident 2's bed was kept in the lowest position outside of cares. Observations on 2/24/26 at 11:45 AM and again at 2:34 PM revealed Resident 2 was lying in bed and the bed was not in the lowest position. Resident 2's bed was between knee and waist height (approximately 2-3 feet). On 2/25/26 at 1:24 PM and 2/26/26 at 5:51 AM, Resident 2 was observed lying flat in bed asleep and the bed was not in the lowest position. Resident 2's bed was at waist level (approximately 3 feet). On 2/25/26 at 1:19 PM, Staff 22 (CNA) stated Resident 2 was not a fall risk. Staff 22 was unaware of any fall precautions for Resident 2. On 2/26/26 at 9:48 AM Staff 25 (LPN) stated Resident 2 was not a fall risk. Staff 22 was unaware of any fall precautions for Resident 2. On 2/27/26 at 10:31 AM, Staff 24 (MDS coordinator-RN), Staff 2 (DNS), and Staff 1 (Administrator) confirmed Resident 2's was a moderate fall risk and her/his care plan included intervention for her/his bed to be in the lowest position outside of cares. Staff 2 and Staff 1 both confirmed they would expect Resident 2's care plan to be followed and her/his bed to be in the lowest position. Staff 1 confirmed the lowest position would be at approximately 18 inches.

Based on observation, interview and record review it was determined the facility failed to ensure overbed lights were accessible, call lights were within reach and bed preferences were honored for 5 of 6 sampled residents (#s 21, 40, 48, 49 and 53) reviewed for accommodation of needs. This placed residents at risk for lack of independence. Findings include: The facility's undated Accommodation of Needs Policy indicated: -The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, expect when the health and safety of the individual or other residents would be endangered. -The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom, bedroom, and common living areas within the facility. -Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment. -Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. 1. Resident 40 was admitted to the facility in 7/2021 with diagnoses including chronic joint disease of the knees and morbid obesity. The 5/25/25 Annual MDS indicated the resident had no cognitive impairment and was dependent for mobility and transfers. A maintenance request dated 1/24/26 completed by Staff 13 (CNA) stated Resident 40 wanted the bed she/he had upstairs because this one is too small. On 2/23/26 at 3:28 PM, Resident 40 stated she/he moved rooms and was told their bed would be moved to the new room. The bed was not moved and she/he was now in a smaller bed. Resident 40 stated she/he preferred the previous bed, because the smaller bed made her/his mobility difficult. On 2/26/25 at 10:05 AM Staff 14 (CNA) stated Resident 40 was in a larger bed prior to moving rooms. Staff 14 stated Resident 40 requested a larger bed and stated maintenance was notified. On 2/26/26 at 12:04 PM, Staff 7 (Director of Facility Services) stated he would expect maintenance requests be completed within 24 hours and was unaware of Resident 40's request dated 1/24/26. He confirmed it was not completed. On 2/26/26 at 2:59 PM, Staff 1 (Administrator) stated Resident 40's previous bed was returned to the rental company. He stated he would expect Resident 40's maintenance request for the larger bed to be completed within 24 hours. 2. Resident 21 was admitted to the facility in 8/2024 with diagnoses including diabetes and left leg abrasion. Resident 21's 6/8/25 Annual MDS indicated the resident had no cognitive impairment and was dependent on staff for mobility, ambulation and transfers. On 2/24/26 at 9:22 AM, Resident 21 was observed in bed and attempted to turn on the overbed light, the resident reached from a lying position in bed, to turn on the overbed light using a butter knife. Resident 21 was unable to reach the light switch with her/his hands and used the butter knife to reach the light. Resident 21 was successful in turning on the light with the butter knife. On 2/24/26 at 9:22 AM, Resident 21 stated there was a toggle like switch to turn the overbed light on, but she/he was unable to reach the switch. Resident 21 stated she/he needed to use the butter knife or had to call staff assistance when she/he needed the light turned on and off. On 2/26/26 at 10:05 AM, Staff 14 (CNA), stated most residents had no way of turning the overbed light on and off without calling for assistance. She stated Resident 21 frequently called for assistance to turn the overbed light on and off. On 2/26/26 at 12:04 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated residents with beds equipped with the toggle-like switch had to activate their call light to receive help. Staff 1 stated if residents were physically capable to operate the overbed light, they should have been provided with the means to do so. 3. Resident 49 was admitted to the facility in 10/2025 with diagnoses including a right hip fracture. Resident 49's 1/18/26 Quarterly MDS indicated the resident had no cognitive impairment and was dependent for mobility, transfers and ambulation. Observations from 2/24/26 through 2/26/26 between the hours of 8:00 AM and 4:30 PM revealed Resident 49 had no ability to turn on her/his overbed light unless she/he called staff for assistance. On 2/24/26 at 1:08 PM, Resident 49 stated there was a little button over there that turned on the overbed light, but she/he was unable to reach the light switch and had to call for staff assistance when she/he needed the light turned on and off. On 2/25/26 at 8:42 AM, Staff 4 (CNA) stated some residents were unable to turn their overbed lights on and off because the newer beds no longer had overbed light controls. Staff 4 stated if a resident did not have a pull cord (such as Resident 49) the resident had to get out of bed or call staff to turn their overbed light on and off. On 2/25/26 at 12:29 PM, Staff 6 (CNA) stated Resident 49's bed did not have a pull cord to turn on her/his overbed light, so the resident had to call for staff assistance when she/he wanted the overbed light on or off. On 2/26/26 at 12:03 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated some residents had pull cords and were able to turn their overbed light on and off but those who did not had to activate their call light to get help. Staff 1 stated if residents were able to physically turn on the overbed light, they should have a way to do so. 4. Resident 53 was admitted to the facility in 1/2026 with diagnoses including multiple fractures of the spine, multiple fractures of the pelvis, fractures of the right lower leg, multiple fractures of the ribs and a fractured neck. Resident 53's 1/18/26 admission MDS indicated the resident had no cognitive impairment, was dependent for bed mobility and was unable to transfer or ambulate. Observations from 2/24/26 through 2/26/26 between the hours of 8:00 AM and 4:30 PM revealed Resident 53 had no ability to turn on her/his overbed light unless she/he called staff for assistance. On 2/23/26 at 9:48 AM and 2/25/26 at 9:20 AM, Resident 53 stated she/he had no way of turning on the overbed light. Resident 53 stated she/he was unable to walk and had no bed controls, so she/he had to call staff for assistance to turn the overbed light on and off. On 2/25/26 at 8:42 AM, Staff 4 (CNA) stated some residents were unable to turn their overbed lights on and off because the newer beds no longer had overbed light controls. Staff 4 stated if a resident did not have a pull cord (such as Resident 53) the resident had to get out of bed or call staff to turn their overbed light on and off. On 2/25/26 at 12:29 PM, Staff 6 (CNA) stated Resident 53's bed did not have a pull cord to turn on her/his overbed light, so the resident had to call for staff assistance when she/he wanted the overbed light on or off. On 2/26/26 at 12:03 PM, Staff 1 (Administrator) and Staff 7 (Director of Facility Services) stated some residents had pull cords and were able to turn their overbed light on and off but those who did not had to activate their call light to get help. Staff 1 stated if residents were able to physically turn on the overbed light, they should have a way to do so. 5. Resident 48 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system). Resident 48's 9/10/25 Care Plan revealed the following interventions:-Staff were to ensure the resident's call light was within reach.-Staff were to remind the resident during encounters to use the call light to request assistance.-The resident required prompt response to all requests for assistance. Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making, experienced upper and lower body impairment on both sides and was dependent on assistance from staff for all ADL care. On 2/23/26 at 10:50 AM, Resident 48 was observed in her/his room in bed. A pressure-activated call light (used by people with limited dexterity or motor skills) was observed wrapped around the top portion of the left upper bed rail across from the resident's left shoulder. The resident was unable to answer any questions about her/his call light at this time. On 2/24/26 at 11:42 AM, Resident 48 stated she/he would use her/his call light if it was within reach. On 2/24/26 at 11:42 AM, 2/25/26 at 8:58 AM and 2/26/26 at 5:47 AM, Resident 48 was observed in her/his room in bed. A pressure-activated call light was observed wrapped around the top portion of the left upper bed rail across from the resident's left shoulder. Resident 48 reached across her/his body with her/his right arm, attempted to activate the call light but was unable to reach it. On 2/26/26 at 10:30 AM, Staff 14 (RN) stated Resident 48 used her/his right arm to activate her/his pressure-activated call light as the resident's left side was more limited. Staff 14 stated Resident 48 would not be able to reach her/his call light if it was placed near her/his left shoulder. On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated Resident 48 did not use her/his left arm for anything and the resident used her/his call light on the days when she/he was more alert. At 1:42 PM, Staff 15 observed the resident in bed with her/his call light wrapped around the left bed rail and stated the resident would probably not be able to access the call light. On 2/27/26 at 10:23 AM, Staff 6 (CNA) stated Resident 48 did better with [her/his] right side, she/he used her/his call light and the call light needed to be positioned by her/his hand. On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated Resident 48 had very low strength on one side and the call light should be placed in her/his lap to be accessible.

Based on interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for required staff postings. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings include:A review of the Direct Care Staff Daily Reports (DCSDR) from 1/23/26 through 2/23/26 revealed 11 of 30 days when portions of the form were left blank or were inaccurate. The incomplete or inaccurate information included daily census and the number of working staff. The dates included:-1/28/26 -2/4/26 -2/5/26 -2/6/26 -2/9/26 -2/10/26 -2/11/26 -2/14/26 -2/18/26 -2/19/26 -2/20/26 On 2/27/26 at 9:11 AM Staff 15 (Staffing Coordinator) stated the lead CNAs were trained to fill in the DCSDRs and a nurse reviewed and signed the report before it was posted for each shift. Staff 15 acknowledged the DCSDRs were incomplete and inaccurate for the identified dates. On 2/27/2026 at 12:30 PM Staff 1 (Administrator) expected the posted DCSDRs were accurate for each shift.

Based on observation, interview and record review it was determined the facility failed to ensure medications were properly secured, stored, labeled and expired medications were removed from the cart for 3 of 6 sampled medications carts reviewed for medication storage. This placed residents at risk for misappropriation and reduced medication efficacy. Findings include: The facility's 4/2025 Medication Storage Policy revealed the following: -All drugs and biologicals were to be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medications rooms) under proper temperature controls. -Refrigerated products were to be maintained at temperatures between 36 degrees F and 46 degrees F.-Unused medications that were outdated were to be destroyed. 1. The 2013 insulin lispro (HumaLOG) Kwikpen manufacturer instructions for storage and handling indicated unopened insulin pens should be stored in the refrigerator between 36 degrees F and 46 degrees F, and once opened, the pens should be discarded after 28 days. The 2018 insulin Humulin 70/30 Kwikpen manufacturer instructions for storage and handling indicated unopened insulin pens should be stored in the refrigerator between 36 degrees F and 46 degrees F, and once opened, pens should be discarded after 10 days. On 2/24/26 at 2:01 PM the 100 floor B wing medication cart was observed to have an unopened insulin lispro (HumaLOG) Kwikpen in a drawer. On 2/24/26 at 2:01 PM Staff 30 (LPN) confirmed the unopened insulin pen was in the medication cart and stated it should be refrigerated until it was opened. On 2/25/26 at 9:06 AM the 200 floor D wing medication cart was observed to have an open humulin 70/30 (NovoLOG) Kwikpen without an open date and one bottle of MaxTussin congestion expectorant with an expiration date of 11/2025 in its drawers. On 2/26/26 at 9:06 AM Staff 17 (RN) confirmed the open and undated insulin pen and expired expectorant. Staff 17 stated, once opened, insulin is generally good for 28 days but varied depending on the type of insulin and insulin pens should be labeled with an open date; additionally, Staff 17 stated the expired medication should have been removed and discarded. On 2/26/26 at 10:32 AM Staff 2 (DNS) confirmed unopened insulin was to be refrigerated and should not be stored in the medication carts. Additionally, Staff 2 stated once insulin is opened, it should be dated with an open date, as insulin was generally good for only 28 days after opening, but varied depending on the type of insulin. Staff 2 further stated expired medications should not be stored in the medication carts and should be promptly removed and destroyed. 2. On 2/23/26 at 9:25 AM, Staff 34 (RN) was observed to leave the medication cart in the D Hall unlocked and unattended where multiple staff were present. At 9:29 AM, Staff 34 returned to the cart and stated it should be locked at all times when not in use. Staff 34 revealed the contents of the cart to include all medications for residents in rooms 180 through 188, insulin pens, bowel care medications, prescription inhalers, eye drops, over-the-counter pain medications and supplements. On 2/26/26 at 6:00 AM, Staff 32 (Agency LPN) stated the medication cart should always be locked when not in use. On 2/26/26 at 10:32 AM, Staff 2 (DNS) stated she expected medication carts to be locked any time they were unattended.

Based on interview and record review it was determined the facility failed to transmit resident assessments in the required timeframe for 7 of 8 sampled residents (#s 15, 78, 79, 80, 82, 83 and 84) reviewed for late assessments. This placed at risk for untimely assessments, delayed and inaccurate care. Findings include:1. Resident 15 was admitted to the facility in 10/2025 with a diagnosis of a right leg fracture.Resident 15's health record revealed she/he was discharged from the facility on [DATE].No evidence was found in Resident 15's health record to indicate the facility transmitted her/his 5-day or Discharge MDS assessments.On [DATE] at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 15's missing Medicare 5-day and Discharge MDS assessments and stated she failed to verify their transmittal status after submitting them.On [DATE] at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.2. Resident 78 was admitted to the facility in 8/2025 with a diagnosis of a right foot fracture.Resident 78's health record revealed she/he was discharged from the facility on [DATE].No evidence was found in Resident 78's health record to indicate the facility transmitted her/his MDS discharge assessment.On [DATE] at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 78's missing MDS Discharge assessment and stated she failed to verify its transmittal status after submitting it.On [DATE] at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.3. Resident 79 was admitted to the facility in 3/2025 with a diagnosis of a left arm fracture.Resident 79's health record revealed she/he was discharged from the facility on [DATE].No evidence was found in Resident 79's health record to indicate the facility transmitted her/his MDS discharge assessment.On [DATE] at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 79's missing MDS discharge assessment and stated she failed to verify its transmittal status after submitting it. On [DATE] at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.4. Resident 80 was admitted to the facility in 6/2024 with a diagnosis of a periprosthetic fracture (a break in the bone occurring adjacent to an orthopedic implant) of the left hip joint.Resident 80's health record revealed she/he was discharged from the facility on [DATE].No evidence was found in Resident 80's health record to indicate the facility completed and transmitted her/his Entry tracking assessment or her/his Medicare 5-day assessment.On [DATE] at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 80's missing MDS Entry and Medicare 5-day assessments and stated she failed to verify their transmittal status after submitting them.On [DATE] at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.5. Resident 82 was admitted to the facility in 4/2025 with a diagnosis of other idiopathic peripheral autonomic neuropathy (acquired disorders with unknown causes that disrupt involuntary bodily functions, such as blood pressure, digestion and sweating).Resident 82's health record revealed she/he was discharged from the facility on [DATE].No evidence was found in Resident 82's health record to indicate the facility completed and transmitted her/his discharge assessment.On [DATE] at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 80's missing Discharge assessment and stated she failed to verify its transmittal status after submitting it.On [DATE] at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.6. Resident 83 was admitted to the facility in 4/2025 with diagnoses including stroke and dementia.Resident 83's health record revealed she/he was discharged from the facility on [DATE].No evidence was found in Resident 83's health record to indicate the facility transmitted her/his discharge assessment.On [DATE] at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 83's missing Discharge assessment and stated she failed to verify its transmittal status after submitting it.On [DATE] at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.7. Resident 84 was admitted to the facility in 3/2025 with a diagnosis of severe protein-calorie malnutrition.Resident 84's health record revealed she/he died in the facility on [DATE].No evidence was found in Resident 84's health record to indicate the facility completed and transmitted her/his Death in Facility discharge assessment.On [DATE] at 4:13 PM Staff 8 (Medical Records) acknowledged Resident 84's missing Death in Facility discharge assessment and stated she failed to verify its transmittal status after submitting it.On [DATE] at 1:47 PM Staff 1 (Administrator) stated MDS assessments were important because they provided information for the development of resident-centered care plans. Staff 1 stated he expected MDS assessments to be completed correctly and submitted in a timely manner.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 5, 10, 11, 12, and 13) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include:A review of personnel records on 2/26/26 indicated the following employees had not received their annual performance evaluations:-Staff 5 (CNA), hired date was 6/1989 and a performance review was not completed.-Staff 10 (CNA), hired date was 12/2024 and a performance review was not completed.-Staff 11 (CNA), hired date was 5/2024 and a performance review was not completed.-Staff 12 (CNA), hired date was 12/2022 and a performance review was not completed.-Staff 13 (CNA), hired date was 7/2002 and a performance review was not completed.On 2/26/26 at 2:59 PM Staff 29 (HR Assistant) stated she was unable to locate the most recent annual performance reviews for Staff 5, Staff 10, Staff 11, Staff 12, and Staff 13 and was unsure if they were completed for Staff 5, Staff 10, Staff 11, Staff 12, and Staff 13. On 2/27/2026 at 12:30 PM Staff 1 (Administrator) expected the annual performances to completed and confirmed annual performance reviews were not completed for Staff 5, Staff 10, Staff 11, Staff 12, and Staff 13.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 3 sampled residents (#48) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activities Policy revealed residents would be encouraged to participate in scheduled activities, and special considerations would be made for developing meaningful activities for residents with dementia and/or special needs. Resident 48 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system).Resident 48's 9/10/25 Activity Care Plan revealed the following:-The resident's preferred activities included visiting with family and friends, watching the Hallmark Channel and the morning and evening news on television, listening to rock and roll, classical, '70s and '80s music and playing bingo. -The resident would inform staff if she/he wanted to participate in activities.-The resident was able to self-direct her/his activity program. Resident 48's 11/2/25 Annual MDS revealed the resident was severely cognitively impaired, dependent on assistance from staff for all ADL care and her/his activities of importance included listening to music and doing her/his favorite activities. Resident 48's 2/17/26 Activity Assessment revealed the resident participated in independent activities of choice and a one-to-one program, rarely initiated conversations and was dependent on others for wheelchair transportation. A review of Activity Progress Note Documentation from 11/1/25 through 2/23/26 revealed Resident 48 received a one-to-one visit on 11/21/25 and 2/2/26. No evidence was found in Resident 48's clinical record to indicate she/he participated in out-of-room activities, including socializing with others or playing bingo. On 2/23/26 at 10:50 AM, Resident 48 was observed in her/his room in bed. No music played and the television that the resident shared with her/his roommate was off. Resident 48 was unable to answer any questions about her/his activity preferences at this time. On 2/23/26 at 3:19 PM, Witness 3 (Family Member) stated Resident 48 did not enjoy watching television, but she/he liked to listen to music, especially soothing music, being around others and visiting with friends. Witness 3 stated the resident experienced a decline in functioning, and as a result, needed help to make decisions. On 2/24/2026 at 8:48 AM, Resident 48 was observed awake in her/his room in bed. The resident's shared television was off. Resident 48 stated she/he wanted to get out of bed to attend activities and to go outside but staff did not help her/him to do so. Resident 48 further stated she/he enjoyed listening to music, especially '80s music, but she/he rarely had the opportunity to listen to this genre of music. On 2/24/26 at 11:42 AM, Resident 48 was observed awake in her/his room in bed. '70s music played on the resident's shared television. Resident 48 stated she/he was usually bored and she/he was interested in getting out of bed, but no staff had offered her/him the opportunity to do so. After this interaction, Resident 48 thanked the state surveyor for the visit. On 2/24/26 at 3:17 PM, Resident 48 was observed in room in bed. The resident's shared television played '70s music. Resident 48 stated she/he received a hand massage today, she/he enjoyed it and it had been a while since she/he last received one. Resident 48 asked the state surveyor to turn off the music as she/he was unable to do so independently. Random observations of Resident 48 on 2/25/26 from 8:58 AM to 2:38 PM revealed the resident to be awake in her/his room in bed. The shared television was off and no music played. On 2/26/26 at 10:06 AM, Resident 48 was observed in her/his room and sat in her/his wheelchair. Rock music played loudly from the resident's shared television. Resident 48 stated she/he did not like the music. On 2/26/26 at 5:13 AM, Staff 23 (CNA) stated Resident 48 was not able to use the television remote independently, and she/he usually watched whatever program her/his roommate selected on their shared television. On 2/26/26 at 5:40 AM, Staff 32 (Agency LPN) stated he was unaware of Resident 48's activity preferences but would look in the resident's care plan to find this information. Staff 32 further stated he had seen the resident out of her/his room once or twice.On 2/26/26 at 5:56 AM, Staff 33 (CNA) stated Resident 48 was usually in bed and she had not seen the resident out of her/his room for any activities. Staff 33 stated the resident was cooperative with care and did not refuse anything.On 2/26/26 at 10:30 AM, Staff 14 (RN), stated Resident 48 got up in her/his wheelchair today for the first time in a long time. Staff 14 stated the resident did not really do much, the resident's cognition varied, she/he was not able to express her/his wants or needs or self-initiate any activities. Staff 14 stated the resident's roommate picked which programs played on their shared television, the resident enjoyed being around others when alert, and she was unaware of any reports of the resident refusing care, including getting out of bed. On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated Resident 48's alertness was on-and-off. Staff 15 stated she was unsure if the resident liked music but thought the resident liked to have the television on, not to watch, but as background. Staff 15 stated she did not know if the resident enjoyed being around others and she was unaware of any activity participation for the resident. On 2/27/26 at 10:23 AM, Staff 6 (CNA) stated Resident 48 alternated between days when she/he would sleep a lot and other days when she/he would be very alert and laughing. Staff 6 stated the resident was cooperative with care on the days she/he was alert but staff did not typically get [the resident] out of bed. On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 24 stated Resident 48 needed to be offered the opportunity to get out of bed as the resident did not request to do so, and they had never been made aware the resident refused to get out of bed. Staff 24 further stated the resident was such a social butterfly and she/he enjoyed being around people and around the building. Staff 1 stated the resident was very much a people person.On 2/27/26 at 11:44 AM, Staff 1 and Staff 26 (Activity Director) were present for an interview. Staff 26 stated residents who were able to self-initiate activities were residents who were very cognitive, outspoken and could self-advocate. Staff 26 stated residents identified to receive one-to-one visits were those residents who could not self-initiate activities and/or did not attend group activities. Staff 26 stated her goal was to visit with residents who were identified as needing one-to-one visits a few times a week, and worse case, one time a week. Staff 26 stated one-to-one visits were documented in the resident's progress notes when they occurred. Staff 26 stated Resident 48 was to receive one-to-one visits and she thought she visited with the resident maybe two-to-three times a month. Staff 26 stated Resident 48 enjoyed watching crime shows on television but did not know how often she/he was able to do so as she was unsure if her/his roommate enjoyed these types of shows. Staff 26 stated the resident enjoyed '70s and '80s music but her/his roommate was not excited about it, so she provided Resident 48 with a personal radio on 2/27/26. Staff 26 stated Resident 48's cognition was not super, and her/his care plan was in need of revision. Staff 26 stated Resident 48 used to get up to play bingo and come out of her/his room, but she had not seen the resident do either in a while. Staff 26 stated she did not think the resident refused to get out of bed and the last time she invited the resident to an activity was around Christmas.

Based on observation, interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were provided for 1 of 1 sampled resident (#1) reviewed for hearing. This placed residents at risk for social isolation and decreased quality of life. Findings include:The facility's 4/9/25 Hearing Services Policy revealed the following:-The facility was to ensure all residents had access to hearing services and received adaptive equipment as indicated. -The social worker/designee was responsible for assisting residents in locating and utilizing any available resources for the provision of hearing services. -Once the need for hearing services was identified, the social worker/designee was to assist the resident to make appointments and arrange for transportation. Resident 1 was readmitted to the facility in 1/2025 with diagnoses including congestive heart failure. A 2/19/25 Audiogram (a graph that plots hearing thresholds to determine the type, degree and configuration of an individual's hearing loss) recommended Resident 1 receive a hearing aid consultation and her/his hearing to be retested in three months. Resident 1's 5/6/25 Care Plan revealed the following:-The resident was hard of hearing and did not wear hearing aids.-Conversations with the resident were best in a low volume environment. -Staff were to use a loud and clear voice. -The resident would ask the speaker to repeat as needed. -The resident preferred to keep the volume of her/his television loud as she/he was hard of hearing. A 7/23/25 and 10/16/25 Care Conference Meeting Note revealed Resident 1 expressed she/he could not hear out of her/his left ear and she/he wanted hearing aids. Resident 1's 1/11/26 Annual MDS revealed the resident was moderately cognitively impaired but was able to communicate with others without difficulty. A 1/8/26 Care Conference Meeting Note revealed Resident 1's left ear was fading and she/he needed hearing aids. No evidence was found in Resident 1's clinical record to indicate her/his hearing was retested or she/he received a hearing aid consultation. On 2/23/26 at 10:04 AM, Resident 1 was observed in her/his room in bed. The resident's television was on and could be heard from the hallway even with the door to her/his room closed. Resident 1 turned off the television and stated she/he could partially hear out of her/his right ear but could not hear at all out of her/his left ear. Resident 1 further stated she/he saw an audiologist about a year ago who recommended hearing aids but nothing was done with this recommendation. On 2/25/26 at 1:47 PM, Staff 31 (CNA) stated Resident 1's hearing was partial and that was why the resident's television volume was always up so high. On 2/26/26 at 5:10 AM, Staff 23 (CNA) stated Resident 1 could not hear on one side, so staff had to yell in order for her/him to hear. Staff 23 stated the volume of the resident's television was always over 100, and staff would ask the resident to reduce the television's volume during interactions in order for the resident to hear better. On 2/26/26 at 5:35 AM, Staff 32 (Agency LPN) stated Resident 1 was very hard of hearing, so much so, that the resident's television could be heard in the kitchen down the hall. Staff 32 stated he frequently repeated his communications to the resident because she/he could not hear. On 2/26/26 at 8:26 AM, Staff 14 (RN) stated Resident 1 always had complaints about her/his hearing. On 2/26/26 at 11:06 AM, Staff 9 (Social Services Director) stated hearing appointments were scheduled for residents as soon as possible after a hearing need was identified. Staff 9 stated she was unaware Resident 1 had an audiogram in 2/2025 and did not know the resident was interested in receiving hearing aids until 1/2026. Staff 9 stated the resident was on a list to be seen by a hearing provider but confirmed the resident had not received any follow up hearing appointments since her/his audiogram in 2/2025. On 2/26/26 at 11:49 AM, Staff 2 (DNS) stated hearing aid referrals should be followed up on as soon as possible, and Resident 1's hearing should have been retested in 5/2025.

Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 1 of 3 sampled residents (#60) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for unknown financial liabilities. Findings include:Resident 60 was admitted to the facility on [DATE] with Medicare A benefits.A 2/2/26 NOMNC (Notice of Medicare Non-Coverage) indicated Resident 60's Medicare Part A benefits ended on 2/4/26.Review of Resident 60's health record indicated the resident remained in the facility and was financially responsible for her/his care from 2/5/26 to 2/26/26. There was no documentation indicating the SNF ABN notification was provided to Resident 60 or their representative to inform them of the resident's daily out-of-pocket costs. On 2/24/26 at 2:27 PM Staff 9 (Social Services Director) acknowledged Resident 60 was not issued a SNF ABN. Staff 9 stated her expectation was residents or their representatives were informed of the resident's daily out-of-pocket costs via a SNF ABN notification form.On 2/27/2026 at 12:30 PM Staff 1 (Administrator) acknowledged Resident 60 was not issued a SNF ABN. Staff 1 stated he expected all residents to be issued a SNF ABN if they stayed in the facility.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received dressing assistance for 1 of 4 residents (#48) reviewed for ADLs. This placed residents at risk for unmet care needs and loss of dignity. Findings include: The facility's 9/2024 Activities of Daily Living Policy revealed the following:-A resident who is unable to carry out, or dependent with, activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. -The facility will maintain individual objectives of the care plan and periodic review and evaluation. Resident 48 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system).Resident 48's 9/10/25 ADL Care Plan revealed the resident required assistance from one person with dressing.Resident 48's 1/25/26 Quarterly MDS revealed the resident experienced short-and-long term memory loss, was severely impaired for decision-making, dependent on assistance from staff for all ADL care and did not exhibit the behavior of rejecting care.A review of Resident 48's Upper and Lower Body Dressing Task Logs from 2/3/26 to 2/25/26 revealed the resident did not refuse to get dressed. On 2/23/26 at 12:27 PM, Resident 48 was observed in her/his room in bed wearing a hospital gown. Resident 48 stated wearing a hospital gown was not her/his preference, and she/he liked to get dressed. Resident 48 further stated no staff offered to assist her/him to get dressed on 2/23/26. On 2/23/26 at 3:19 PM, Witness 3 (Family Member) stated Resident 48 got dressed every morning prior to her/his admission to the facility. Witness 3 stated the last few times he visited Resident 48 at the facility; the resident was dressed in a hospital gown. On 2/24/26 at 3:17 PM, Resident 48 was observed in her/his room in bed wearing a hospital gown. Resident 48 stated she/he wanted to get dressed in regular clothes, but no staff had offered to assist her/him to do so. On 2/25/26 at 1:42 PM, Resident 48 was observed in her/his room in bed wearing a hospital gown. On 2/26/26 at 5:13 AM, Staff 23 (CNA) stated she was unaware of Resident 48's clothing preferences, but stated all residents were expected to get dressed in the morning unless the resident refused. On 2/26/26 at 5:56 AM, Staff 33 (CNA) stated Resident 48 was cooperative with care and did not refuse anything. On 2/26/26 at 10:30 AM, Staff 14 (RN) stated she had not seen Resident 48 dressed in something other than a hospital gown in the last month. Staff 14 further stated she thought Resident 48 preferred to wear nightgowns during the day and she had never received reports from CNA staff of the resident refusing to get dressed or change clothes. On 2/26/26 at 1:28 PM, Staff 15 (CNA) stated she encouraged all residents to get up and get dressed before breakfast. Staff 15 stated Resident 48 was dependent on staff assistance to get dressed and the resident did not refuse. On 2/27/26 at 10:32 AM, Staff 1 (Administrator), Staff 2 (DNS) and Staff 24 (MDS Coordinator-RN) were present for an interview. Staff 2 stated she expected all residents to get dressed in the morning unless their care plan specified otherwise. Staff 24 further stated Resident 48's care plan did not specify a preference to wear hospital gowns or that she/he was resistive to care.

Based on observation, interview and record review, it was determined the facility failed to assess and conduct weekly wound evaluations for pressure ulcer care for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. This placed residents at an increased risk for delayed healing and inadequate treatment. Findings include: Resident 2 was admitted to the facility in 7/2024, with diagnoses including atherosclerosis of the arteries (build up of plaque in the arteries, narrowing them and reducing blood flow), diabetes, hypertension, chronic heart failure and atrial fibrillation. On 2/27/25 at 9:25 AM, 12:38 PM, and on 2/28/25 at 8:25 AM, Resident 2 was observed sitting in her/his electric wheelchair in her/his room or through the facility. Resident 2 was pleasant, alert and oriented with clear speech. On 2/28/25 at 10:32 AM, RN surveyor observed Resident 2's pressure ulcer located on her/his right buttock, ischial area (lower part of the pelvis) to be closed, smaller than the size of a penny, reddened area. Resident 2's 1/26/25 Weekly Skin Evaluation identified the resident had a right buttock pressure ulcer, 0.25 x 0.25 x 0.0 cm, with no drainage. The stage of the wound was not identified. Resident 2's 1/29/25 Progress Note indicated the resident has open excoriation to the right ischium which has declined and the wound was open., with defined wound edges and measuring 0.4 x 0.5 x 0.0 cm. The wound bed is 100% slough, no serous drainage (a clear, thin, watery fluid that is released from a wound) noted. The open wound appears pressure related and suspected to be an unstageable pressure injury. There was no documented evidence weekly skin evaluations were conducted until 2/16/25, 17 days after 1/29/25. Subsequent weekly skin evaluations on 2/5/25 and 2/12/25 were not conducted. Resident 2's Weekly Skin Evaluations found the following: -2/16/25: Right gluteal fold, pressure. Right buttock pressure injury, clean with wound cleanser, skin prep surrounding skin, cover with a foam dressing every day until resolved. -2/23/25: Wound to right buttock. Moisture associated skin damage (MASD) to right and left quadrant. Dressing to right buttock dry and intact. The Weekly Skin assessments for 2/16/25 and 2/23/25 did not identify the stage of the pressure ulcer, include measurements, or provide a description of the wound. On 2/27/25 at 1:54 PM, Staff 2 (RN/Wound Nurse) stated Resident 2 has a Stage 3 on her/his buttocks due to the resident not wanting to get out of her/his electric wheelchair. Staff stated we encourage the resident to get off her/his buttocks, but the resident prefers to be up in her/his wheelchair. On 2/28/25 at 8:31 AM, Staff 4 (CNA) stated Resident 2 was independent with her/his ADLs and was always in her/his electric wheelchair. In an interview on 2/28/25 at 11:06 AM, Staff 1 (DNS), stated she would expect weekly skin assessments to be conducted and to have a wound staged, measured and description provided on the skin evaluations. Staff stated she had ordered a wheelchair cushion for the resident, but she/he removes the cushion and places it in her/his manual wheelchair.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' change of condition was assessed for 2 of 6 sampled residents (#s 38 and 89) reviewed for hospitalization and unnecessary medications. This failure, determined to be an immediate jeopardy situation, resulted in the delayed assessment of Resident 89 when she/he was experiencing a significant change in condition, resulting in delayed treatment. Resident 89 later died at the hospital. This placed all residents at risk for delayed assessments and treatments and constituted substandard quality of care. Findings include: Per National Library of Medicine online resource: Bleeding in the upper stomach and intestinal region carries a high morbidity (sudden onset of a health condition) and mortality (death) which can be lowered by timely evaluation and treatment. Signs of this condition include vomit which looked like coffee grounds. 1. Resident 89 was admitted to the facility on [DATE] with a diagnosis of lung cancer with metastasis (cancer spreads to other body systems). Resident 89's [DATE] physician orders revealed Resident 89 was a full code (life sustaining treatment provided if there were no respirations or heart beat). Vital signs from [DATE] to [DATE] revealed Resident 89's vital signs were last obtained on [DATE] at 2:22 PM. Resident 89's pulse was 81 (normal healthy adult range ,d+[DATE]) and respirations were 18 breaths per minute (normal healthy adult range ,d+[DATE]) and blood pressure was not obtained. Progress Notes revealed the following: -[DATE] Resident 89 was admitted to the facility for therapy. Resident 89 was alert to person, place, time, and situation and was able to make her/his needs known. Resident 89 was continent of bowel and bladder and was able to eat independently. -[DATE] Resident 89 was able to make her/his needs known. -[DATE] Resident 89 was assessed by her/his physician and was assessed to be a full code. Resident 89 reported she/he wanted to get stronger and go home. Resident 89 was assessed to have a normal thought process, was in no distress, and interacted during the exam. Resident 89's abdomen was soft and nontender. Resident 89 was also assessed to have normal range of motion to her/his arms, had weakness to the left ankle, and her/his skin was normal in appearance and temperature. Resident 89 was a candidate for hospice but prefers to be a full code. -[DATE] and [DATE] Resident 89 participated with therapy without issue and was alert with some forgetfulness. -[DATE] note written at 3:40 AM by Staff 30 (LPN) indicated Resident 89 vomited once, Zofran (treats nausea) was administered, and Resident 89 did not have continued vomiting. Resident 89 was placed on alert charting. There was no documentation of vital signs, characteristics of the vomit, or if the resident's physician was notified. -[DATE] note written at 10:09 AM revealed at 6:50 AM Resident 89 was observed by a nurse to be in bed sleeping. At 7:20 AM a CNA summoned the nurse urgently and Resident 89 was found without a pulse or respirations. Staff initiated CPR (cardiopulmonary resuscitation: chest compressions and manual ventilations), emergency services were notified, and at 8:00 AM Resident 89 was transported to the local hospital. -[DATE] note written at 12:13 PM and 12:20 PM by Staff 2 (DNS) revealed she called Staff 34 (CNA) who worked the night shift on [DATE] and Staff 34 stated Resident 89 reported nausea and vomited once. The vomit looked like coffee grounds. The note indicated Staff 34 reported to Staff 30 (LPN) Resident 89 vomited but nothing else. Staff 34 reported Resident 89 was a little pale, not acting her/himself, and maybe a little lethargic. Staff 34 stated on [DATE] at 5:15 AM she checked on the resident and Resident 89 was pale and sleeping. The note indicated Staff 34 was educated to inform the nurse of the color and consistency of fluids even if the nurse did not ask. Staff 30, who worked [DATE], reported the CNA informed her Resident 89 vomited at about 1:30 AM. Staff 30 stated she assessed the resident, the resident was able to talk, was able to report nausea, had good color and no other signs or symptoms. On [DATE] at 12:41 PM Staff 34 stated prior to [DATE] Resident 89 was usually very talkative and engaged when she provided care. On [DATE] at approximately 11:00 PM Resident 89 was clammy, tired, and did not talk much. Staff 34 stated she requested Staff 30 check on Resident 89. Staff 34 stated she was not sure if Staff 30 checked on Resident 89 because Staff 34 was busy caring for other residents. Staff 34 stated at approximately 1:00 AM, when she next checked on Resident 89, she found the resident with vomit coming out of her/his mouth and on her/his gown, the resident was incontinent of a large bowel movement, and she/he did not respond very much. Staff 34 stated she notified Staff 30. Staff 34 also stated she told Staff 30 Resident 89 had coffee ground vomit. Staff 34 indicated she was in the room with Resident 89 for about 10 minutes providing care after she notified the nurse and the nurse did not come into the room. Staff 34 stated she was not sure when Staff 30 checked on the resident. Staff 34 stated she did not obtain vital signs and the next time she saw Resident 89 was at about 5:15 AM and she/he was breathing but was still pale and clammy. On [DATE] at 1:21 PM Staff 33 (Nurse Practitioner) stated if a resident was a full code, no matter their medical condition, staff needed to treat a resident's change of condition. If a resident had coffee ground vomit and a medical provider was not on site to assess the resident, staff were to send the resident out to the hospital because staff were limited in the interventions they would be able to provide at the facility. On [DATE] at 2:00 PM Staff 35 (Physician) stated if a resident had coffee ground vomit and was stable the facility could monitor the resident in the facility. Monitoring would include vital signs. Staff 35 stated if a resident had a change in mental status, was pale and clammy, in addition to the coffee ground vomit, the resident would not be stable, the physician should be notified for guidance, and the resident should be sent to the hospital for evaluation. On [DATE] at 3:55 PM Staff 30 stated she did not recall Resident 89, but stated if a resident had coffee ground vomit the resident should be sent to the hospital because it could indicate internal bleeding. Staff 30 also stated if a resident's physician was called to obtain orders a note should be made in the progress notes regarding the resident's condition which required communication with the physician. On [DATE] at 12:01 PM and 3:58 PM Staff 2 (DNS) stated when she walked into the building on [DATE] staff were already performing CPR on Resident 89. Staff 2 stated she spoke to staff who worked the night shift and the day shift nurse who found Resident 89 without pulse or respirations. The day nurse stated Staff 30 reported the resident had nausea, vomiting, and nothing else. Staff 30 stated the resident was nauseated, she gave Zofran and it helped. Staff 2 stated Staff 30 reported she did not evaluate or see the vomit. Staff 2 indicated she called Staff 34, asked about the vomit, and she stated you won't believe it, but it looked just like coffee grounds. Staff 2 stated she educated the Staff 34 to always describe to the nurse what the vomit looked like. Staff 2 also educated Staff 30 to always do more of an assessment and ask what the vomit looked like. Staff 2 acknowledged on [DATE] at approximately 1:00 AM Resident 89 was administered Zofran and the resident was found without a pulse or respirations at about 7:00 AM. Staff 2 verified there were no vital signs obtained on [DATE] and there was no assessment of the resident and resident's vomit. Staff 2 stated Staff 30 reported she did an assessment but did not document it. Staff 2 confirmed on [DATE] at approximately 11:40 AM Resident 89 died at the hospital. On [DATE] at 10:18 AM Staff 2 (Administrator) was notified of the immediate jeopardy (IJ) situation and was provided the IJ template related to the facility failure to assess, monitor, and document a resident's significant change of condition. As a result of the deficient practice, treatment was delayed for Resident 89. On [DATE] at 3:27 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following: -On [DATE] a review of other residents' change of condition, over the past week that may be affected, was completed by the DNS and designated staff. Other residents identified with a change of condition were to have assessments completed by the end of the day and residents' primary care physicians would be notified as appropriate. -Education for the Nurse and CNA was completed by the assistant DNS after the incident on [DATE]. Further education would be completed on [DATE] with every employee (clinical, administrative, social service, activities, housekeeping, dietary and maintenance) to communicate changes in condition. Employees not on shift would be trained prior to starting shift with review of policy and procedure , then signing off on understanding and implementation. Once notified of a change of condition, the nurse would document, complete an assessment that day, and notify the primary care physician as appropriate. - Performance Improvement Project for change of condition would be initiated by the DNS or designee to audit 1.) Resident change of condition and 2.) Nurse assessments were completed the day of reported change of condition. The audits would be conducted weekly for one month, then twice a month for two months, and randomly thereafter. Results would be shared with Quality Assurance and Performance Improvement committee until substantial compliance was achieved. Additional documentation was later provided to show additional staff were educated about reporting changes of condition by staff 2 during huddles on [DATE], [DATE], [DATE] and [DATE], thereby removing the immediate jepordy on [DATE]. 47000 2. Resident 38 was admitted to the facility in ,d+[DATE] with diagnoses including hypertension (a condition where the pressure of blood in the blood vessels is consistently too high), coronary artery disease (heart disease) and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm or become blocked). Resident 28's [DATE] Annual MDS revealed the resident was cognitively intact and received a diuretic (a medication used to treat fluid retention [edema] and swelling caused by congestive heart failure, liver disease, kidney disease and other medical conditions). The Dehydration/Fluid Maintenance CAA indicated the resident had adequate fluid intake and did not appear dehydrated. In response to the question in the CAA which asked whether or not dehydration/fluid maintenance would be addressed in the resident's care plan, not assessed was checked. A review of Resident 38's weights revealed the following: -On [DATE] the resident weighed 154.5 pounds. -On [DATE] the resident weighed 163.4 pounds. This represented an 8.9 pound weight gain from her/his weight on [DATE]. -On [DATE] the resident weighed 171.5 pounds. This represented an 8.1 pound weight gain from her/his weight on [DATE] and a 17 pound weight gain from her/his weight on [DATE]. Resident 38's [DATE] Physician Progress Note indicated the resident experienced brawny edema (a type of edema that does not indent when pressure is applied, unlike pitting edema, when a swollen part of your body has a dimple [or pit] after you press it for a few seconds) of her/his lower legs. A [DATE] Physician's Order directed Resident 38 to receive furosemide (a diuretic) one time daily for edema. No evidence was found in Resident 38's clinical record to indicate the resident's weight gains had been reported to the resident's physician or the underlying cause of the weight gain had been assessed, any systems were in place to monitor changes in the resident's edema or the potential for fluid overload (indicative of too much water in a person's body which can raise blood pressure and force the heart to work harder) had been assessed. On [DATE] at 12:24 PM Staff 2 (DNS) stated Resident 38's edema was not being monitored and should be and she did not know if Resident 38's physician had been notified of the resident's weight gains. On [DATE] at 12:52 PM Resident 38 was observed in her/his room in bed. Staff 40 (RN) removed the resident's socks in order to assess her/his legs and feet. An indent in each of the resident's legs was observed once the socks were removed. When Staff 40 pushed on the resident's ankles, she/he yelled out and stated Staff 40 was hurting her/him. Staff 40 stated the resident's ankles were a plus 1 for edema (a barely visible dent that immediately rebounded after pressure was applied) but the top of her/his feet were a plus 2 (a slight pit that went away within 15 seconds). Staff 40 stated the resident did not have scheduled monitoring for her/his edema, the top of her/his foot was not normally like that, the change in swelling was not reported to her and the physician had not been notified of this change. On [DATE] at 2:03 PM Staff 41 (Agency RN) stated she was the charge nurse for day shift and was responsible for Resident 38's care. Staff 41 stated she did not receive any reports of Resident 38's edema. On [DATE] at 3:05 PM Staff 2 acknowledged the findings and provided no additional information.

Based on observation, interview and record review it was determined the facility failed to ensure residents received timely specialized rehabilitative services (PT and OT services) for 1 of 1 sampled resident (#20) reviewed for rehabilitation and restorative. This failure resulted in Resident 20 displaying a depressed mood, verbalizing feelings of frustration and a decline in physical functioning. Findings include: The facility's 1/2023 Therapy Evaluation Policy indicated the following: -The Rehabilitation Department was to be notified when a physician order was written for therapy evaluation and treatment. -The licensed therapist was to perform a chart review and initiate the evaluation. -The initial evaluation was to be completed within two to three days from the time the referral was written. Resident 20 was admitted to the facility in 9/2022 with diagnoses including a history of falls. A review of Resident 20's clinical record revealed she/he was hospitalized from 10/23/23 to 10/27/23 related to sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, causing inflammation, blood clots and leaky blood vessels) secondary to a urinary tract infection. Resident 20's 10/26/23 PT Treatment Note completed during the resident's hospital stay indicated the resident was able to complete a stand-pivot transfer to a chair, bedside commode or wheelchair with a gait belt, front-wheeled walker and contact guard assist (a type of assistance where a caregiver places one or two hands on a patient to help with balance but does not provide any other help with a task). The note further indicated the resident required standby assistance from a caregiver for bed mobility. Resident 20's 10/27/23 ICF Admission Orders directed nursing staff to continue with the functional mobility and ADL levels established in the hospital as allowed per weightbearing status until the resident was seen by PT. Resident 20's 10/27/23 Physician Orders indicated PT and OT was to assess and treat the resident. Resident 20's 10/27/23 Readmission Form indicated the resident required limited assistance from staff with transfers. No evidence was found in Resident 20's clinical record to indicate she/he was assessed and treated by PT or OT since she/he readmitted to the facility from the hospital on 10/27/23. Resident 20's 9/1/24 Modification of Annual MDS Assessment indicated the resident was moderately cognitively impaired, dependent on staff assistance for transfers and experienced mild depression. The CAAs further indicated the resident required extensive assistance with bed mobility as she/he experienced deconditioning (a decline in physical and mental function that occurs due to a lack of physical activity or extended bed rest), pain and weakness. Resident 20's 9/11/24 ADL Performance Deficit Care Plan revealed the following: -The resident required assistance from two staff and the use of a Hoyer lift (a mobile device that helps caregivers safely transfer patients with limited mobility from one place to another) for all transfers. -The resident was unable to use a bedside commode or toilet. On 10/7/24 at 12:01 PM Resident 20 was observed in her/his room, in bed. Resident 20 stated she/he did not receive any therapy, no one does any exercises with me and she/he pretty much just stayed in bed and waited for friends to come and visit. Resident 20 stated no one at the facility gave a shit and she/he thought all the staff had written [her/him] off. On 10/10/24 at 1:43 PM Resident 20 stated she/he felt as if she/he had physically declined and was weaker all over. Resident 20 stated she/he did not sit up very well anymore because she/he spent all her/his time laying down, she/he wanted to be able to stand again and she/he did not like feeling weaker and dependent. On 10/10/24 at 10:00 AM Staff 20 (CNA/RA) stated she was not responsible for assisting the resident with any restorative exercises and the resident did not currently receive any therapy services. On 10/10/24 at 10:36 AM Staff 23 (Agency CNA) stated Resident 20 required a Hoyer lift for transfers and the resident no longer used the toilet or bedside commode but had incontinent care provided in bed instead. Staff 23 stated the resident was a more active participant in her/his ADLs a few months ago but right now she had to do everything for [the resident's] lower body. On 10/10/24 at 10:46 AM Staff 24 (CNA) stated she had not seen Resident 20 get out of bed since 2/2024. Staff 24 further stated in 2/2024 the resident required the assistance of one to two staff with transfers but now she/he used a Hoyer lift. On 10/10/24 at 2:12 PM Staff 21 (Director of Therapy) stated she was not aware of Resident 20's order for PT and OT from 10/27/2023 and the last time the resident received therapy services was in 5/2023. On 10/10/24 at 4:37 PM Staff 2 (Interim DNS) acknowledged the findings and confirmed the resident should have received therapy services following her/his hospitalization in 10/2023 but did not.

Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed regarding their legal rights. Findings include: On 10/14/24 at 1:01 PM Staff 1 (Administrator) stated the facility offered a Mediation and Arbitration Clause to residents upon admission. Staff 1 stated he and Staff 5 (Bookkeeper) were responsible for the process of explaining the agreement to residents upon admission. On 10/14/24 at 1:06 PM Staff 5 stated she was responsible to provide residents with information related the facility's Mediation and Arbitration Clause. Staff 5 stated the information was part of the admission handbook, she did not explain the arbitration process to residents nor did she obtain signatures with dates. On 10/14/24 at 1:06 PM Staff 1 acknowledged the facility did not have a clear process for providing information regarding binding arbitration agreements to residents.

Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG monitors were cleaned with an approved disinfectant for 3 of 6 sampled units (2, 2D and 1B) observed during medication administration and random observations, failed to implement EBP (enhanced barrier precautions: gloves and gowns worn during high contact for wounds and indwelling devices) timely for 1 of 2 sampled residents (#5) reviewed for pressure ulcers, failed to transport linens in a sanitary manner, and failed to ensure a legionella water management plan for 1 of 1 facility. This placed residents at risk for cross contamination. Findings include: 1. On 10/8/24 at 8:34 AM Staff 15 (LPN) was observed to clean a community use CBG with an alcohol swab. Staff 15 was stopped prior to entering a resident's room to perform a CBG check. Staff 15 stated she used alcohol swabs to clean CBG machines and at times used bleach wipes. On 10/8/24 at 9:05 AM Staff 37 (LPN) sated she cleaned the community use CBG on the 1B hall with alcohol wipes. All residents with CBG orders were reviewed and were found to not have any bloodborne pathogen diagnoses. On 10/8/24 2:35 PM Staff 2 (DNS) acknowledged alcohol wipes were not effective against blood borne pathogens. 2. Resident 5 was admitted to the facility in 4/2024 with a diagnosis of a chronic pressure ulcer. Resident 5's TARs revealed wound care was provided from 4/24/24, date of admission, to the current date. Progress Notes by Staff 29 (IP) revealed the following: -4/25/24 Resident 5 was identified to have a urostomy tube (surgical tube to drain urine from the bladder), an advanced bone infection from a chronic pressure ulcer, and had a history of a drug resistant organism. The note also indicated Resident 5 does not require any Transmission Based Precautions (EBP) at this time. Resident 5's care plan was not updated with EBP until 8/2024. On 10/11/24 at 9:34 AM Staff 29 stated when a resident was admitted to the facility she looked at the admission paperwork to identify if a resident had a clinical need for EBP, including chronic wounds, a care plan was implemented, signage placed on the resident's door and the PPE was placed by the resident's room. Staff 29 acknowledged Resident 5 was admitted to the facility in 4/2024 and EBP was not implemented until 8/2024. 50927 3. On 10/10/24 at 12:16 PM Staff 22 (Laundry Services) was observed to deliver clean resident clothing throughout wings B and C on the 2nd floor. A small sheet was draped over a portion of the cart but did not cover all of the clean clothing as staff went from room to room. On 10/10/24 at 12:16 PM Staff 22 indicated she always delivered clean laundry in this manner. On 10/11/24 at 2:10 PM Staff 1 (Administrator) acknowledged the findings of this investigation and did not provide any additional information. 4. On 10/10/24 at 8:45 AM Staff 10 (Campus Director of Facility Services) was asked about the facility's water management program related to potential areas of Legionella growth. Staff 10 stated she was not aware of a program. Staff 10 stated she had not monitored for areas of potential Legionella growth since taking the position in March 2024. On 10/10/24 at 4:19 PM Staff 1 (Administrator) confirmed the facility had not developed and implemented a water management program. No further information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure dignified language was used to address residents and their equipment for 1 of 1 facility and 1 of 2 sampled residents (#14) reviewed for dignity. This placed residents at risk for a decreased quality of life. Findings include: The Alzheimer's Association's Greater Missouri Chapter's 7/2017 Person Centered Care in Nursing Homes and Assisted Living revealed language is important in the change to person centered care. Language can either support change efforts or undermine them. Concepts of personalization and relationship-building cannot take root when a resident requiring assistance at mealtime is referred to as a feeder or when the act of walking is referred to as ambulation. Purposeful lives unfold in communities, not in facilities. The widely used language of long-term care continues to reflect an institutional orientation. Part of a change effort must be thoughtful consideration of the words and expressions used to describe the care provided and the way people and spaces are referred to in long term care communities. 1. On 10/7/24 at 11:54 AM three metal meal tray carts on the facility's second floor and on 10/15/24 at 10:47 AM one metal meal tray cart on the facility's first floor were observed with a sign posted on each above an open container that read: For bibs/cloth protectors and green wipes only. On 10/15/24 at 9:13 AM Staff 1 (Administrator) acknowledged the findings and did not provide any additional information. 2. Resident 14 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues and other health concerns). A 9/16/24 Progress Note revealed Resident 14 was identified as a 1:1 feeder. On 10/7/24 at 1:04 PM an unidentified CNA entered Resident 14's room with the resident's meal tray and stated the resident was a feeder. On 10/14/24 at 10:48 AM Staff 26 (CNA) stated the facility used the term feeder to describe residents who needed supervision at mealtimes and Resident 14 was considered a feeder. On 10/15/24 9:13 AM Staff 1 (Administrator) acknowledged the findings and did not provide any additional information.

Based on observation, interview and record review it was determined the facility failed to provide a homelike environment for 1 of 1 resident (#340) reviewed for hospice and in 1 of 1 facility reviewed for environment. This placed residents at risk for a lack of autonomy and living in an unkempt environment. Findings include: The facility's revised 7/3/23 Safe and Homelike Environment Policy directed staff in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment. The facility would create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. 1. Resident 340 was admitted to the facility in 8/2024 with diagnoses including dementia. On 10/7/24 at 12:01 PM Resident 340 was observed in her/his room with no personalized items or decorations in the room. On 10/10/24 at 1:47 PM Resident 340 stated she/he would like something good to look at in her/his room. On 10/14/24 at 9:50 AM Staff 7 (Activities Coordinator) stated it was up to the residents' family to bring in items to personalize a residents' room. On 10/14/24 at 11:16 AM Staff 9 (Social Services Coordinator) stated she provided social services for Resident 340's room. Staff 9 stated if the long-term residents wanted to decorate the residents' room, they could have their family bring personal items into the facility and she would check with administration first to see if it was okay. To her knowledge, Resident 304's family had not been contacted and the facility had not provided personalized decorations for her/him to look at in her/his room. On 10/15/24 at 9:13 AM Staff 1 (Interim Administrator) acknowledged he expected resident rooms' to be personalized. 43690 Observations of the facility's general environment and residents' rooms from 10/7/24 through 10/15/24 identified the following issues: -Hall C had 2 missing handrail end caps on each side of the hall exposing sharp/jagged edges. -The west hall outside the kitchen entrance had a missing handrail end cap. -The handrails across from therapy room had an approximate 2 inch open gap exposing metal. -The sitting area on the 1st floor surrounding the nurses station had four couches made from synthetic material that were torn and tattered. -The library on the 2nd floor had a couch and chair made from synthetic material that were torn and tattered. -Large sections of missing brown paint on the door frames for rooms 135, 144, 156, 169, 183, 184, 260, and the housekeeping closet (1st floor) door across from room [ROOM NUMBER]. -room [ROOM NUMBER]'s door had an approximate 4 inch piece of wood missing on the lower section exposing sharp/jagged edges. -Dirty light fixtures outside room [ROOM NUMBER] and outside the 1st floor elevator on the west hall. -room [ROOM NUMBER] had large sections of missing paint on the door. -The lower sections of the corner walls outside Rooms 237, 243, 253, 256, 283 had an approximate 4 inch gouge with missing paint and exposed drywall. On 10/15/24 at 8:20 AM Staff 1 (Administrator) and Staff 10 (Director of Facility Services) acknowledged the identified rooms and maintenance concerns needed to be repaired.

Based on interview and record review it was determined the facility failed to ensure a bed hold policy was provided to a resident when transferred to the hospital for 2 of 2 sampled residents (#s 16 and 33) reviewed for hospitalization . This placed residents at risk for lack of knowledge related to the right to return to the facility. Findings include: 1. Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. Progress Notes revealed Resident 16 was discharged to the hospital on 6/24/24. Resident 16's clinical record did not indicate Resident 16 was provided a facility bed hold policy. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. On 10/7/24 at 10:25 AM Resident 16 stated she/he did not recall staff providing her/him a bed hold policy when she/he went to the hospital. On 10/10/24 at 12:51 PM Staff 2 (DNS) stated upon admission to the facility residents were provided a bed hold policy. Staff 2 stated usually the admission director provided a bed hold policy upon discharge, but currently there was no admission director. No additional information was provided. 41458 2. Resident 33 was admitted to the facility in 12/2021 with diagnoses including chronic respiratory failure with hypoxia (a condition in which the body does not have enough oxygen in the blood). A review of Resident 33's health record revealed she/he was transferred to the hospital on 6/1/24, 6/14/24, 7/11/24, 9/8/24 and 10/2/24. No evidence was found in Resident 33's health record to indicate a written notice of the facility's bed hold policy was provided to Resident 33 when she/he was transferred to the hospital on 6/1/24, 6/14/24, 7/11/24, 9/8/24 and 10/2/24. On 10/11/24 at 9:32 AM Staff 3 (Medical Records) stated the facility did not provide residents with a written bed hold policy prior to transferring them to the hospital. On 10/15/24 at 10:27 AM Staff 1 (Interim Administrator) acknowleged residents were not provided with written bed hold policies upon transfer to the hospital.

Based on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 4 of 13 sampled residents (#s 5, 7, 35, and 73) reviewed for accidents, pressure ulcers, position and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 was admitted to the facility in 4/2024 with a diagnosis of paralysis. A 7/17/24 Pressure Injury investigation revealed a new DTI (Deep tissue injury: damage to the soft tissue beneath the skin caused by pressure or shear. Often appears as a dark purple or maroon area) to the inner knee. The cause of the injury was determined to be from her/his bedside table putting pressure on the knee. Resident 5's care plan was not updated to direct staff to monitor pressure on Resident 5's leg from the bedside table. On 10/11/24 at 9:11 AM Staff 2 (DNS) stated Resident 5 did not have sensation in her/his legs. When the wound nurse performed wound care to the resident's sacral region she found the inner knee DTI. The wound nurse identified the bedside table was pressing on the area. Staff 2 acknowledged the care plan was not updated to ensure pressure was not applied to the resident's legs. 41458 2. Resident 73 was admitted to the facility in 9/2023 with diagnoses including a fractured hip. a. Resident 73's 9/21/23 Care Plan indicated the resident was incontinent of bowel and bladder. Resident 73's 9/15/24 Annual MDS indicated the resident was always continent of bowel and bladder. On 10/10/24 at 12:04 PM and 12:54 PM Staff 24 (CNA) and Staff 26 (CNA) reported Resident 73 was independent with most care and was continent of bowel and bladder. On 10/11/24 at 10:55 AM Staff 2 (Interim DNS) reviewed Resident 73's current care plan and reported the resident was not incontinent, and the resident's current care plan did not accurately reflect her/his continence status. She stated she expected residents' care plans to accurately reflect current interventions. b. A 7/9/24 Facility Incident report indicated Resident 73 left the facility around 1:00 PM on 7/8/24 and did not return until 7:00 AM on 7/9/24. New interventions were identified which included ensuring the resident took her/his cell phone and water bottle with her/him when leaving the facility. Also, Staff 17 (Social Service Director) would provide Resident 73 with a fanny pack to carry her/his cell phone and wallet, and facility key personnel names and phone contact information would be placed in the fanny pack. Resident 73 was to take her/his fanny pack when she/he left the facility. Resident 73's 9/5/24 Care Plan indicated the following: -The resident was to sign out and tell staff when she/he was leaving the facility. -The resident would take her/his cell phone when going out. Resident 73's 9/15/24 Annual MDS indicated the resident was able to make her/his own decisions and direct her/his own care. On 10/10/24 at 9:51 AM Resident 73 was able to locate her/his fanny pack in her/his room and stated she/he was supposed to take the fanny pack when leaving the facility. On 10/10/24 at 1:55 PM Staff 2 (Interim DNS) reviewed Resident 73's care plan and confirmed the resident's care plan did not accurately reflect her/his current care plan interventions related to leaving the facility. She stated she expected residents' care plans to accurately reflect current interventions. 3. Resident 35 was admitted to the facility in 1/2018 with diagnoses including a stroke and difficulty swallowing. Resident 35's 3/19/22 Care Plan indicated the following: -No straws allowed (due to difficulty swallowing). Resident 35's 5/14/24 SLP Discharge Summary did not indicate the resident was unsafe using straws. Resident 35's 9/8/24 Quarterly MDS indicated the resident had no choking or coughing during the assessment period. Multiple observations from 10/7/24 through 10/14/24 between the hours of 8:00 AM and 4:30 PM revealed Resident 35 used straws to drink liquids. On 10/7/24 at 1:24 PM Staff 25 (CNA) stated the resident used straws when drinking. On 10/14/24 at 10:42 AM Staff 2 (Interim DNS) stated she reviewed Resident 35's care plan interventions and the resident's care plan was inaccurate regarding the resident's safety using straws. She stated she expected residents' care plans to accurately reflect current interventions. 50927 Resident 7 was admitted to the facility in 11/2019 with diagnoses including multiple sclerosis and depression. Resident 7's health record revealed she/he had contractures to the left shoulder, hips, and knees upon admission. A 3/17/24 annual MDS revealed Resident 7 had impaired mobility of her/his upper and lower extremities. A 9/23/24 Care Plan revealed Resident 7 had an RA program related to maintaining baseline ROM to her/his bilateral upper extemities as long as possible. Random observations of Resident 7 from 10/7/24 through 10/11/24 from 11:31 AM to 4:16 PM revealed Resident 7 in bed with her/his left arm contracted. The resident had difficulty turning her/his neck to see who was in the room. On 10/11/24 at 1:56 PM Staff 2 (Interim DNS) stated the RA program for Resident 7 was discontinued on 10/18/23 when she/he was admitted to the hospital. Staff 2 acknowledged the care plan had not been revised.

Based on interview and record review, the facility failed to complete a discharge summary with required information for wound care and possible wound infection for 1 of 1 sampled resident (# 17) reviewed for unsafe discharge. The facility's failure to provide instructions for the care of the wound and the possible wound infection in the discharge summary information caused the resident's wound to worsen at home resulting in re-admission to a hospital. Findings include: Resident 17 was admitted to the facility in 5/2024 with diagnoses including hip fracture with surgical repair, heart failure, and a history of falling. Resident 17's care plan dated 5/14/24 indicated the resident required frequent skin inspections. Staff were to observe for redness, open areas, scratches, cuts, bruises, and report changes. Resident 17 was also at risk for developing pressure injuries and new skin issues related to her/his right hip fracture from a ground level fall. A hospital Discharge Summary dated 5/14/24 directed the following: follow up with orthopedic surgeon for post operative care, X-ray and staple removal on 5/27/24 and complete INRs (blood test) per facility protocol while on Warfarin. Resident 17 was subsequently discharged from the nursing facility on 6/3/24. At that time, the surgical staples had not been removed, there was no evidence a timely follow-up appointment with the orthopedic surgeon, and an INR scheduled for 6/3/24 was not completed. Resident 17's Weekly Skin Evaluation dated 5/28/24 at 9:38 AM listed the resident's wounds and skin issues as including the following: -Superior incision to the right hip with 9 staples intact. Scant serosanguinous (fluid with small amount of blood) drainage noted. -Inferior incision to the right hip with slough (dead tissue within a wound) and 14 staples intact. Scant serosanguinous (fluid with blood) drainage noted. -Anterior incision to the right thigh with 2 staples intact. 1 staple had fallen out. -More posterior incisions to the right thigh, one with 3 staples intact and another with 2 staples intact. Mild redness noted to staples of all incisions, no abnormal warmth, periwound with moderate bruising and swelling. The resident complained of pain related to the incisions. -Right hip with moderate bruising and swelling. -Scattered scabbing and bruising. -MASD (moisture associated skin damage) to the rectum. -New: mild rash to both axilla (armpits). -Right shin, calf and foot with increased redness and warmth -3+ pitting edema to both flanks, hips, and thighs. -Monitor redness and warmth to the right lower extremities (alert charting) On 5/28/24 at 9:53 AM Staff 25 (LPN) wrote a note to the provider: Resident 17's right shin, calf and foot had increased redness, warmth, and pain. The resident was also noted with new 3+ pitting edema (swelling) to bilateral flanks, hips & thighs. Please assess. On 5/29/24 at 10:01 PM an Alert Note indicated the resident remained on alert to monitor redness and warmth to right lower extremities. On assessment, redness was noted to the right lower extremity, right upper quadrant, and the right lower quadrant. On 5/29/24 at 2:58 PM Staff 27's (Provider) progress note indicated the right lower extremity was no longer warm but still with redness. Please contact surgeons' office and alert them of the change. Did the patient have a follow-up appointment with the surgeon? On 5/29/24 at 2:59 PM Staff 27's (Provider) additional progress note included: The resident's right leg seems somewhat improved today but right lower incision with slough. Continue to monitor closely and alert providers if warmth returns or further concerns. Would like to defer to surgeons' office if able but please call if not able to get a return call within 24 hrs or there is worsening of condition. Discharge Condition: Guarded. Resident 17 will need close follow up. Discharge Instructions: The facility was to provide instructions upon discharge. Home Health needs: Nursing, Physical Therapy, Occupational Therapy Follow up Appointments: Follow up with PCP and specialists upon discharge. Erythema noted to the RLE. Continue to monitor. Continued slough in the lower incision to the right lateral thigh. The resident will need to follow up with surgeon. A review of the facility's 5/31/24 Discharge Instructions Tool revealed the discharge tool was not complete and failed to include the following required information: -No facility physician, Primary Care Physician (PCP), or pharmacy information was included and no contact information was provided. -The In-Home Care section listed To Be Determined. A Home Health Agency was not identified, home health needs were not listed, and no appointments were set up for the resident. Per a medical provider progress note the resident required: Nursing, Physical Therapy, and Occupational Therapy Home Health upon discharge. -No medication education was provided to the resident or representative. -Prevention and Disease Management education was not provided. -COVID testing and Vaccination information was not provided. -A Brief Medical History and Review of Reason for Admission was not included. - Current treatments, Therapies, and Education provided: there was only one note present which directed to follow up with hospital ACC (Anticoagulation Clinic) as an INR was due that day. No provider was identified for the follow up INR which was due that day. The resident discharged after 3:30 PM but the INR due that day was not completed by staff. -No infection information was included in the Discharge Tool. On 5/28/24 Staff 25 (LPN)identified lower extremity redness, warmth, and pain. The concern for those symptoms would be a possible infection in the wound. There was no follow-up by staff related to the possible infection and no wound care information or instructions were provided to the resident or family at discharge. The Discharge Tool revealed no information related to the following: mobility level, transfer status, scheduled appointments or tests, or barriers to discharge. A 6/3/24 at 3:27 PM progress note indicated the resident discharged home at 3:30 PM via medical transport. A facility Discharge Summary dated 6/3/24 signed by the physician on 6/15/24 (12 days later) contained a final diagnosis and a summary of the treatment provided but was not given to the resident at the time of discharge. A 6/5/24 hospital Emergency Department discharge to hospital Neurotrauma ICU Admission report included the following information: -The resident's family brought the resident into the hospital because she/he had become more lethargic over the last 24 hours and they were concerned about infection in her/his hip. The resident had discharged to home two days prior on 6/3/24 from a skilled nursing facility. -Resident 17 was admitted with a post-operative wound infection and persistent encephalopathy (brain disease which alters brain function or structure). The resident had a progressive and notable decline in mental and functional status over the last few months. -Recent right neck fracture with surgical intervention. Recovered at a skilled nursing facility but did not have follow-up with Orthopedic surgeon. Staples remained in place and per report should have been removed 10 days postoperative. Surgical sites with erythema (redness), exudates (oozing fluid or pus), induration (hardening of soft tissue). Orthopedic surgery consults for evaluation of surgical sites, with follow-up surgical swab completed and now growing Gram-positive bacteria and Gram-negative bacteria. The resident was started on an antibiotic and further antibiotics would be determined pending speciation (formation of new species of bacteria) -SKIN: The resident's skin was pale, warm, dry, with multiple areas of wounds over the chest wall, abdomen, buttock, bilateral arms, and fingertips. The right hip surgical wounds were reviewed and staples remained in place. Upper linear wound with significant drainage. The lower vertical lateral wound had sutures still in place with exudates and some wound dehiscence (wound reopened) and erythema. -Wound History: break in the right femoral neck. Surgical site infection with wound dehiscence. A 6/10/2024 hospital Intraoperative Wound note indicated a right hip irrigation and debridement was performed by the surgeon. On 7/3/24 at 12:30 PM Witness 10 (Family member) stated when the resident discharged home her/his mentation was very different from her/his baseline and her/his physical condition had deteriorated. Witness 10 said the resident was home less than 48 hours when they had to send her/him to the hospital. The resident broke her/his hip on 5/6/24 and the staples should have been removed within 2-3 weeks but they were never taken out and both large incisions were swollen and weeping. The lower incision staples were zigzagged and there were pitted holes along the suture line. When the resident went back to the hospital on 6/5/24, she/he had surgery again to open the wound and flush out an infection. The facility staff did not provide any oral or written communication for wound care or follow up for the possible infection to the resident or family. No plan of care was provided when the resident discharged and Witness 10 said she was completely unprepared for how to care for the resident. On 7/25/24 at 2:23 PM Staff 3 (RNCM) acknowledged the Discharge Tool for Resident 17 was not completed thoroughly. A copy of the completed Tool was supposed to go home with the resident. Staff should be using the Tool which was in place. The resident did not receive all the information required for discharge. On 7/29/24 at 12:38 PM Staff 25 (LPN) stated Resident 17's surgical wounds were draining since admission. There was no follow-up provided with the surgeon while the resident was at the facility. Staff 25 said staff called the surgeon for an urgent appointment but for after the resident discharged . The incision staples were not removed. Staff 25 stated staff must have missed the staple removal order on the admit orders. The admit orders also indicated a surgical follow-up appointment was needed in 3 weeks. Staff 25 said no appointment was mentioned, or the need to make an appointment, in the Discharge Tool. Staff 25 also stated when she looked at the Discharge Tool there were no instructions for the resident's wound care or possible infection and wound care information should have been in the discharge paperwork. On 7/30/24 at 1:08 PM Staff 2 (DNS) acknowledged the Discharge Summary Tool was not complete, thorough or contain the required information for the resident's discharge which should have included wound care instructions and follow-up for the possible wound infection.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 1 sampled resident (#69) reviewed for diabetic medication. Resident 69 required emergency treatment and was hospitalized for [REDACTED]. Findings include: Resident 69 was admitted to the facility in 5/2019 with [DIAGNOSES REDACTED]. The 5/10/19 physician order [REDACTED]. A 5/20/19 progress note by Staff 11 (LPN) indicated Resident 69 received 100 units of [MEDICATION NAME] R U-500 insulin using regular facility needles instead of U-500 needles (resulting in an excessive dose). The nurse immediately reported the medication error to the charge nurse and the doctor was notified. At 9:19 AM a [MEDICATION NAME] injection (medication to increase blood glucose) was given. The doctor immediately visited the resident and stayed in the room until paramedics arrived. The resident was in stable condition talking to the doctor until she/he left the faciity on a stretcher. The 5/20/19 incident report indicated the following: -Staff 11 drew up 120 units of [MEDICATION NAME] R U-500 insulin using a U-100 syringe vs using a U-500 syringe resulting in the resident receiving approximately four times the amount of insulin ordered. -The error was detected immediately by the nurse when the resident asked if she used her/his special needle to draw up the insulin. She stopped giving the insulin and went to the medication cart to re-check the order and look for the special needles and realized she made the mistake. However, she had already given the resident 100 units of the [MEDICATION NAME] R U-500 (concentrated) insulin using a U-100 syringe. -Staff 11 notified the charge nurse of the mistake. The resident's physician was in the facility, was notified immediately and went to the resident's room. Staff 11 notified the resident of the mistake and the resident was informed that she/he needed to go the hospital via 911 for monitoring. -The resident was given a [MEDICATION NAME] injection and the physician stayed with the resident until paramedics arrived. The resident was alert and oriented with no change in level of consciousness when she/he left the facility. -The resident was sent to the hospital and returned to the facility on [DATE] in stable condition. The resident's U-500 insulin was discontinued. On 9/13/19 at 10:12 AM Staff 11 stated on 5/20/19 she administered medication to Resident 69 for the first time. She stated the order was reviewed and she confirmed the dose of insulin with the resident who was alert and oriented. She stated the MAR indicated [REDACTED]. She further stated she administered insulin to the resident and when the resident stated she/he had her/his own insulin needles she stopped and went out to the medication cart. She stated she looked through all of the drawers and found the resident's specific needles in the bottom drawer stored away from the regular insulin needles. She stated she immediately reported the incident and the physician was on-site and able to stay with the resident until paramedics arrived. She stated the resident's blood sugars were dropping and the resident received a [MEDICATION NAME] injection, was alert and oriented, and blood sugars were monitored until the resident left with paramedics. Progress notes indicated the following: -5/20/19 3:01 PM spoke to resident's spouse and the resident is doing well in the emergency room and planned to return on 5/21/19. -5/21/19 7:03 PM (late entry) resident returned from emergency department and the insulin orders were changed from [MEDICATION NAME] R U-500 to [MEDICATION NAME] R U-100 per physician. A 5/20/19 physician progress notes [REDACTED]. -Admitting Diagnoses: [REDACTED]. -Resident admitted from the nursing facility after accidentally being given four times the normal insulin dose. -Given [MEDICATION NAME] and sent to the emergency room and was admitted . No further information available. Team will continue to follow while the resident remains hospitalized . -5/21/19-throughout the night able to keep CBG greater than 80 with food and drink. Anticipate discharge. Team will continue to follow while the resident remains hospitalized . Resident 69's emergency room visit and hospitalization records were not located in the resident's clinical record. On 9/13/19 at 8:29 AM Staff 3 (RNCM) stated the physician did a chart review of Resident 69 and the facility did not have medical records for Resident 69's hospitalization . On 9/13/19 at 11:54 AM Staff 6 (LPN Resident Care Coordinator) stated Resident 69 received the wrong dose of insulin due to Staff 11 using the wrong needle. She stated Staff 11 responded immediately, the resident was sent to the hospital at approximately 10:00 AM on 5/20/19, was hospitalized overnight, and the facility received updates from the hospital. She stated the resident returned to the facility on [DATE] at approximately 3:00 AM. She stated in-services were completed on 5/23/19 and staff were now required to have two nurses check the [MEDICATION NAME] R U-500 insulin before administration. No evidence was found to indicate additional deficient practice occurred after 5/20/19. Due to the facility's identification of the deficient practice and corrective measures put in place on 5/23/19 the deficient practice was determined to be past noncompliance.

Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards related to the administration of insulin for 1 of 1 licensed nurse (#11) reviewed for diabetic medication administration. Resident 69 required emergency treatment and was hospitalized for [REDACTED]. Findings include: Per Division 45 Standards and Scope of Practice for the LPN and RN: [PHONE NUMBER] Conduct Derogatory to the Standards of Nursing Defined: Conduct that adversely affects the health, safety, and welfare of the public, fails to conform to legal nursing standards, or fails to conform to accepted standards of the nursing profession, is conduct derogatory to the standards of nursing. Such conduct includes, but is not limited to: (2) Conduct related to achieving and maintaining clinical competency (c) Accepting an assignment when individual competency necessary to safely perform the assignment have not been established or maintained. (8) Conduct related to other federal or state statute or rule violations (q) Failing to dispense or administer medications in a manner consistent with state and federal law. Resident 69 was admitted to the facility in 5/2019 with [DIAGNOSES REDACTED]. The 5/10/19 physician order [REDACTED]. A 5/20/19 progress note by Staff 11 (LPN) indicated Resident 69 received 100 units of [MEDICATION NAME] R U-500 insulin using regular facility needles instead of U-500 needles (resulting in an excessive dose). The nurse immediately reported the medication error to the charge nurse and the doctor was notified. At 9:19 AM a [MEDICATION NAME] injection (medication to increase blood glucose) was given. The doctor immediately visited the resident and stayed in the room until paramedics arrived. The resident was in stable condition talking to the doctor until she/he left the faciity on a stretcher. The 5/20/19 incident report indicated the following: -Staff 11 drew up 120 units of [MEDICATION NAME] R U-500 insulin using a U-100 syringe vs using a U-500 syringe resulting in the resident receiving approximately four times the amount of insulin ordered. -The error was detected immediately by the nurse when the resident asked if she used her/his special needle to draw up the insulin. She stopped giving the insulin and went to the medication cart to re-check the order and look for the special needles and realized she made the mistake. However, she had already given the resident 100 units of the [MEDICATION NAME] R U-500 (concentrated) insulin using a U-100 syringe. -Staff 11 notified the charge nurse of the mistake. The resident's physician was in the facility, was notified immediately and went to the resident's room. Staff 11 notified the resident of the mistake and the resident was informed that she/he needed to go the hospital via 911 for monitoring. -The resident was given a [MEDICATION NAME] injection and the physician stayed with the resident until paramedics arrived. The resident was alert and oriented with no change in level of consciousness when she/he left the facility. -The resident was sent to the hospital and returned to the facility on [DATE] in stable condition. The resident's U-500 insulin was discontinued. On 9/13/19 at 10:12 AM Staff 11 stated on 5/20/19 she administered medication to Resident 69 for the first time. She stated the order was reviewed and she confirmed the dose of insulin with the resident who was alert and oriented. She stated the MAR indicated [REDACTED]. She further stated she administered insulin to the resident and when the resident stated she/he had her/his own insulin needles she stopped and went out to the medication cart. She stated she looked through all of the drawers and found the resident's specific needles in the bottom drawer stored away from the regular insulin needles. She stated she immediately reported the incident and the physician was on-site and able to stay with the resident until paramedics arrived. She stated the resident's blood sugars were dropping and the resident received a [MEDICATION NAME] injection, was alert and oriented, and blood sugars were monitored until the resident left with paramedics. Progress notes indicated the following: -5/20/19 3:01 PM spoke to resident's spouse and the resident is doing well in the emergency room and planned to return on 5/21/19. -5/21/19 7:03 PM (late entry) resident returned from emergency department and the insulin orders were changed from [MEDICATION NAME] R U-500 to [MEDICATION NAME] R U-100 per physician. A 5/20/19 physician progress notes [REDACTED]. -Admitting Diagnoses: [REDACTED]. -Resident admitted from the nursing facility after accidentally being given four times the normal insulin dose. -Given [MEDICATION NAME] and sent to the emergency room and was admitted . No further information available. Team will continue to follow while the resident remains hospitalized . -5/21/19-throughout the night able to keep CBG greater than 80 with food and drink. Anticipate discharge. Team will continue to follow while the resident remains hospitalized . Resident 69's emergency room visit and hospitalization records were not located in the resident's clinical record. On 9/13/19 at 8:29 AM Staff 3 (RNCM) stated the physician did a chart review of Resident 69 and the facility did not have medical records for Resident 69's hospitalization . On 9/13/19 at 11:54 AM Staff 6 (LPN Resident Care Coordinator) stated Resident 69 received the wrong dose of insulin due to Staff 11 using the wrong needle. She stated Staff 11 responded immediately, the resident was sent to the hospital at approximately 10:00 AM on 5/20/19, was hospitalized overnight, and the facility received updates from the hospital. She stated the resident returned to the facility on [DATE] at approximately 3:00 AM. She stated in-services were completed on 5/23/19 and staff were now required to have two nurses check the [MEDICATION NAME] R U-500 insulin before administration. No evidence was found to indicate additional deficient practice occurred after 5/20/19. Due to the facility's identification of the deficient practice and corrective measures put in place on 5/23/19 the deficient practice was determined to be past noncompliance. Refer to F760

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment of [REDACTED].#402) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 402 was admitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. The 9/7/18 physician's orders [REDACTED]. -Irrigate wound with saline using irrigation syringe, cleanse wound with wound cleanser, fill with . 1/4 inch packing strip, be sure to leave a wick of approximately 1 inch . Review of the 9/2018 and 10/2018 TAR revealed wound care was provided. Review of 9/2018 and 10/2018 Skin/Wound Progress Notes revealed the following: -9/12/18: Buttock wound has improved. -9/17/18: Buttock wound has improved. -9/21/18: Buttock wounds clinically have improved . -9/28/18: Buttock wound has improved. -10/9/18: Wound appeared to be closed, no further wound care needed. -10/18/18: Assessed reported draining wound .copious amounts drainage, noted something yellowish/white protruding from the opening .it was a four centimeter folded piece of 1/4 inch packing strip-eight centimeters total in length. It is believed that the packing strip had slipped inside the stage 4 pressure injury at one point in the past and the body healed over it, leading to an abscess. -10/19/18: Wound reopened on 10/18/18. Previous dressing orders resumed. The 11/13/18 Surgery Center Progress Notes indicated the wound was opened an additional two centimeters to allow for further visualization and exploration to ensure no additional packing was in the wound. In an interview on 1/23/19 at 11:00 AM, Resident 402 stated her/his buttocks wound was completely healed for about a week. He/she stated Staff 1 (DNS) discovered packing strip gauze was left in the closed wound and caused an abscess (a collection or pocket of pus caused by an infection). Resident 402 stated she/he had to be sent out for a surgical procedure to ensure no other packing strip or dressing materials were left in the wound. On 1/23/19 at 12:03 PM, Staff 5 (LPN) stated Resident 402's right buttock pressure ulcer was healed and closed. She stated the healed wound developed an abscess, opened back up and gauze packing strip was discovered in the wound. On 1/24/19 at 10:15 AM, Staff 5 (LPN) was observed providing wound care to Resident 402. The wound was a circular crater and the diameter of a quarter with no signs of infection. Staff 5 was observed to cleanse the wound and pack it with 1/4 inch gauze. On 1/24/19 at 12:17 PM, Staff 1 (DNS) stated it was unfortunate the packing was inadvertently left in Resident 402's wound and never should have been. She stated the wound abscessed and opened back up and stated this incident set Resident 402 back about three to six months. Staff 1 stated after this incident, in house training for wound care was provided.

Based on observation, interview and record review it was determined the facility failed to ensure the treatment and services provided met professional standards of practice for 1 of 1 sampled resident (#402) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: The 2014 National Pressure Ulcer Advisory Panel Quick Reference Guide instructed the following: -Ensure all wound dressing products are completely removed with each dressing change; -Retained gauze in a (pressure) ulcer bed can serve as a source of infection. Resident 402 was admitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. The 9/7/18 physician's orders [REDACTED]. -Irrigate wound with saline using irrigation syringe, cleanse wound with wound cleanser, fill with . 1/4 inch packing strip, be sure to leave a wick of approximately 1 inch . Review of the 9/2018 and 10/2018 TAR revealed wound care was provided. Review of 9/2018 and 10/2018 Skin/Wound Progress Notes revealed the following: -9/12/18: Buttock wound has improved. -9/17/18: Buttock wound has improved. -9/21/18: Buttock wounds clinically have improved . -9/28/18: Buttock wound has improved. -10/9/18: Wound appeared to be closed, no further wound care needed. -10/18/18: Assessed reported draining wound .copious amounts drainage, noted something yellowish/white protruding from the opening .it was a four centimeter folded piece of 1/4 inch packing strip-eight centimeters total in length. It is believed that the packing strip had slipped inside the stage 4 pressure injury at one point in the past and the body healed over it, leading to an abscess. -10/19/18: Wound reopened on 10/18/18. Previous dressing orders resumed. The 11/13/18 Surgery Center Progress Notes indicated the wound was opened an additional two centimeters to allow for further visualization and exploration to ensure no additional packing was in the wound. In an interview on 1/23/19 at 11:00 AM, Resident 402 stated her/his buttocks wound was completely healed for about a week. He/she stated Staff 1 (DNS) discovered packing strip gauze was left in the closed wound and caused an abscess (a collection or pocket of pus caused by an infection). Resident 402 stated she/he had to be sent out for a surgical procedure to ensure no other packing strip or dressing materials were left in the wound. On 1/23/19 at 12:03 PM, Staff 5 (LPN) stated Resident 402's right buttock pressure ulcer was healed and closed. She stated the healed wound developed an abscess, opened back up and packing strip was discovered in the wound. On 1/24/19 at 10:15 AM, Staff 5 (LPN) was observed providing wound care to Resident 402. The wound was a circular crater the diameter of a quarter with no signs of infection. Staff 5 was observed to cleanse the wound and pack it with a 1/4 inch gauze strip. On 1/24/19 at 12:17 PM, Staff 1 (DNS) stated it was unfortunate the packing was inadvertently left in Resident 402's wound and never should have been. She stated the wound abscessed and opened back up and stated this incident set Resident 402 back about three to six months. Staff 1 stated after this incident, in house training for wound care was provided.

1. Based on interview and record review it was determined the facility failed to provide care and services consistent with professional standards of practice to promote the prevention and healing of pressure ulcers for 1 of 3 sampled residents (#71) reviewed for pressure ulcers. This resulted in Resident 71 developing a facility acquired unstageable pressure ulcer. Findings include: Resident 71 admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The 5/23/18 Braden Scale (pressure ulcer risk assessment) identified Resident 71 was a high risk for developing pressure ulcers. The 5/23/18 Admit Screener (admission assessment) indicated Resident 71 had no pressure ulcers. A 5/31/18 Physician Communication Note revealed the physician was notified of a suspected Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer. The note indicated a RN had to stage the wound and an order for [REDACTED]. The Admission MDS with a 6/2/18 assessment reference date revealed Resident 71 had an unstageable pressure ulcer, severely impaired daily decision making skills, was a total two person staff assist for bed mobility, had functional limitation in range of motion on one side of her/his upper and lower extremities and was always incontinent of bowel and bladder. The Pressure Ulcer CAA did not include a comprehensive assessment of the wound and was completed by Staff 8 (LPN/MDS Coordinator). Resident 71's progress notes revealed the following: * 5/26/18: a Stage I pressure ulcer (non-blanchable [DIAGNOSES REDACTED] of intact skin) to the coccyx. * 5/29/18: a small red area on the coccyx. * 5/31/18: a Stage II which measured 2.0 x 0.4 cm and no RN was available to assess the pressure ulcer. * 6/3/18: Staff 9 (RN) staged the pressure ulcer as unstageable (obscured full-thickness skin and tissue loss) with slough (dead tissue, cream or yellow in color). Resident 71's weekly skin progress notes completed by Staff 7 (LPN) revealed the following: * 6/4/18: unstageable pressure injury to coccyx measured 0.8 x 0.7 CM with 100% slough and scant amount of serosanguinoius (both blood and serous fluid) drainage. * 6/12/18: unstageable pressure injury to coccyx measured 1.2 x 0.7 x 0.1 CM with 100% slough. * 6/18/18: unstageable pressure injury to coccyx measured 0.8 x 0.5 x 0.1 CM with 100% slough. The resident's 6/4/18, 6/12/18 and 6/18/18 weekly skin progress notes revealed no RN had assessed or staged Resident 71's pressure ulcer. The 6/5/18 Pressure Injury care plan instructed staff to monitor, document and report to the physician as needed for change in skin status including appearance, color, wound healing, wound size and stage. The care plan also instructed staff to monitor the resident's nutritional status. Resident 71's 5/2018 and 6/2018 MARs revealed no pressure ulcer treatment until 5/31/18 which included daily monitoring and to apply [MEDICATION NAME] to the coccyx pressure ulcer TID and PRN until resolved. The order indicated staff was to notify the treatment nurse or care manager if the resident's wound worsened. The resident's clinical record revealed the physician was not notified when the resident's Stage II pressure ulcer developed into an unstageable pressure ulcer. In addition, the resident's pressure ulcer treatment was not reviewed or changed when her/his pressure ulcer worsened. Resident 71 was discharged to the hospital on [DATE]. On 6/21/18 at 11:40 am, Staff 4 (LPN/Resident Care Coordinator) acknowledged the physician was not notified when the resident's Stage II pressure ulcer worsened to an unstageable pressure ulcer and the resident's treatment was not changed. On 6/22/18 at 2:00 pm and on 6/25/18 at 8:10 am, Staff 7 (LPN) stated in her role as a treatment nurse she assessed and treated wounds, monitored for worsening of the wound and notified the physician as needed. Staff 7 stated there was no consistent RN involvement in wound care and no RN had comprehensively assessed Resident 71's coccyx pressure ulcer. 2. Based on observation, interview and record review it was determined the facility failed to evaluate and modify interventions for ongoing refusal of care and treatment for 1 of 3 sampled residents (#77) reviewed for pressure ulcers. This placed residents at risk for worsening of unavoidable pressure ulcers. Findings include: Resident 77 was readmitted to the facility in 3/2018, with [DIAGNOSES REDACTED]. On 6/19/18 at 2:42 pm, Resident 77 was observed lying in bed watching television. The resident had a [DEVICE] (a type of therapy to help wounds heal), an air mattress and foam boots on both feet. The resident's 1/2018 and 2/2018 Progress Notes documented the following refusal of treatment and care: -1/5/18: .Resident has been allowing treatments to be done more often in the evenings, but refuses to leave bilateral lower extremities OTA (open to air) . -1/8/18: .This LN (licensed nurse) encouraged res (resident) to allow staff to clean area and apply cream as this is refused often .expressed concerns to charge nurse regarding resident's constant refusing of care . -1/14/18: .Resident refuses to stand for this nurse to be assessed for skin integrity . -1/21/18: Pt (patient) continues to refuse this LN to assess the integrity of pt buttock .tx (treatment) nurse was in there as a witness that pt refused to allow LN to look to assess skin. -1/25/18: .This LN attempted to apply new dressing to resident buttock and resident refused . -1/28/18: Numerous discussions with this resident have proven unsuccessful in convincing her/him to be transferred to bed, to be repositioned from side to side for skin integrity . -2/1/18: .Pt refused leg treatment due to being upset about pressure ulcer .pt refusing to get out of recliner for the evening . -2/6/18: Patient .refuse to get bilateral lower extremities dressing change this shift .patient refuse shower this evening . -2/8/18: Unstageable pressure ulcer to left buttock/gluteal cleft . -2/15/18: .This LN noted a new deep tissue injury to left heel .and new unstageable pressure ulcer to right heel . -2/21/18: Unstageable pressure ulcer to right heel . -2/9/18: Patient .refuse to get [MEDICATION NAME] (a skin barrier ointment) applied or any treatment from this nurse today . Resident 77's care plan dated 1/25/18 and 5/22/18 did not address the resident's refusal of care behavior or identify any interventions to prevent further care refusals. In addition, there was no evidence in the resident's clinical record to indicate the interdisciplinary team assessed the resident's multiple refusals of care and treatment in relation to the resident's pressure ulcer to determine if other interventions could be used to prevent the resident refusing care and treatment. In an interview on 6/20/18 at 3:44 pm, Staff 25 (CNA) stated Resident 77 refused to get out of her/his recliner and lay in her/his bed. In interviews on 6/21/18 at 12:37 pm, 3:13 pm and 3:29 pm, Staff 26 (CNA), Staff 27 (LPN) and Staff 28 (LPN/Treatment Nurse) each stated the resident at times refused wound treatments and refused to lay in bed rather than sit in her/his recliner. In an interview on 6/25/18 at 11:02 am Staff 29 (CNA) stated Resident 77 refused to be repositioned every two hours. In an interview on 6/25/18 at 11:06 am and at 11:19 am, Staff 6 (RNCM) stated Resident 77's pressure ulcers were unavoidable and was aware of the resident's refusal of care behavior. Staff 6 was unable to provide any documentation to show the resident's refusals were re-assessed to determine other possible interventions to prevent the resident refusing care and treatment. In an interview on 6/25/18 at 1:37 pm, Staff 1 (Executive Director) stated she would expect the team to talk about Resident 77's refusal of cares. Staff 1 stated she was not aware Resident 77 had refused care.

1. Based on observation, interview and record review it was determined the facility failed to identify, assess and develop interventions to prevent a weight loss for 1 of 4 sampled residents (# 77) and failed to reassess nutritional status after removal of tube feeding for 1 of 1 sampled resident (# 71) reviewed for nutrition. As a result, Resident 77 experienced a severe weight loss of 11% in three months and 18% weight loss in six months. Findings include: a. Resident 77 was readmitted to the facility in 3/2018, with [DIAGNOSES REDACTED]. According to the facility's Assessing Changes in Weight Policy and Procedures revised on 5/23/18, All residents are weighed at least monthly .RCM/RCC will complete weight audits, notify MD, Dietary Manager, and make a list for RD to review .Criteria for monthly review is as follows: All residents with a 5% weight loss or gain since last recorded weight or in the last 30 days. This is regardless of known or unknown cause. All resident's with a 10% weight loss or gain since last recorded weight or in the last 180 days. This is regardless of known of unknown cause . On 6/20/18 at 9:30 am, Resident 77 was observed eating breakfast. Resident 77 stated she/he ate independently but was not very hungry. The resident's clinical record weight history was as follows: -11/1/17 at 236 lbs -12/1/17 at 233 lbs -1/1/18 at 233 lbs -2/1/18 at 227 lbs -3/1/18 at 232 lbs -3/29/18 at 207 lbs -5/14/18 at 198 lbs -5/31/18 at 191 lbs -no weight recorded for 6/2018 Resident 77's last RD consultation on 2/15/18 noted RD was consulted due to the resident's new pressure injuries. The resident's RD review noted she/he had a gradual weight loss but not significant and included recommendations to add large protein portions to all meals to help support wound healing, add Zinc supplements and RD will continued to monitor. Resident 77's Nutritional CAA dated 4/9/18 assessed the resident had an ideal body weight of 194 lbs related to being in the overweight range and had no significant change in weight from admit. The resident had a Stage 3 pressure ulcer to her/his right gluteal, Stage 3 pressure ulcer to her/his right heel, an Unstageable pressure ulcer to her/his left heel and had no issues consuming meals. Resident 77's Nutritional CAA dated 5/18/18 assessed the resident's current weight of 198 lbs. The resident had a 10% decline from 235 lbs on 11/15/17. The resident was on diuretics for [MEDICAL CONDITION] and weight loss was anticipated and consumed 75-100% of meals. Resident 77's care plan dated 5/22/18 identified the resident had a nutritional problem related to [DIAGNOSES REDACTED]. The goal was Resident 77 would have her/his nutritional needs meet with interventions including RD to evaluate PRN, obtain/monitor labs, and explain consequences of refusals and obesity risk factors. The facility failed to address Resident 77's severe weight loss. The resident's Nutritional CAAs and current care plan failed to identify, assess and develop interventions to address the resident's severe weight loss. Resident 77 had a 11% weight loss from 3/1/18 to 5/31/18 (90 days) and a 18% weight loss from 12/1/17 to 5/31/18 (180 days). In an interview on 6/21/18 at 12:37 pm, Staff 26 (CNA) stated she noticed the resident doesn't eat as much and the resident had lost weight. Staff 26 stated she recognized the resident lost weight due to the resident's extra skin from her/his arms and legs and she can now see her/his ribs. In an interview on 6/21/18 at 3:13 pm, Staff 27 (LPN) stated she was not aware the resident had a weight loss. Staff 27 reviewed the resident's clinical record and confirmed the resident had a 42 pound weight loss since 11/2017. When asked how staff monitor weight loss, Staff 27 stated the RNCM monitored weight loss. In an interview on 6/22/18 at 8:40 am, Staff 12 (RD) stated she expected Resident 77 to be monitored closely given her/his multiple pressure ulcers or at least consider a NAR (Nutritionally at Risk) meeting. Staff stated a high BMI was actually preferred in elderly patients, as it gives them reserves and stated an ideal body weight was all about healing and meeting nutritional needs. Staff 12 stated she would have expected another RD review since the resident's last RD review in 2/2018. After Staff 12 reviewed Resident 77's clinical record, Staff 12 stated she would have expected a progress note or a RD note addressing the resident's weight loss after her/his return from the hospital. In an interview on 6/25/18 at 10:32 am, Staff 33 (LPN) stated she had not seen a weight loss in Resident 77. In an interview on 6/25/18 at 11:02 am, Staff 29 (CNA) stated she noticed the resident change since working at the facility 8-9 months ago. Staff 29 stated the resident used to eat 80-100% of her/his dinner, but over the last two months the resident hasn't been eating very much of her/his dinner. Staff 29 stated the resident lost weight. In an interview on 6/25/18 at 11:10 am, Staff 6 (RNCM) after reviewing Resident 77's clinical record, confirmed the resident had a severe weight loss. Staff 6 was unable to provide any documentation to show the resident's weight loss was identified and assessed. Staff 6 stated the MDS Coordinators may have missed the resident's weight loss which was why the resident's weight loss was not addressed in the Nutritional CAAs. Staff 6 acknowledged she had not reviewed the resident's Nutritional CAAs to ensure the assessments were correct. In an interview on 6/25/18 at 1:14 pm, Staff 1 (Executive Director) was informed and acknowledged the findings for Resident 77's severe weight loss was not identified or assessed. b. Resident 71 admitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. A 5/30/18 Registered Dietitian (RD) Assessment indicated Resident 71 admitted with orders for a regular diet and internal support due to inadequacy of oral intake. Resident 71 did not like the nutritional supplements, her/his oral meal intake ranged from 25-75% and had internal (tube feeding) in place for 12 hours per day. The plan was to continue the current diet and internal orders, monitor for weight changes and to notify the RD PRN. The 6/2/18 Admission MDS indicated Resident 71 utilized a feeding tube as nutritional approach due to dysphagia (difficulty swallowing). A 6/12/18 Physician order [REDACTED]. A 6/15/18 progress note indicated Resident 71 consumed less than 1500 cc of fluid on average since the NG and tube feed was discontinued. The resident received a nutritional support BID, a new order to encourage fluid was initiated and the physician was notified. Resident 71's 5/2018 and 6/2018 progress notes revealed a worsening, facility acquired pressure ulcer. The resident's clinical record indicated no further dietary assessments after the NG tube was removed. There was no documentation the RD was notified of the NG and tube feed discontinuation or the worsening facility acquired pressure ulcer. On 6/21/18 at 11:22 am, Staff 12 (RD) stated she reviewed residents within five days of their admission and had the expectation she would be notified for any resident with a wound, a significant weight change, diet changes, or any referral from either nursing or the physician. Staff 12 stated she would reassess a resident when a tube feeding was discontinued and would monitor the resident closely to ensure they received adequate oral intake. Staff 12 stated she was not notified Resident 71's tube feed and NG tube were discontinued and verified she did not reassess Resident 71's nutritional status. On 6/21/18 at 11:40 am, Staff 4 (LPN/Resident Care Coordinator) verified the RD was not notified when Resident 71's tube feed and NG tube were discontinued. On 6/25/18 at 9:26 am, Staff 13 (RD) stated Resident 71 was not on her list of residents to review that day. Staff 13 verified she was notified the resident had returned from the hospital but was unaware of her/his nutritional history. 2. Based on interview and record review, it was determined the facility failed to ensure residents maintained weight within acceptable parameters for 1 of 4 sampled residents (# 35) reviewed for nutrition. This placed residents at risk for weight loss. Findings include: The revised 5/23/18 facility policy and procedure for Assessing Changes in Weight indicated all residents were weighed according to physician orders [REDACTED]. Electronic Health Record (EHR) weights were updated within 24 hours. The Resident Care Manager (RCM)/Resident Care Coordinator (RCC) will complete weight audits, notify the resident's physician, Dietary Manager and make a list for the Registered Dietician (RD) to review. A note should be placed in each residents medical record as needed by RD, RCM/RCC or designee. Criteria for monthly review included the following: All residents with a 10% weight loss since the last recorded weight or in the last 180 days, regardless of known or unknown cause; All residents with pressure injuries (newly developed of those that are not responding to treatment or declining) possibly requiring nutritional interventions; and All residents who had new interventions resulting from the last review would be followed by the RCM/RCC/designee. Resident 35 was readmitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. The most recent RD Evaluation completed on 3/1/18 indicated the resident was admitted with severe protein calorie malnutrition, chronic immobility from [DIAGNOSES REDACTED] and meal refusals. No recent weight was documented with the last documented weight being 207.5 lbs in 12/2017. The resident had Stage III pressure injuries to the left hip and buttock; Stage II pressure injuries to the left thigh and right ischium and Unstageable pressure injuries to her/his coccyx, right buttock. The resident was noted with increased nutrient needs related to wound healing as evidenced by multiple pressure injuries present. Interventions included continuing to obtain new weights. Registered Dietician will continue to follow-up per facility protocol and to consult if significant weight change present or if PO intake is less than 25% for greater than three days. The 4/29/18 Nutrition CAA summary indicated the resident was at nutritional risk related to poor appetite, having pressure injuries, [DIAGNOSES REDACTED]. Resident weights were not done per orders, with the last weight being 208 lbs in 12/2017. The resident's 5/25/18 Physician order [REDACTED]. The facility failed to monitor the resident's weight to ensure the resident did not experience any weight variance and failed to consult a RD when the resident's pressure ulcers remained unhealed. The last documented weight in Resident 35's clinical record was entered on 12/13/17 and was 207 lbs. On 6/21/18 at 1:05 pm, Staff 27 (LPN) stated Resident 35 was admitted with pressure sores on her/his buttocks and they continued to be chronic. Staff 27 stated the resident does not eat the facility food and instead eats outside foods others bring in for her/him. Staff 27 verified the resident's weights in the EHR were last done on 12/13/17 and was not sure why the weights were not entered. On 6/21/18 at 1:20 pm, Staff 28 (LPN) was the treatment nurse for Resident 35 and acknowledged the resident had pressures sores on her/his buttocks with one staged at a Stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures). Staff 28 stated the resident's pressure ulcers have been chronic since her/his initial admission to the facility in 7/2017. On 6/21/18 at 3:41 pm and 6/25/18 at 11:00 am, Staff 6 (RNCM) acknowledged Resident 35's last weight in the EHR was in 12/2017. Staff 6 was unsure why there were no other weights and stated the resident frequently refused being weighed. Staff 6 further stated the resident was bed bound since returning to the facility in 2/2018. When asked about the facility protocol for weight refusals or weight loss, specifically for residents with unhealed pressure ulcers, Staff 6 stated she would review the resident's nutritional status including the weights. Staff 6 could not find any documentation she had done so and did not follow up on the weight refusals. On 6/22/18 at 10:07 am, Staff 12 (RD) stated she was unaware of the resident's condition and status, was not made aware of any weight variances or concerns and had not been informed by the facility to review the resident. Staff 12 stated she would expect any residents with weight variances and other factors such as non-healing pressure ulcers would be referred to and followed by the registered dietician. On 6/22/18 at 10:59 am, Staff 22 (Staffing Coordinator) verified she was in charge of scheduling and getting resident weights completed. Staff 22 stated she would notify Restorative Aide (RA) staff who would then proceed to get each resident's weight. Once the weights were obtained, Staff 22 would enter them in each resident's electronic health record (EHR). If residents refused, Staff 22 stated she would notify the RCM/RCCs. Staff 22 was unable to provide any documentation Staff 6 was notified of Resident 35's weight refusals.

Based on interview and record review it was determined the facility did not allow a resident to return to the facility after the resident left to perform personal errands for 1 of 3 sampled residents (#9) reviewed for facility discharge. This failure, determined to be an immediate jeopardy situation, resulted from the facility failure to allow Resident 1 to return to the facility leaving the resident homeless and without medications and treatments. Findings include: Resident 9 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/27/18 Hospitalist Discharge Summary indicated the resident was admitted to the facility with acute on chronic heart failure related to illicit drug use. The resident had a [DIAGNOSES REDACTED]. The 2/27/18 admission orders [REDACTED]. The 2/27/18 Admit/Readmit assessment indicated the resident was alert and oriented to person, place, time and situation. The resident was assessed to require supervision to walk with the use of the walker. The resident was not assessed to have a balance problem. The post hospital plan of care included stabilization of medications to treat the heart failure. In addition the resident required assistance for obtaining housing. 2/28/18 physician dictation indicated the resident was admitted to the facility for physical therapy, occupational therapy and complex medical management. The resident felt much better with improved energy. The dictation also indicated the resident's diabetes remained uncontrolled and the resident was to complete antibiotics for pneumonia. The resident was identified to be homeless but lived independently. The Progress Notes indicated on 2/27/18 the resident was alert, oriented and reported she/he needed to leave the facility to pick up her/his wallet. The 3/1/18 notes by Staff 15 (LPN) indicated the resident left the facility and went to the park with a friend at 10:00 am and the resident left against medical advice. The resident left all belongings received from the facility and did not take her/his personal glucose meter and test strips. The (MONTH) (YEAR) MARs indicated on 3/1/18 the resident did not receive the evening dose of antibiotic, the evening heart medication, the scheduled lunch insulin and the resident's CBG was not checked before dinner and at bedtime to determine if the resident required additional insulin. The chart did not have documentation to indicate the resident requested a discharge, the resident's needs were not able to be met at the facility or the resident's behavior endangered her/himself or other residents. On 3/13/18 at 11:10 am Staff 15 indicated she was on break when Resident 9 left the building. Staff 15 indicated the resident was to have a pass written by the physician in order for the resident to leave the facility. The resident tried to come back in the evening at approximately 6:00 pm but the resident was not allowed to return. Staff 15 indicated she did not speak to Resident 9 when she/he returned to the facility. Staff 2 and Witness 6 (Health Carrier RN Care Manager) spoke to the resident at the front entrance. On 3/13/18 at 12:00 pm Witness 6 indicated the resident was alert, oriented and cooperative with care. When the resident was in the hospital the resident's phone and wallet were misplaced. There resident wanted to replace her/his identification card and left the facility. The facility had a policy in place that indicated if a resident had a history of [REDACTED]. The facility informed the resident before she/he left to complete errands that if she/he left the the facility the resident would not be allowed to return. On 3/13/18 at 11:12 am Staff 2 (LPN Resident Care Coordinator) indicated for approximately one year the facility had a policy in place that indicated if a resident had a history of [REDACTED]. If the resident left the facility the resident was not allowed to return. Staff 2 indicated Resident 9 was focused on replacing her/his wallet contents. Staff 2 indicated the resident's friend was at the facility was was waiting to take the resident to complete errands. Staff 2 indicated she communicated with Staff 1 (DNS) and Staff 1 indicated if the resident left the facility the resident was to be discharged from the facility. On 3/15/18 at 12:18 pm Staff 1 indicated the facility had an unwritten policy that indicated if a resident currently used illicit drugs, left the facility without a pass the resident was discharged . Staff 1 indicated Resident 9 did not have orders to leave the facility. The resident was informed if she/he left the building the resident would be discharged from the resident. Staff 1 indicated once the resident left the facility the resident was considered to have left by choice, against medical advice and was therefore discharged from the facility. On 3/16/18 at 1:41 pm Witness 7 (Physician) indicated he reviewed the 2/28/18 physician assessment and the documentation indicated the resident was medically stable to leave the facility to run personal errands. On 3/1/18 Witness 7 indicated he was at the front reception area of the facility when Resident 9 returned to the facility. The resident indicated she/he was waiting to be informed by the staff if she/he still had a facility bed. On 3/13/18 at 12:30 pm and on 3/16/18 at 5:30 pm Staff 16 (Administrator) indicated Resident 9 did not want to wait for the facility to obtain an order to allow the resident to leave the facility. The resident left the facility without an order and once the resident left the resident was no longer a resident at the facility. Staff 16 acknowledged the resident did not initiate a discharge when the resident left the building to do errands and was not allowed to return to the facility. On 3/14/18 at 8:15 am Witness 8 (Health Carrier Case Manager) indicated he was not certain where the resident went in the community after the resident was not allowed to return to the facility. The resident may have been able to stay with family. Witness 8 indicated the resident did not have medications. Witness 8 indicated he provided Resident 9 a hotel voucher when the resident did not have a place to stay. On 3/16/18 at 5:32 pm the facility was notified of the facility failure to allow Resident 9 to return to the facility after the resident performed personal errands, who was homeless and without medications including insulin, in consultation with survey management, to be an immediate jeopardy situation. An acceptable plan to abate the immediate jeopardy situation was submitted by the facility on 3/16/18 at 6:15 pm. The plan included: The facility would permit residents to return to the facility after they were hospitalized or placed on therapeutic leave. Effective immediately the charge nurses, Resident Care Coordinators and Admission Coordinator (decision makers on right to return) were in-serviced on the right of the residents to return to the facility if the residents were on therapeutic leave. All unplanned discharges would be reviewed until compliance was obtained. On 3/16/18 at 6:16 pm the facility's implementation was abatement plan was verified. Staff 1 (DNS) indicated the staff in the building with decision making capacity were educated on the resident's right to return from a therapeutic leave and all staff not currently in the building with decision making capacity were notified by phone of the change. On 3/16/18 at 6:17 pm the facility administrator was notified the immediate jeopardy was abated.

Based on interview and record review it was determined the facility failed to implement policies and procedures to rule out neglect of care for 1 of 3 sampled residents (# 103) reviewed for falls. Resident 103 fell and sustained a [MEDICAL CONDITION]. Findings include: The facility's Abuse Prevention Policy indicated all cases of abuse, including injuries of unknown origin, shall be thoroughly and completely investigated and reported according to State and Federal regulations. The definition of abuse included the failure to provide basic care or services to a resident, which failure results in physical harm or unreasonable discomfort. Investigations include: Interviews of all the parties involved. This may include signed and dated statements from individuals in their own words that describe the incident. The facility's Conducting Incident/Accident Investigations Procedure indicated the goal was to Find out what happened - rule out abuse, Was the care plan followed - rule out neglect . Collect Data . Conduct staff interviews, Check to see if the care plan followed at the time of the incident . These are to be documented on the incident report and/or in the resident clinical record. Resident 103 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. In an interview on 2/23/16 at 9:57 am Witness 1 (Complainant) stated Resident 103 moved to the facility for rehabilitation of a broken hip. Witness 1 said Resident 103 had dementia but was still cognitive, and before the fracture the resident walked. Witness 1 said about three months after moving to the facility Resident 103 fractured her/his other hip after a fall out of bed, and on another occasion fell out of her/his wheelchair. Witness 1 also stated Resident 103 needed assistance to transfer and use the bathroom. Resident 103's quarterly care plan, updated 10/20/15, identified the resident was a fall risk due to dementia/cognitive deficits, recent fall with fracture, and recent non-injury fall. Interventions included use of appropriate footwear. An 11/15/15 progress note revealed Resident 103 was found on the floor in her/his room. Staff 10 (LPN) documented, . noted to be wearing regular socks . The resident was not identified to have any injuries. The facility's 11/17/15 investigative summary concluded, It appears that this fall possibly could have been avoided if (she/he) would have had non-skid socks on prior to going to bed . Resident 103's care plan was updated on 11/17/15 to reflect the use of non-skid socks at night. A 12/13/15 progress note indicated Resident 103 was transferred to a local hospital for increasing left hip pain r/t (related to) fall, hematoma to left temple, and skin tear to left elbow . resident was in bed and appeared to be resting quietly during each visual check, call light was within reach of resident, resident did not use call light or verbally call out for assistance, door to residents (sic) room was open, and resident states (she/he) was trying to get out of bed without assistance . The facility's investigation, initiated by Staff 9 (LPN) on 12/12/15 at 9:40 pm, indicated Staff 9 found the resident on the floor on her/his right side. The resident complained of pain on her/his left side, had a lump on her/his left temple and a skin tear on her/his left elbow. Staff 9 documented, Noted resident not wearing non-skid socks. Resident trying to get out of bed by (her/himself). Noted wheelchair placed against wall near doorway. Call light within reach. Staff 9 further documented he made inquiry with the assigned CNA who reported putting the resident to bed at 8:00 pm, then checked the resident at 8:30 pm. There was no documented evidence Staff 9 questioned the CNA about the use of non-skid socks. The 12/14/15 hospital Discharge Summary revealed a [DIAGNOSES REDACTED]. The facility's 12/15/15 investigative summary, completed by Staff 3 (RNCM) included an analysis of Resident 103's physical and medical status in the days prior to the fall. The investigation noted the assigned CNA toileted and assisted Resident 103 to bed with nightclothes and non-skid socks at approximately 8:00 pm. A visual check of Resident 103 at 8:30 pm showed the resident was laying in bed. Contributing factors were noted to be poor orientation, [DIAGNOSES REDACTED]. Staff 3 concluded the care plan was followed and the fall was unavoidable due to the resident's impulsivity and poor safety awareness. The investigation did not document information related to Staff 9 identifying Resident 103 was not wearing non-skid socks, a care plan fall intervention. Resident 103 was not a current resident of the facility at the time of the survey, from 2/22/16 through 2/29/16. On 2/25/16 at 3:42 pm Staff 1 (Administrator) and Staff 2 (DNS) confirmed the CNA who worked with Resident 103 at the time of the falls on 11/15/15 and 12/12/15 no longer worked at the facility. On 2/26/16 at 2:36 pm Staff 10 (LPN) confirmed she worked at the time of Resident 103's falls on 11/15/15 and 12/12/15. Staff 10 stated she recalled the 11/15/15 occasion because the resident had regular socks on and she chewed out the CNA. Staff 10 said she was not assigned to the resident on the night of 12/12/15, but she responded to assist Staff 9 (LPN). Staff 10 stated she was not there to assist the resident off the floor, she saw the resident after the resident was transferred to bed. Staff 10 stated she could not recall if the resident had non-skid socks on. On 2/26/16 at 10:24 pm Staff 9 stated he recalled finding Resident 103 on the floor on 12/12/15. He said he immediately did a body check and the resident had no pain, then he did neurological checks and the resident reported pain. Staff 9 stated he and the CNA transferred the resident to bed, he then asked the CNA about when checks were last done. When asked if he recalled his note regarding the resident not wearing non-skid socks Staff 9 stated he did not recall what he wrote on the report. He stated if he wrote it, that must have been what he saw. When asked if he questioned the CNA about the use of non-skid socks, Staff 9 stated he had no recollection of what they discussed. When asked if he was interviewed by a supervisor about the non-skid socks, Staff 9 stated he was interviewed, but he could not recall the details of those conversations. At that time Staff 9 requested to end the interview. On 2/29/16 at 10:08 am Staff 3 (RNCM) stated her investigative process included meeting with staff and residents about what happened and reading staff notes. Staff 3 stated she documented what happened, included her notes, then the information went into the Incident Report notes section of the facility's investigation. Staff 3 stated she also reviewed and updated residents' care plans. Staff 3 stated she attempted to interview staff the day of the incident or the following day, and she interviewed the assigned CNA. When completing a fall investigation she interviewed the person who found the resident on the floor. When asked if Staff 9 was interviewed about Resident 103 being found without non-skid socks, Staff 3 stated she did talk to Staff 9 and he did not think they were on, but Staff 10 and the assigned CNA indicated non-skid socks were on. When asked if she thought the investigation was complete and clearly determined the care plan was followed to rule out neglect of care, Staff 3 stated, Most likely (it was) not. On 2/29/16 at 10:41 am Staff 1 and Staff 2 indicated they were involved in the investigation and had multiple conversations regarding Resident 103. Staff 2 stated she signed off on investigations once the RNCMs completed their investigations and all statements were in. Staff 2 could not recall if she spoke with Staff 9. Staff 2 stated they met to discuss reporting the injury fall, but the decision was made there was no need to report. Staff 1 recalled meeting with staff, but did not recall details. On 2/29/16 at 11:34 am, Staff 2 had additional information from her personal notes regarding speaking with Staff 9 and 10, but the notes did not detail what was discussed or how it was determined the care plan was followed. Staff 2 stated she thought since Staff 10 and the CNA reported the socks were in place and likely Staff 9 did not recall the issue they felt the non-skid socks were in place. Staff 2 said she expected Staff 3 to document sufficient information to rule out abuse.

1. Based on interview and record review it was determined the facility failed to ensure fall interventions were implemented for 1 of 3 sampled residents (# 103) reviewed for falls. Resident 103 fell and sustained a fractured hip. Findings include: Resident 103 admitted to the facility in 2015 with [DIAGNOSES REDACTED]. In an interview on 2/23/16 at 9:57 am Witness 1 (Complainant) stated Resident 103 moved to the facility for rehabilitation of a broken hip. Witness 1 said Resident 103 had dementia but was still cognitive, and before the fracture the resident walked. Witness 1 said about three months after moving to the facility Resident 103 fractured her/his other hip after a fall out of bed, and on another occasion fell out of her/his wheelchair. Witness 1 also stated Resident 103 needed assistance to transfer and use the bathroom. The 7/20/15 Admission MDS indicated Resident 103 required extensive two-person assistance for bed mobility, transfers and toileting. The resident was identified as frequently incontinent of bowel and bladder. It also indicated the resident had an injury fall prior to admission and a non-injury fall after admission. The 7/21/15 Fall CAA revealed, Care area triggered related to resident having an unsteady gait; being not steady, only able to stabilize with staff assistance for transferring and ambulating r/t (related to) generalized weakness/decline in mobility status/recent hip fx (fracture) and surgical procedure, and having actual falls prior (and since) to admission . Other risk factors include (her/his) cognitive deficit, and frequent incontinence . was noted to be somewhat impulsive during the (assessment) look back period . attempting to self transfer at times without staff assistance . noted to have a non-injury fall on 7/18 . Resident 103's quarterly care plan, updated 10/20/15, identified the resident was a fall risk due to dementia/cognitive deficits, recent fall with fracture, and a non-injury fall. Interventions included: anticipate needs, keep needed items within reach, call light within reach and encourage use with prompt response to all requests for assistance, ensure appropriate footwear (personal leather shoes, bedroom slippers, non-skid socks), safe environment free from spills/clutter, glare-free light, bed in low position at night and when providing care, one person transfer, and offer toileting every two hours. An 11/15/15 progress note revealed Resident 103 was found on the floor in her/his room. Staff 10 (LPN) documented, .CNA states when she entered residents (sic) room to check on resident, resident noted to be sitting on floor in room, in front of door . Resident states (she/he) was going to go to the bathroom. CNA states resident assisted to toilet at 0430 . noted to be wearing regular socks . The facility's 11/17/15 investigative summary concluded, In this fall it appears that an hour after being toileted (the resident) had the impulse to use the toilet. (She/He) was not wearing the appropriate footwear and when (she/he) independently transferred, (she/he) used (her/his) wheelchair as a walker and attempted to ambulate to the bathroom independently . It appears that this fall possibly could have been avoided if (she/he) would have had non-skid socks on prior to going to bed . Resident 103's care plan was updated on 11/17/15 to reflect the use of non-skid socks at night. A 12/13/15 progress note indicated Resident 103 was transferred to a local hospital for increasing left hip pain r/t (related to) fall, hematoma to left temple, and skin tear to left elbow . resident was in bed and appeared to be resting quietly during each visual check, call light was within reach of resident, resident did not use call light or verbally call out for assistance, door to residents (sic) room was open, and resident states (she/he) was trying to get out of bed without assistance . The facility's investigation, initiated by Staff 9 (LPN) on 12/12/15 at 9:40 pm, indicated Staff 9 found the resident on the floor on her/his right side. The resident complained of pain on her/his left side, had a lump on her/his left temple and a skin tear on her/his left elbow. Staff 9 documented, Noted resident not wearing non-skid socks. Resident trying to get out of bed by (her/himself). Noted wheelchair placed against wall near doorway. Call light within reach. Staff 9 further documented he made inquiry with the assigned CNA who reported putting the resident to bed at 8:00 pm, then checked the resident at 8:30 pm. The 12/14/15 hospital Discharge Summary revealed a [DIAGNOSES REDACTED]. The facility's 12/15/15 investigative summary, completed by Staff 3 (RNCM) included an analysis of Resident 103's physical and medical status in the days prior to the fall. The investigation noted the assigned CNA toileted and assisted Resident 103 to bed with nightclothes and non-skid socks at approximately 8:00 pm. A visual check of Resident 103 at 8:30 pm showed the resident was laying in bed. Staff 3 concluded the care plan was followed and the fall was unavoidable due to the resident's impulsivity and poor safety awareness. The investigation did not document information related to Staff 9 identifying Resident 103 was not wearing non-skid socks, a care plan fall intervention. Resident 103 was not a current resident of the facility at the time of the survey, from 2/22/16 through 2/29/16. On 2/25/16 at 3:42 pm Staff 1 (Administrator) and Staff 2 (DNS) confirmed the CNA who worked with Resident 103 at the time of the falls on 11/15/15 and 12/12/15 no longer worked at the facility. On 2/25/16 at 7:47 pm, Staff 19 (CNA) described Resident 103 as impulsive. Staff 19 stated fall interventions were use of a low bed, 15 minute visual checks and socks with grips. On 2/26/16 at 2:36 pm Staff 10 (LPN) stated fall interventions for Resident 103 were bed in lowest position, bathroom light on with the door open, frequent checks because the resident self-transferred, and encourage call light use. Staff 10 stated at times staff found the resident out of bed. Staff 10 stated shortly after safety checks the resident seemed to get up, so after regular checks were done staff checked the resident again. Staff 10 confirmed she worked at the time of Resident 103's falls on 11/15/15 and 12/12/15. Staff 10 stated she recalled the 11/15/15 occasion because the resident had regular socks on and she chewed out the CNA. Staff 10 said she was not assigned to the resident on the night of 12/12/15, but she responded to assist Staff 9 (LPN). Staff 10 stated she was not there to assist the resident off the floor, she saw the resident after she/he was transferred to bed. Staff 10 stated she could not recall if the resident had non-skid socks on. On 2/26/16 at 10:24 pm Staff 9 (LPN) stated Resident 103 was confused and was a fall risk. Staff 9 said interventions were frequent checks, leaving the bathroom light on and door open. Staff 9 recalled finding the resident on the floor on 12/12/15 and said he immediately did a body check and the resident had no pain, then he did neurological checks and the resident reported pain. Staff 9 stated he and the CNA transferred the resident to bed, and he then asked the CNA about when checks were last done. When asked if he recalled his note regarding the resident not wearing non-skid socks Staff 9 stated he did not recall what he wrote on the report. He stated if he wrote it, that must have been what he saw. When asked if he questioned the CNA about the use of non-skid socks, Staff 9 stated he had no recollection of what they discussed. When asked if he was interviewed by a supervisor about the non-skid socks, Staff 9 stated he was interviewed, but he could not recall the details of those conversations. At that time Staff 9 requested to end the interview. On 2/29/16 at 10:08 am Staff 3 (RNCM) stated her investigative process included meeting with staff and residents about what happened and reading staff notes. When completing a fall investigation she interviewed the person who found the resident on the floor. When asked if Staff 9 was interviewed about Resident 103 being found without non-skid socks, Staff 3 stated she did talk to Staff 9 and he did not think they were on, but Staff 10 (LPN) and the assigned CNA indicated the non-skid socks were on. When asked if she thought the investigation was complete and clearly determined the care plan was followed to rule out neglect of care, Staff 3 stated, Most likely (it was) not. On 2/29/16 at 11:34 am, Staff 2 (DNS) had additional information from her personal notes regarding speaking with Staff 9 and 10, but the notes did not detail what was discussed or how it was determined the care plan was followed. Staff 2 stated she thought since Staff 10 and the CNA reported the socks were in place and likely Staff 9 did not recall the issue they felt the non-skid socks were in place. Staff 9 said she expected Staff 3 to document sufficient information to rule out abuse. 2. Based on observation, interview and record review the facility failed to provide an environment free of accident hazards for 2 of 5 sampled residents (#s 9 and 24) reviewed for accidents. This placed residents at risk for avoidable injuries. Findings include: a. Resident 9 was readmitted to the facility in 2009 with [DIAGNOSES REDACTED]. Resident 9's 7/12/15 MDS indicated the resident received extensive assistance for bed mobility and was on a turning/repositioning program. On 2/23/16 at 9:35 am Resident 9 was observed to have a yellow bruise on the left side of her/his forehead approximately the size of two quarters. Resident 9 stated the bruise was caused by the resident's trapeze (triangular-shaped assistive device) falling on her/his head over a week ago. Resident 9 stated the bar fell on its own when she/he was not using it. Resident 9 indicated the trapeze was in place for years and was used for positioning and exercise. Resident 9 stated she/he told a nurse about the trapeze falling, but couldn't remember which nurse she/he told. Resident 9's trapeze was observed to be positioned in such a way that it could fall off of the overhead bar it was resting on and strike the resident's head. A review of Resident 9's medical record did not reveal an assessment or investigation of the head injury. Resident 9's current care plan, updated 1/5/16, did not indicate use of a trapeze. On 2/23/16 Staff 3 (RNCM) expressed no knowledge of the resident's head injury and acknowledged no investigation was completed regarding the incident. Staff 3 stated trapeze use was normally initiated by the therapy department. On 2/24/16 at 1:28 pm Staff 6 (LPN) indicated Resident 9 used the trapeze to assist staff when they repositioned the resident. Staff 6 stated the resident told her about the trapeze falling a few weeks ago; a couple of days after it occurred. Staff 6 indicated she did not report the incident because she believed other staff already did so. On 2/24/16 at 1:50 pm Staff 12 (CNA) stated Resident 9 used the trapeze bar to lift her/his body up while staff repositioned the resident. Staff 12 stated she worked with the resident the past few weeks. Staff 12 indicated she learned of the incident on 2/22/16 when the resident mentioned it. Staff 12 stated she assumed the resident told staff about it when it occurred. On 2/25/16 at 11:28 am Staff 14 (Rehabilitation Director) indicated the therapy department had not worked with Resident 9 since the resident's admission. Staff 14 stated trapezes were used for positioning assistance but not for exercise. Staff 14 stated trapezes should be stored in the down position (dangling from the chain connecting the trapeze to the bar, as opposed to resting on top of the bar itself). Staff 14 stated trapeze chains could be shortened or lengthened, or the overhead bar could be raised or lowered so the trapeze would be at the appropriate height for use without being able to strike the resident. On 2/25/16 at 1:59 pm Staff 14 was observed while she inspected the trapeze and talked to the resident. The trapeze was in the same position as previously observed. Staff 14 acknowledged the trapeze was able to strike the resident's head as positioned. The resident indicated she/he used the trapeze as it was positioned (resting on top of the overhead bar) because it was at the proper height that way. Staff 14 stated the bar could be raised up so the trapeze would hang and not be able to strike the resident. On 2/25/16 at 3:30 pm Staff 3 stated the incident should have been brought to the floor nurse's attention to do an initial investigation to assess the resident's safety and rule out abuse. b. Resident 24 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. An incident report dated 1/17/16 indicated the resident was previously found with bruising on her/his left arm near the biceps. The report indicated the bruises were caused by the resident's arms striking her/his bed rails while turning or having tremors in bed. The report stated, (The resident's) care plan has been reviewed and updated as necessary. On 2/23/16 at 1:04 pm Resident 24 was observed to have an approximate two inch bruise on her/his left forearm. The resident was not able to be interviewed regarding the injury due to cognitive impairment. A review of Resident 24's medical record revealed no assessment or investigation of the bruise on the left forearm. A review of Resident 24's current care plan, dated 1/7/16, revealed no updates since the 1/17/16 investigation. On 2/26/16 between 9:30 am and 11:30 am Staff 8 (LPN), Staff 17 (CNA) and Staff 18 (CNA) were interviewed regarding Resident 24. None of the staff expressed knowledge that Resident 24 had arm bruises or any history of injury from the use of side rails. On 2/26/16 at 11:11 am Resident 24 was observed laying in bed with side rails up on both sides. The bed rails felt hard to the touch and were not padded. On 2/26/16 at 11:38 am Staff 3 acknowledged no safety assessment was completed regarding the continued use of the side rails after the resident's bruises were previously identified and attributed to the presence of side rails.

Based on observation, interview and record review it was determined the facility failed to ensure professional standards of practice were followed related to care planned transfer interventions for 1 of 1 sampled resident (#1) reviewed for fractures. Resident 1 sustained a fracture. Findings include: 851-063-0030 Authorized Duties and Standards for Certified Nursing Assistants (6) Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse; 851-063-0090 Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title "CNA," who, in the performance of nursing related duties, may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Conduct unbecoming a nursing assistant includes but is not limited to: (1) Conduct related to the client's safety and integrity Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/14/12 Care Plan revealed Resident 1 required two person assistance with pivot transfers. A 10/18/12 Progress Note indicated Resident 1 was alert and oriented to herself/himself and had sustained an injury to the left upper extremity during a transfer with Staff 2, CNA. The resident was transported to the emergency room for assessment. The 10/18/12 x-ray report identified "a lengthy 10 cm" [MEDICAL CONDITION] arm. The facility's 10/18/12 investigation disclosed when the resident was being transferred from bed to a commode by Staff 2, the staff member heard a "cracking" sound. The resident was tense and moaning prior to the transfer, cried out in pain and stated the staff member "twisted (Resident 1's) arm." It was determined the care plan had not been followed for a two person transfer. Staff 2 reported she was told at the beginning of shift the resident was a one person transfer, but had not verified that information with the resident's care plan. In interview on 10/30/12 at 11:50 am, Staff 1, DNS, stated the care plan had not been followed during Resident 1's transfer. In interview on 10/30/12 at 12:08 pm, Staff 2, CNA, stated on 10/18/12, she had received report from Staff 4, CNA, the resident could be transferred with one to two person assistance. Staff 2 stated she had not checked the care plan before transferring Resident 1. Staff 2 stated when she transferred Resident 1 from bed to the commode, the resident was very nervous, and grabbed the staff member's arm. Staff 2 stated she heard a "crack, crack". Staff 2 stated she had heard bones pop or crack before, but this was "louder, not the typical popping of joints." In interview on 10/30/12 at 12:44 pm, Staff 3, RN, stated she was not aware of a change in the resident's care plan as the resident had always been a two person transfer. In interview on 10/31/12 at 6:30 am, Staff 4, CNA, stated he had not reported a change in the resident's transfer status to Staff 2, as the resident was always a two person transfer.

Based on observation, interview and record review it was determined the facility failed to ensure care planned transfer interventions were followed for 1 of 1 sampled resident (#1) reviewed for fractures. Resident 1 sustained a fracture. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/14/12 Care Plan revealed Resident 1 required two person assistance with pivot transfers. A 10/18/12 Progress Note indicated Resident 1 was alert and oriented to herself/himself and had sustained an injury to the left upper extremity during a transfer with Staff 2, CNA. The resident was transported to the emergency room for assessment. The 10/18/12 x-ray report identified "a lengthy 10 cm" fracture of the left arm. The facility's 10/18/12 investigation disclosed when the resident was being transferred from bed to a commode by Staff 2, the staff member heard a "cracking" sound. The resident was tense and moaning prior to the transfer, cried out in pain and stated the staff member "twisted (Resident 1's) arm." It was determined the care plan had not been followed for a two person transfer. Staff 2 reported she was told at the beginning of shift the resident was a one person transfer, but had not verified that information with the resident's care plan. In interview on 10/30/12 at 11:50 am, Staff 1, DNS, stated the care plan had not been followed during Resident 1's transfer. In interview on 10/30/12 at 12:08 pm, Staff 2, CNA, stated on 10/18/12, she had received report from Staff 4, CNA, the resident could be transferred with one to two person assistance. Staff 2 stated she had not checked the care plan before transferring Resident 1. Staff 2 stated when she transferred Resident 1 from bed to the commode, the resident was very nervous, and grabbed the staff member's arm. Staff 2 stated she heard a "crack, crack". Staff 2 stated she had heard bones pop or crack before, but this was "louder, not the typical popping of joints." In interview on 10/30/12 at 12:44 pm, Staff 3, RN, stated she was not aware of a change in the resident's care plan as the resident had always been a two person transfer. In interview on 10/31/12 at 6:30 am, Staff 4, CNA, stated he had not reported a change in the resident's transfer status to Staff 2, as the resident was always a two person transfer.

1. Based on observation, interview and record review, it was determined that the facility failed to provide necessary care and services regarding bowel protocol, pain, incontinent care and care plan interventions for 3 of 10 sampled residents (#'s 3, 6, & 7). As a result, Resident 6 experienced pain and discomfort, which resulted in harm to the resident during bowel care. Findings include: a. Resident 6 was admitted to the facility in 11/2010, with physician orders [REDACTED]. The resident's 12/2010 As Needed Administration Report indicated that there were six occasions when the resident's bowel protocol had to be administered. The resident's progress note dated 12/3/10 indicated, "resident c/o (complained of) low abd (abdominal) pain trying to pass stool - soft stool found in rectum upon digital exam." The resident's progress note dated 12/8/10 indicated, "tried removing stool with no success. Moved client (resident) to bed where dig-stem, removal of an extra large bm (bowel movement)." The resident's progress note dated 12/12/10 indicated,"pt (patient) having difficulty moving bowels when on commode. This nurse did rectal exam. Hard stool noted in rectal canal. Pt (patient) screaming & flailing arms while stool being removed. 2 CNAs holding pt (patient) while stool removed. Redness noted to pt's (patient's) L (left) wrist, will monitor for bruising. Pt (patient) given Tylenol for general discomfort." After the third incident of digital examination/removal, the resident's doctor was finally notified. In interview on 1/5/11 at 9:39 am, Staff 7, LPN, stated that she was the resident's aide on 12/12/10. Staff stated that during the resident's treatment for [REDACTED]. In interview on 1/5/11 at 9:53 am, Staff 5, LPN, stated that it would be her expectation that after the first attempt of treating the resident's constipation that a call to the resident's doctor should have been made and the resident's bowel protocol should have been reviewed. In interview on 1/6/11 at 11:24 am, Staff 6, LPN, stated that she had been the nurse on 12/3/10 and observed the resident having trouble with a bowel movement. Staff 6 stated that she had to digitally remove a small amount of stool from the resident. There had been no documented evidence that the resident's bowel protocol had been reassessed after the resident experienced in 12/2010, three incidents of digital removal of stool and six days where the bowel protocol had been administered. b. Resident 6 had been assessed as an aspiration risk due to swallowing problems related to the resident's [MEDICAL CONDITIONS]. The resident's current care plan and aspiration precautions indicated that the resident required one to one supervision during meals. The resident's progress note dated 1/4/11 indicated, resident had been found "sitting in w/c (wheelchair) with dinner & table in front of her facing the hallway. Pt (patient) had towel with food/emesis on it in front of her & was silent, not making noise & pointing to throat...sat pt (patient) more upright quickly & pt (patient) coughed & vomited food & emesis out at that time." In interview on 1/5/11 at 2:56 pm, Staff 8, CNA, stated that at the time of the incident she was not in the room with the resident during the resident's dinner meal. In interview on 1/5/11 at 3:02 pm, Staff 3, RNCM, stated that at the time of the incident the resident was sitting in her wheelchair, in her room's doorway, facing outward toward the hallway. Staff 3 stated that the resident had been eating unsupervised. c. Resident 7 had [DIAGNOSES REDACTED]. The 7/2010 Bladder Incontinence Evaluation disclosed the resident was totally dependent and had multiple daily episodes of incontinence with no apparent pattern. The 10/18/10 Nursing Summary identified the resident was at high risk for skin issues due to decreased mobility and incontinence. The current care plan directed staff to check the resident for incontinence every two hours and as needed. On 1/4/11 at 7:36 am, the resident was observed to be in her geri chair, in the hallway by the nurse's station. At 8:12 am, she was taken to the dining room for breakfast, then was returned to the hallway by the nurse's station at 9:08 am. At 10:45 am, the resident was still in her geri chair, sitting in the same location. There was a strong urine odor. At 10:48 am, Staff 13, CNA, took the resident to her room to provide incontinence care. The resident's pants and the incontinence pad in the geri chair were soiled with urine. The resident was observed to have a reddened area on her coccyx. Staff 13 changed the resident's pants, however, did not change out the incontinence pad prior to transferring the resident back into the geri chair until stopped by the surveyor. In interview directly afterwards, Staff 13 stated that she had last provided incontinence care to the resident prior to the 7:36 am observation, a period of at least three hours and acknowledged that the resident had gone too long without receiving incontinence care. At 11:13 am, Staff 4, RNCM, stated that the resident should have been given incontinence care after breakfast and should not have gone that long without care provided. Directly afterwards, Staff 4 performed a skin audit and noted a redness of an approximate 0.3 cm x 0.5 cm crease in gluteal fold, however, the previously observed redness had resolved. According to Staff 4, the resident's skin became red very easily. In interview on 1/4/11 at 3:30 pm, Staff 12, CNA, stated that she checked the resident every hour, even though the resident was care planned for every two hours, due to her liquid diet and large amounts of urine. Additionally, Resident 7 was care planned to have posey boots on her feet. The care plan did not identify when the resident was to wear the boots. During observations on the afternoon of 1/3, throughout the day on 1/4 and the morning on 1/5/11, the posey boots were not on the resident's feet. The boots were observed to be on a chair in her room. In interview on 1/4/11 at 3:30 pm, Staff 12 stated that the resident was to have the boots on when in bed. In interview on 1/5/11 at 9:28 am, Staff 11, CNA, transferred the resident from the geri-chair to the bed. Staff 11 did not place the boots on the resident. When asked why the boots were not placed on the resident, Staff 11 stated that she thought they were only to be used when the resident was in bed at night. In interview directly afterwards, Staff 4 stated that the resident was to have the boots on when in bed. d. Resident 3 had [DIAGNOSES REDACTED]. The current care plan indicated that a new pain assessment was to be completed quarterly and/or with any new complaints of pain. The last updated Pain Evaluation was completed on 8/19/10. The assessment revealed the resident denied pain at that time. An 11/28/10 progress note revealed the resident had a fall and complained of back pain on 11/29/10. On 12/1/10, the resident complained of pain in his rib/abdominal area. An x-ray was obtained and revealed a possible rib fracture. Progress notes dated 12/3 and 12/6 revealed the resident complained of pain. The 11/2010 and 12/2010 MARs indicated the resident received an increase in PRN pain medications since the fall had occurred. During observations on 1/3 through 1/5/11, the resident was observed to be in his room, mostly in bed. In interviews on 1/3 and 1/5/11, Staff 4 stated that since his fall in 11/2010, the resident had become more reclusive, had declines in ADLs and had an increase in pain. Staff 4 stated that the resident's new onset of pain, due to the possible rib fracture, should have been re-assessed. Staff 4 was not sure if the resident's decline in condition was related to his pain. 2. Based on interview and record review, it was determined that the facility failed to provide documented evidence of monitoring and emergency procedures for 1 of 1 sampled resident (#11) who went out of the facility for [MEDICAL TREATMENT]. Findings include: Resident 11 was admitted to the facility in 12/2010 and required [MEDICAL TREATMENT] three times a week through a clavicle shunt. Review of the resident's care plan and current TAR's indicated no procedures on how to monitor the resident's [MEDICAL TREATMENT] shunt or what procedures to take in the event of an emergency were to occur with the resident's shunt (e.g. bleeding/hemorrhaging, infection/bacteremia/septic shock). Interview on 1/7/11 at 11:32 am, Staff 3, RNCM, acknowledged that there was no documented evidence on how to handle the resident's shunt in the event of an emergency or documented evidence that the facility staff had been monitoring the resident's [MEDICAL TREATMENT] shunt.